Indian Burden Dr Jagdish Kaur

8/12/2019 Indian Burden Dr Jagdish Kaur

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Burden of Smokeless Tobacco

India

Dr. Jagdish Kaur

Chief Medical Officer

Directorate General of Health Services

Ministry of Health & Family Welfare

Government of India

[email protected]


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Smokeless Tobacco

o The termsmokeless

tobacco includes a large

variety of commercially or

non-commercially

available products andmixtures that contain

tobacco as the principal

constituent and are used

either orally (through themouth) or nasally (through

the nose) without

combustion.


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Global Adult Tobacco Survey- India

2010

Total

(%)

Males

(%)

Females

(%)

Tobaccousers 34.6 47.9 20.3

Smokers 14.0 24.3 2.9

Smokeless

Tobacco

users

25.9 32.9 18.4


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GATS India 2010

Smokeless tobacco has emerged as themost prevalent tobacco product as per

GATS India with 163.7 million users of

only smokeless tobacco. In addition,42.3 million users of both smoking and

smokeless tobacco products (total 206

million).


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Prevalence of Smokeless Tobacco by Age,

education and Occupation

6

16

29

31

34

34

33

25

15

33

35

6

18

33

0 10 20 30 40

15-24

25-44

45-64

65+

NO FORMAL EDUCATION

LESS THAN PRIMARY

PRIMARY BUT LESS THANSECONDARY

SECONDARY AND ABOVE

GOVT AND NON-GOVT EMPLOYEE

SELF EMPLOYED

STUDENT

HOMEMAKER

RETIRED AND UNEMPLOYED


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International Agency for Research in Cancer (IARC)

Monograph (WHO)- Oral Forms of smokeless tobacco

Tobacco alone(w ith aromaand f lavou r ings) e.gCreamy o r dry snu f f ,Gudakhu, Gul, Mishri , Redtooth powder

Tobacco with oth ercomponents( lime, sod iumbic arbonate, ash) e.gKhain i, Zarda, Maras,Naswar

Betel quid w ith tobacco(inclu des areca nut, slakedl ime, catechu and tobaccow ith sp ices) e.g B etelqu id, Gutkha, Mawa


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Smokeless forms of tobacco products

Mawa

Mishri (masheri)

Pan masala (betel quid)Creamy snuff

Khaini

Qiwam

Gutkha


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Smokeless forms of tobacco products

Zarda

Red Tooth

Powder

Snus (snuff))

Other smokeless forms of tobacco products

are:

Gudhaku (tobacco paste)Tuibur (Tobacco water)


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Rank All Persons Males Females

1 Khain i 11.6%

2 Gutkha 8.2%

3 Betel quid with tobacco

6.2%

4 Tobacco used for oral

application 4.7%

Khain i 18.0%

Gutkha 13.1%

Betel quid with

tobacco 7.5%

Other smokeless

tobacco products

3.5%

Tobacco used for

oral application

6.3%

Other smokelesstobacco products

5.4%

Betel quid with

tobacco 4.9%

Khaini 4.7%

Most Commonly Used smokeless tobacco Products

10


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5

5

5

6

6

7

8

811

11

12

15

19

19

22

22

25

26

26

28

28

31

33

36

41

41

43

45

4547

48

49

0 10 20 30 40 50 60

HIMACHAL PRADESH

GOA

CHANDIGARH

PONDICHERRY

HARYANA

PUNJAB

JAMMU & KASHMIR

TAMIL NADU

DELHI

KERALA

UTTARANCHAL

ANDHRA PRADESH

RAJASTHAN

KARNATAKA

GUJARAT

WEST BENGAL

UTTAR PRADESH

SIKKIM

INDIA

MAHARASHTRA

MEGHALAYA

MADHYA PRADESH

ASSAM

ARUNACHAL PRADESH

MIZORAM

TRIPURA

ORISSA

MANIPUR

NAGALAND

CHHATTISGARH

JHARKHAND

BIHAR

Users of Smokeless Tobacco by

States

11


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Most Commonly Used 5 Tobacco ProductsStates with Prevalence among Males Exceeding 25%

