Tobacco in the South East

Asia Region

Prakash C. Gupta

Healis – Sekhsaria Institute for Public Health,

Navi Mumbai, India

Bangkok, June 11-13, 2013

Prakash C. Gupta,

Tobacco problem is more

complex in SEAR.

Tobacco is smoked and used

in smokeless forms in a large

variety of ways and products

Prakash C. Gupta, Cecily S. Ray, WHO SEARO, August 16-17, 2011

Prakash C. Gupta

Product Name:

(Sticks)

Common

Ingredients

Wrapper

Country of Origin

Cigarette Tobacco (fine cut

flue cured)

Paper Bangladesh, DPR

Korea, India, Indonesia,

Myanmar, Nepal, Sri

Lanka, Thailand

Roll-your-own

cigarettes

Tobacco (fine cut) Paper Thailand

Bidi Tobacco, may be

flavoured

Tendu or temburni

leaf

India, Bangladesh

Cheeroot Tobacco,

sometimes

molasses, tamarind

Tobacco leaf,

square cut ends

India, Myanmar

Cigar Tobacco (air cured

fermented)

Tobacco leaf,

tapered ends

India, and others

Chutta Tobacco India

Dhumti, Keeyo Tobacco (finely

cut), bark of keeyo

tree in Myanmar

Banana leaf or

other green leaves

India, Myanmar

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Product Name:

(Pipes)

Common

Ingredients

Wrapper

Country of

Origin

Water pipe

(hookah)

Tobacco,

molasses,

flavouring

“Water pipe”

made of bamboo,

wood, metal,

plastic

India, Thailand

Hookli, chilum Tobacco, Clay pipe India

Pipe Tobacco, Wood India, Thailand

Sources for smoking products: Pindborg et al, 1992; Bhonsle et al 1992;

various web sources.

Smokeless Products in SEAR

Prakash C. Gupta, Cecily S. Ray, WHO SEARO, August 16-17, 2011

Product name Common ingredients Countries of origin

Betel quid with

tobacco Tobacco, slaked lime,

areca nut, catechu, betel

leaf, various

condiments

All the countries or

SEAR, except DPR

Korea

Chewing

tobacco leaf

either whole or

broken

Tobacco; users mix

slaked lime with it

before using it, if not

with betel quid

All the countries or

SEAR, except DPR

Korea and Bhutan

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Fire cured snuff Pyrolyzed tobacco powder

(dark roasted)

Indonesia

Gudhaku (used as

a dentifrice)

Tobacco powder with

molasses

India, Nepal

Gul (a pyrolized

dry snuff), or

Tapkheer (dry

snuff)

Pyrolyzed tobacco powder

(light); may contain

alkaline modifiers

Bangladesh, India

Gundi/Kadappan Tobacco, coriander seeds,

spices, heated and

powdered, mixed with a

resinous oil

India

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Gutka (a chewing

product)

Tobacco, slaked lime, areca

nut, catechu, flavours, etc

India, Pakistan,

Nepal

Hnatsay/Huey

paung

Tobacco, honey, alcohol or

lemon juice

Myanmar

Kimam (Qiwam)

(chewed in betel

quid)

Tobacco paste pellets or

granules, made from

deveined tobacco, with

saffron, cardamom etc

India

Khaini (a moist

snuff, kept in the

mouth)

Tobacco, slaked lime paste,

flavorings (including

menthol)

Bangladesh, India,

Myanmar, Nepal

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Mawa (chewing

product)

Tobacco, slaked lime,

areca nut

India

Mainpuri

tobacco

Tobacco, slaked lime,

areca nut, spices

India, Pakistan

Mishri

(dentifrice)

Pyrolized (dark) tobacco

powder

India

Red

Toothpowder

Herbs, unspecified

ingredients

India, Nepal

Tobacco

toothpaste/

creamy snuff

Tobacco, aromatic

substances

India

Tuibur/Hidakphu

(for gargling)

Water through which

tobacco smoke has passed

India

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Watery Tobacco Tobacco mixed with water Myanmar

Zarda Finely cut tobacco, slaked

lime, flavours and spices,

Bangladesh,

India, Myanmar,

Nepal

Sources: IARC, 2007 p 49-54; IARC, 2004; Bhonsle et al.,

1992; Reddy and Gupta, 2004; Sinha 2006; MOH Myanmar

2009; Kyiang et al, 2004; Aryal GR, 2011.

