The Silent Killer
A young career-driven woman in her early twenties, Ria is into heavy smoking. Puffing a cigarette pack each day, the number rises on stressful days. The catch is that Ria is also a scientist and well aware of the pitfalls of her habit. She started smoking while still in school, picking up the habit from her mother. Ria thinks the habit helps her keep calm in stressful moments. When asked about the hazards of smoking, she says: “If there are people who smoke like a chimney well into their nineties, then why can’t I?”
Ria is not alone. “Mai phikra ko dhuen main udaata chala gaya” or so it seems with most youngsters today. With tobacco use increasing among the 12-18 age group, we are staring in the face of a tobacco epidemic 20 years from now. As per the Global Youth Tobacco Survey (GYTS), 5,500 Indian adolescents pick up the habit everyday, almost 37 per cent of them before the age of 10 years.
India has a lot to worry over the World Health Organisation’s (WHO) prediction that tobacco-related mortality in the country will increase from 1.4 per cent of all deaths in 1990 to 13.3 per cent in 2020. Each year almost 55 lakh lives are lost globally to tobacco-related diseases. Of these 10 lakh deaths occur in India, which means nearly 2,700 Indians lose their lives each day because of tobacco use.
Health hazards associated with tobacco use in India are more diverse than other countries. Tobacco is consumed in multiple forms here — from cigarettes (20 per cent of all tobacco consumed) to bidis and gutkha (40 per cent of entire tobacco consumption). The rustic bidi is more harmful than cigarettes, as a person inhales greater amount of carbon monoxide while smoking it.
“Bidi extinguishes faster and hence a person needs to take more puffs than required for smoking a cigarette. In the bargain the person ends up inhaling greater quantities of carbon monoxide,” said Raj Kumar from the Department of Respiratory Allergy and Applied Immunology, VP Chest Institute.
A report released during the recently observed World No Tobacco Day also highlighted a disturbing trend — a large number of women, intentionally or unintentionally, are getting exposed to tobacco. “Close to half of all women in the Asia-Pacific region are exposed to second-hand smoke at their homes or workplaces, often due to cultural and social norms,” said KD Raju from the Department of Health and Family Welfare.
Women constitute 20 per cent of the world’s one billion smokers and if the current tobacco usage continues, smoking will kill eight million people a year by 2030 — of which 2.5 million will be women.
“There is a rising trend of young women from the lower middle class taking to chewing tobacco easily available in low cost sachets. Tobacco chewing is not projected as tobacco habit that is associated with smoking; so, there is a relative social acceptance of the same,” said Srinath Reddy, cardiologist and president, Public Health Foundation of India.
Teenage girls, too, are taking to tobacco in a big way. Though sale of tobacco to minors is banned in India, according to a Ministry of Health and Family Welfare report, 8.3 per cent girls between 13 and 15 years said they had smoked or chewed tobacco.
As per the National Family Health Survey-III data, current tobacco use among adult women (ages 15-49 years) in India is 10.9 per cent (54 million women), as compared to 57 per cent in men. Of these, only 1.6 per cent women smoked cigarettes or bidis, compared to 33.5 per cent men.
The gap, however, is narrowing down. Data of 10-16 year-olds from 32 schools in Delhi and Chennai published in the journal, Nicotine & Tobacco Research, in December 2009 showed that 4.9 per cent girls and 6.5 per cent boys use tobacco regularly.
Women also continue to be an important target group for the tobacco industry, which associate smoking with increased social liberty and emancipation. A study conducted by HRIDAY (Health Related Information Dissemination Amongst Youth), a Delhi-based NGO, concluded that exposure to tobacco advertisements and receptivity to tobacco marketing was significantly related to increased tobacco use among youth. No wonder a study in 22 countries found that comprehensive bans could reduce tobacco consumption by 6.3 per cent.
The tobacco industry has also used promotional activities targeted at the rural population to encourage tobacco users to shift from bidis and smokeless tobacco (like gutkha) to cigarettes. Studies in India have shown a significant correlation between cigarette advertising and smoking behaviour.
Much before the coming into effect of the WHO’s Framework Convention on Tobacco Control (FCTC), Parliament enacted the Cigarettes Act in 1975. Further, in the interest of public health, the Cigarettes and other Tobacco Products Act (COTPA) was enacted by Parliament in 2003 with regulations against the serious threat of tobacco use. India has also in place comprehensive tobacco control laws, which prohibit smoking in public and workplaces and direct and indirect advertising of all tobacco products.
However, the 2006 GYTS results show that almost seven of 10 girls and boys have seen cigarettes being advertised on billboards. The cigarette and gutkha companies also market themselves by offering to renovate strategically located houses on highways — the second part of the deal being the permission to advertise their products on the outer walls of the building.
As for rural women, social norms also promote tobacco use among them. Serving ‘tobacco water’ — known locally as tuibur — especially by women, to guests is a common practice in Mizoram, where 61 per cent women chew tobacco. Women are expected to smoke frequently and produce sufficient quantities of the tobacco water in order to serve their guests.
The National Family Health Survey 2005-06 states that 8.5 per cent of antenatal mothers and 10.8 per cent of breastfeeding women use tobacco in some form. Smoking reduces women’s fertility. Women smokers tend to take longer to conceive than non-smokers and are at a higher risk of not being able to get pregnant at all.