Khain i

Chhattisgarh, Jharkhand,

Bihar, Nagaland, Manipur,

Assam

Tobacco used for oral

application

Chhattisgarh

Betel quid with tobacco

Nagaland, Manipur, Tripura

Gutkha

Madhya Pradesh

12


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States with prevalence among Females exceeding 25%

Other smokeless

tobacco products

Bihar

Tobacco used for oral

application

Chhattisgarh

Khaini

Mizoram

Betel quid with tobaccoTripura

Nagaland, Manipur,

Meghalaya

13


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Cessation efforts by Smokeless

Tobacco users


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Quit ratio of smokeless tobacco use among ever daily smokeless

tobacco users

5

5

5

5

6

0 2 4 6 8 10

Overall

Male

Female

Rural

Urban

16


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Percentage of users of smokeless tobacco who made a quit attempt by state/UT

8

9

13

15

19

19

21

21

2223

24

25

26

29

30

32

33

3434

35

35

37

38

38

40

40

41

43

44

49

51

54

0 10 20 30 40 50 60 70 80 90 100

Delhi

Chandigarh

West Bengal

Punjab

Nagaland

Orissa

Jammu & Kashmir

Assam

SikkimArunachal Pradesh

Tripura

Meghalaya

Tamil Nadu

Jharkhand

Mizoram

Chhattisgarh

Haryana

ManipurMaharashtra

Bihar

India

Kerala

Uttaranchal

Himachal Pradesh

Goa

Gujarat

RajasthanUttar Pradesh

Pondicherry

Karnataka

Andhra Pradesh

Madhya Pradesh

18


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0 10 20 30 40 50 60 70 80 90 100

Bihar

Odisha

Jharkhand

Haryana

Manipur

Madhya Pradesh Punjab

Assam

Sikkim

Delhi

Maharashtra

India

Uttar Pradesh

Meghalaya

West Bengal

Kerala

Rajasthan

Chhattisgarh

Gujarat

Chandigarh

Jammu & Kashmir

Mizoram

Tripura

Uttarakhand

Arunachal Pradesh

Puducherry

Karnataka Tamil Nadu

Goa

Nagaland

Himachal Pradesh

Andhra Pradesh

15

16

17

19

19

2121

21

23

24

26

27

27

27

28

28

29

30

32

32

33

34

34

36

37

40

4042

44

51

52

53

Includes only those users of smokeless tobacco who visited a health careprovider in the past 12 months 19

Percentage of users of smokeless tobacco who were advised to quit by health care

provider* by state/UT


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Chemical composition There are 3095 chemical

components in smokeless tobacco

products (including gutkha), among

them 28 are proven carcinogen. The

major and most abundant group of

carcinogens is the tobacco-specific

N-nitrosamines (TSNA) and no safe

level of this chemical has been

ascr ibed so far.

Other carcinogens reportedly

present in smokeless tobacco

include volat i le N-ni trosamines,certain volati le aldehydes,

polynu clear aromat ic hydroc arbon s,

certain lactones, urethane, metals,

and radioact ive polo nium .


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o Various studies have found high levels of

Nitrosamines in the branded Indian smokelesstobacco products available in the market .

o Studies also demonstrated presence of high levels

of heavy metals (Lead, Cadmium, Chromium,

Arsenic and Nickel) in these products, with onestudy report ing almost 30% of gutkha brand

samp les exceeding the permiss ib le levels o f heavy

metals Lead and Copper, when com pared to the

pro vis ional tolerable intake lim its determined by theFAO/WHO


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Harmful effects of smokeless tobacco

CANCERS - The r isk has been fou nd to increase with th e durat ionand frequency of smokeless tob acco us e.

Oral pre-malignant lesions/cond i t ion s like leukoplakia,

erythroplakia, submucous fibrosis or lichen planus

(either alone or in combination).

Oral cancer - Highest in India

Oesophageal cancer

Stomach cancer

Panc reatic cancer

Throat (pharynx and larynx )

cancer

Renal cancer


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MORTALITY

Studies indicate anincreased risk of all-cause

mortality or all-cancer

mortality in smokeless

tobacco users compared tonon-users, and the

increased risk was seen

predominantly in female

users. Evidence also of

increased risk of dying

from cardiovascular

disease among the users.