Also see www.aftcindia.org

2. Economics

Agricultural Production

• Tobacco: India, Bangladesh, Indonesia and to

a limited extent Nepal and Sri Lanka

• Areca nut: Bangladesh, India, Indonesia,

Myanmar, Thailand.

Manufacture Smokeless

• Smokeless: India, Bangladesh, Myanmar,

Indonesia, et al.

• Smoked:

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Market concentration –except for cigarette

• Manufacture is dispersed among hundreds

of small producers, a few big players

Income and consumption

• The poor often use unmanufactured tobacco

(sold loose, unadvertised, untaxed)

• Low & Middle income consumers buy

small pouches – very convenient

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Sales & Taxation

Except for cigarette

• Sales and excise data hard to get

• Rampant tax evasion is a feature in India

• Considerable research and data needed on

taxation, trade and other economic aspects

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3. Youth Prevalence

• ST appeals to youth: cheap, attractive packaging,

surrogate advertisements, fragrant, sweet taste

• GYTS conducted in 10 countries of SEAR

• “Other” tobacco ranged from 3.5% in Maldives to

17.8% in Timor Leste (2007-9)

• More boys than girls use ST

• “Other” tobacco higher than cigarette smoking in

Bangladesh, Nepal, Sri Lanka, India, Myanmar

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3.8 2.0

20.3

3.9

1.2

11.7

3.8

12.4

4.9

24.6

3.5

6.0 6.5 8.0 8.6

10.8 11.9 12.0

14.1

17.8

0

5

10

15

20

25

30

%

GYTS – Cigarette Smoking versus Other tobacco use

Currently smoke cigarettes

Currently use other tobacco products

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14.1

11.1 10.3

9.6 8.8

7.3

5.8 5.3

6.0

2.7

3.9

2.9

4.1 4.2

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

(%)

GYTS – Smokeless Tobacco Use

Boys

(%)

Girls

(%)

4. Adult Prevalence

Information available from Global Adult

Tobacco Surveys in Bangladesh, India,

Indonesia, Thailand and STEPS in Bhutan,

Myanmar, Nepal and Sri-Lanka.

No data from DPR Korea

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1.5 1.1

26.4 31.2

24.9 21.5

32.9

51.4

67.0

46.6 47.7

35.5 29.9

8.7

24.3

44.8

0

10

20

30

40

50

60

70

80

%

Smoking vs Smokeless Use (% Men)

Smokeless

Smoking

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51.4

32.9 31.2

26.4 24.9 21.5

1.1 1.5

16.1 18.4

4.6

27.9

6.9

17.6

5.2 2

0

10

20

30

40

50

60

%

Prevalence of Smokeless Tobacco Use (%)

MEN

WOMEN

3. Adult SLT prevalence, cont’ed

• Populations are only superficially aware of

the harms that can be caused by smokeless

tobacco

• Quit attempts are rare

• The number of users of smokeless tobacco

in SEAR may be close to 250 million

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Monitoring

• For monitoring of prevalence,

implementation of tobacco control policies

and their effect on the population, we

require repeat, periodic surveys.

• In SEAR, Thailand conducted a repeat

GATS.

• Findings seem somewhat inexplicable.