Tobacco poses unusual economic burden as well — both in terms of direct expenditure on tobacco products and the resulting direct and indirect expenditures on healthcare. In India, manufactured tobacco worth Rs 12,075.2 crore is sold annually to an estimated 24 crore tobacco-users. The direct medical cost for treating diseases related to tobacco use in 2004 was Rs 5,217 crore. The indirect medical cost was Rs 2,173.75 crore —16 per cent more than the total excise tax revenues collected from all tobacco products in India for 2003-04.
The 39th Parliamentary Standing Committee Report is a reminder of Government apathy towards tobacco use. The funds allocated this year to the National Tobacco Control Programme (NTCP) have to be revised downwards as the expenditure under the programme was a dismal Rs 16.6 crore from the allocated Rs 30 crore for 2009-10. Launched as a pilot project in 12 districts in 6 States in 2007-08, the programme could just be extended to 42 districts in 21 states by 2009-10 — the target being 100 districts by the end of 2008-09. Further, referral labs to test tar and nicotine contents in tobacco products are yet to be launched. This remains a major reason for hookah bars to function in cities. The owners say they use flavoured non-nicotine tobacco and we have no testing labs to ascertain their claims! Community mobilisation and knowledge of law are paramount to curb the increasing use of tobacco. As part of the National Rural Health Mission, Accredited Social Health Activist (ASHA) workers are provided with a tobacco control booklet to spread the message in the villages. Awareness about the ill-effects of tobacco also use needs to be mainstreamed with other programmes of the Health Ministry.
“Tobacco use is a multi-factoral problem that needs a multi-sectoral response and inter-governmental coordination at the Centre and State levels to efficiently curb this epidemic. Only then, tobacco control will become an important issue for the Government,” said Monika Arora, social scientist and senior director, HRIDAY.
Pictorial warnings, which have achieved desired results in Canada and Australia and are in place in India since 2009, are an effective way of broadcasting health messages across a wide spectrum of the population. They detract glamour from tobacco products and help other tobacco control measures such as establishing smoke-free environments gain public acceptance. Besides, in a country like India where one-third of the population is illiterate, pictorial warnings communicate health messages effectively.
However, the current pictorial warnings of a scorpion and tobacco smoke in lungs fall short of FCTC size requirements, thanks to lack of political will and aggressive lobbying by the tobacco industry. Originally scheduled for March 2010, the new warnings — showing the picture of a man with mouth cancer — will now be implemented by the year-end. By the health ministry’s own admission, the industry is not “ready” for the change.
Prevention of initiation, however, is not the solution. WHO projects that by 2050, if the focus is only on prevention of initiation and not cessation, there will be an additional 160 million smoking-related deaths. It is not possible to reduce these deaths over the next few decades, unless adult smokers are encouraged to quit. Special chewing gums to curb the urge to smoke are readily available in the market. So are cessation centres that help smokers break away from the deadly habit.
In every country, especially developing ones, the poor consume more tobacco than the affluent. Tobacco consumption exacerbates poverty as it compromises the amount of money for food, healthcare, education, etc. The cost of treatment entraps an individual into a vicious circle of poverty, threatening his right to have a decent and healthy life for himself and his family. Tobacco use may thrill, but it definitely kills.
Up in smoke
- India remains the third largest producer of tobacco in the world.
- Around 70 lakh people are involved in tobacco-related work.
- For every 300 cigarettes manufactured, one tree is cut down for curing. As a result, almost nine million acres of forests are lost each year.Bidi industry
- Women constitute 76 per cent of the total employees in bidi manufacture.
- The All India Bidi, Cigar and Tobacco Workers Federation put the figure at 90 to 95 per cent.
- The bidi industry is male-dominated, often leading to economic exploitation of women.
- A large number of women engaged in bidi-rolling also get addicted to tobacco.Tooth problem
- A study from Ernakulum district in Kerala reports that 92 per cent (3,013 of 3261) female tobacco users specified tooth-related problems as the reason for tobacco use. Many tobacco companies take advantage of such a misconception by packaging and positioning their products as dental-care products.School & smoking
- A parliamentary legislation prohibits sale of any tobacco product to a person below the age of 18 years or within 100 yards of any educational institution.
- In a study by the students of Loreto Convent College, Lucknow, 78 per cent of the people said they had seen tobacco shops within 100 yards radius of schools and colleges.
- Of the 36 schools/colleges visited by the students, 30 had one or more shops selling cigarettes and tobacco products, in some cases right next to their entry gates.
- Further, 51 per cent of the youth who used tobacco products could buy cigarettes from a store and 72 per cent who bought cigarettes from a store were not refused purchase because of their age.Pictorial warnings help
- Evidences from Canada and Australia show that pictorial warnings increase awareness about the health risks of smoking and reduce consumption.
- In Brazil, 54 per cent of smokers changed their opinion on the health consequences of smoking because of the pictorial warnings and 67 per cent smokers said the warnings made them want to quit.Tax hike works
- 10 per cent rise in tobacco tax could lower tobacco consumption by 8 per cent in developing countries and save about 10 million lives.
- 90 per cent of this reduction in deaths could occur in low and middle income countries.
- Hand-made bidis are subject to lower excise at Rs 16 per 1,000 sticks than the machine-made at Rs 29 per 1,000 sticks. Duty-free sale and purchase of tobacco products is also allowed.Miscellaneous
- In India, 57 per cent of males and 10.8 per cent females aged between 15-49 years use tobacco in some form.
- Tobacco smoke is a complex mixture of over 4,000 chemicals including 70 known or probable human carcinogens.
- Approximately 700 million children — almost half of the world’s children and 50 million pregnant women — are exposed to second-hand smoke each year.