NON CANCEROUS


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NON-CANCEROUS

DISEASES/CONDITIONS

Oro-dental health- Different types of periodontal

diseases (inflammation, gingival recession and

bleeding, staining, tooth loss) and/or caries.

Hypertension & Cardiovascular diseases - Fatalmyocardial infarction.

Nervous sys tem diseases- Fatal cerebrovascular

stroke

Metabo l ic abno rmal i ties- Abdominal obesity, high

cholesterol level, high triglycerides level,

hypertension, diabetes or hyperglycemia.


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Gastro-intestinal and Respiratory

o Increased prevalenceof benign

gastrointestinal

diseases

(oesophagitis, sub-mucous fibrosis).

o It has been associated

with chronic bronchitis

and impaired lung

function with chronic

use.


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Economics of Smokeless Tobacco Products

Production characterized by small-scale informal sector

producers, both handmade and machine made products, and

a wide range of products/prices.

Taxes are either ad valorem or levy schemes based on pouch

producing capability of packing machines.

Overall market knowledge is poor and monitoring &

regulation mechanisms are weak.

A smokeless tobacco manufacturing unit can be set up very

easily and at low cost.


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Economics of Smokeless Tobacco Products

Smokeless tobacco products like gutkha pouches are available

at very low prices (1-7 Rupees) making it very affordable to the

poor and vulnerable groups like women and children.

As per GATS India, 54.7% buy from store; 10.4% from street

vendor; 31.9% from kiosks; 3% from other sources.

There is no licensing for sale of these products and these aresold freely in all kinds of kiosks, tea shops, road side stalls etc.

This distribution network and easy availability also promotes

usage.


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ECONOMIC COSTS

Using healthcare expenditure data fromthe National Sample Survey of India, a

study found direct medical costs for

treating smokeless tobacco associated

cancers and diseases as USD 285

million. Indirect morbidity costs (including

costs of caregivers and work loss due

to illness) amounted to USD 104 million.

The total economic cost of tobacco use

was reported as USD 1.7 billion whichwas many times more than the annual

government expenditure on tobacco

control and about 16% more than the

total tax revenue generated from

tobacco.


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Environmental Costs

o Besides harmful effects on environmente.g. deforestation, depleting soil of

nutrients at a faster rate etc., the plastic

packaging of smokeless tobacco products

is a major threat to environment.

o Solid waste management not able to

handle the amount of waste generated by

such packs especially in high prevalencestates.


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Provisions under COTPA

o Ban on all direct and indirectadvertisements of all tobacco products.

o Ban on sale to minors

o Ban on sale within 100 yards ofeducational institutions

o Health warnings including pictorial, on all

tobacco products


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Mass Media Awareness Campaign

Public Awareness Campaigns on ill effects of tobacco

use is main component of the National TobaccoControl Programme (NTCP) both at national & subnational level.

A mass media campaign was launched by MoHFW in

2009 in collaboration with WLF to raise awareness,increase knowledge and build risk perceptions of

health consequences of smokeless tobacco.

There are low levels of awareness about ill-effects ofsmokeless tobacco use

Limited knowledge about presence of tobacco in many

of the products like pan masala, toothpaste etc.

Violations reported related to prohibition on


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Violations reported related to prohibition onDirect/Indirect advertising

Misuse of the point-of-sale boards by the

tobacco industry by depicting back-lit and

illuminated advertisements on the same.

Pan masala companies are violating the

tobacco advertising ban by advertising non-

tobacco pan masala products which share

their brand names with popular Gutkha

(pan masala containing tobacco) products.

Aggressive advertising strategies, using

film/tv stars


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Content Regulation

Nicotine and tar contents not to exceed maximum permissible

limits as per the Tobacco Control Act. This provision is not yetnotified.

Regional laboratories for testing tobacco product contents and

Apex lab for research and validation identified. These labs aremandated to test nicotine levels of the smokeless tobacco products(as per law).

Challenge Standardized and validated methods required, large no.

and variety of smokeless tobacco products


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Indian Burden Dr Jagdish Kaur