• Repeat GATS also in Turkey. Prakash C. Gupta

GATS Thailand, 2009 & 2011 • Overall tobacco use unchanged: from 27.2% to 26.9%

• Overall smokeless tobacco use: from 3.9% to 3.2%

• ƒƒQuit attempts in the past 12 months declined from 49.8% in

2009 to 36.7% in 2011 among current smokers;

• The advice by the health care providers to quit did not change

from 51.9% in 2009 to 55.8% in 2011

• ƒƒThe proportion of current smokers who thought of quitting

because of a pictorial health warning (PHW) on the packages

decreased from 67.0% in 2009 to 62.6% in 2011 (8 in 10 PHWs

have been used more than 5 years)

• ƒƒPrevalence of exposure to secondhand smoke at home increased

from 33.2% in 2009 to 36.0% in 2011

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GATS Turkey, 2008 & 2012

• Smoking prevalence decreased significantly; from

31.2% to 27.1%, and the number of smokers in

Turkey dropped from 16 million adult smokers in

2008 to 14.8 million in 2012.

• Exposure to secondhand smoke dropped

dramatically, most notably in restaurants – from

55.9% in 2008 to 12.9% in 2012.

• More current smokers in 2012 thought of quitting

because of health warning labels on cigarette

packages than current smokers in 2008 (53% versus

46.3%).

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6. Mortality – all cause

Cohort studies

• Sweden – two large studies in men found

RR (men)=1.2, RR (men)=1.4

• India – two large studies found

RR (men)=1.2, RR (women)=1.3

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7. Diseases & SLT

Cancers

• Oral cancer - the most widely known disease

Case-control studies in India (betel quid+T)

OR (men) = 4 to 5

OR (women) = 25 to 42

(Nandakumar et al, 1990; Balaram et al, 2002)

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0.3 1.2

5.6

14.5

24.6

31.8

0.3 2.1

15.9

1.2

8.5

34.1

5.6

17.6

46.1

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

15-24 25-34 35-44 45-54 55-64 65-74

An

nu

al in

cid

en

t p

er

10

0,0

00

India, Ahmedabad (Mouth Cancer),Male

1985

Cohort (15-24)

Cohort (25-34)

Cohort (35-44)

7. Diseases & SLT, cont’ed

• Other cancers in users of SLT include

pharyngeal, esophageal (with areca nut),

and stomach (tuibur), with excess risks of at

least around double those in never users

• Limited evidence for penile, breast, cervical

cancers

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7. Diseases, cont’ed

Circulatory System Diseases & SLT

• SLT users have a slightly higher risk of death due to circulatory

causes compared to never-tobacco users in death cohort studies:

RR=2.1 (1.5-2.9) for all Cardiovascular Disease related deaths

(Bolinder et al, 1994)

RR=1.25 (1.05–1.49) for Ischemic heart disease deaths

(ICD10, I10-I11,13,21,24,25,46,50) (Gupta et al, 2005)

Chewing tobacco raises risk of acute myocardial infarction OR =2.23

(1.41-3.52) (Teo et al, 2006)

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7. Diseases, cont’ed

Reproductive Effects of SLT

• Lower birth weights in SLT users, e.g. average

87 g birth weight deficit in ST users (p=0.02)

(Gupta and Sreevidya, 2004)

• More still births HR=2.6 (2.4-4.8) in ST users

(Gupta and Subramoney, 2006)

• More pregnant women SLT users are anemic

( Hb, 10 g / dl) OR =1.7 (1.2-2.5)

(Subramoney and Gupta, 2008)

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• Periodontal disease and tooth loss are higher

in SLT users than non-users

• Unfortunate since many users start using SLT

to “cure” toothache or as a breath freshener.

• Lack of access to dental care and lack of

knowledge about effective self-care for oral

health are characteristic of the SEA Region

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7. Diseases, cont’ed

Oral Health Problems due to SLT

10. CONCLUSIONS

• SLT a crucial part of tobacco problem in

India

• SLT a very important problem for SEA

Region

• Globally, SLT becoming more important

as TTCs introduce newer products

Prakash C. Gupta

Thank you for your attention

Prakash C. Gupta