Tobacco use is a major preventable cause of premature death and disease worldwide. Nearly one million people die in India every year due to tobacco use. Tobacco smoking is a major risk factor for many diseases, including cardiovascular disease (CVD), respiratory disease, and cancers at multiple sites. Tobacco use, including reverse smoking (smoking with the lit end inside the mouth), chewing of betel quid (a mixture of areca nut, slaked lime, and tobacco wrapped in betel leaf), and use of smokeless tobacco increases the risk of cancers of the upper aerodigestive tract. In the past few decades inadequate public awareness of smoking risks, combined with aggressive marketing by tobacco companies, has resulted in a sharp increase in tobacco addiction in India.
Indian perspective of tobacco use
In terms of tobacco habit, India is unique. In 17 states of India, tobacco use is more than 69 %. The North-Eastern region exhibits highest rates of tobacco use - in Mizoram more than 80 per cent of men use some form of tobacco, followed by Tripura (76 %) and Assam (72%). Arunachal Pradesh is the second largest state after Mizoram whose people chew tobacco products (Gupta 2006). Only 22% of total tobacco is consumed in India in the form of cigarettes, 54% is in the form of bidis and 24% is consumed in the form of chewing tobacco, pan masala, snuf, khaini, gutkha, masheri and tobacco tooth paste. These chewable tobacco products contain purified tobacco, paraffin, areca nut, lime, catechu and 230 permitted additives and flavours including known carcinogens.
Global adult tobacco survey (GATS) of India
According to GATS 2009-2010 the key features have been enlisted below-
1. The prevalence of tobacco use in India is very high and more than one-third (35%) of adults in India use tobacco in some form or the other.
2. The prevalence of overall tobacco use is 48 % among men and 20 % among women.
3. Among them 21 % adults use only smokeless tobacco, 9 % only smoke and 5 % smoke as well as smokeless tobacco.
4. The estimated number of tobacco users in India is 274.9 million.
5. There is significant variation in prevalence of both smoking and smokeless tobacco use in different regions and states. The prevalence of tobacco use among all the states and Union Territories ranges from the highest of 67 % in Mizoram to the lowest of 9 % in Goa.
6. Prevalence of tobacco use is higher among rural population as compared to urban and prevalence is found to decrease with increase in education level.
Tobacco use prevalence among youth
According to the Global Youth Tobacco Survey (GYTS, 2006), a total of 36.9% children in India initiate smoking before the age of 10. Among students 4.2% smoke cigarettes with rate for boys significantly higher than girls and 11.9% students use other tobacco products. Cigarette smoking among youth is higher in central, southern and north-eastern regions (12%). Exposure to second-hand smoke (SHS) in public places is as high as 40%.
Toxic chemistry of tobacco
Nearly 3000 chemical constituents have been identified in smokeless tobacco, while 4000 are present in tobacco smoke. These include alkaloids such as nicotine, nornicotine, cotinine, anatabin, anabasin; aliphatic hydrocarbons present in the waxy leaf coating and hundreds of isoprenoids that give the aroma to tobacco. Phytosterols such as cholesterol, campesterol, etc. and alcohols, phenolic compounds, chlorogenic acid, rutin, carboxylic acids and several free amino acids are present in tobacco. A wide range of toxic metals including mercury, lead, cadmium, chromium and other trace elements have been found in Indian tobacco. The alkaloids nicotine and nornicotine give rise to carcinogenic N-nitrosonornicotine (NNN), while another potent carcinogen 4-methylnitrosamino- 1-(3pyridyl)-1-butanone (NNK) is derived from nicotine. N-nitrosoanatabin (NAT) and N-nitrosoanabasin are other N-nitrosamines derived from the alkaloids anabasin and anatabin, respectively. Both NNN and NNK are present in high concentrations in smokeless tobacco and tobacco smoke.
The tobacco related carcinogens can be metabolically activated to intermediates that react with DNA, forming covalently bound products known as DNA adducts. With persistence of DNA adducts during DNA replication permanent DNA mutation may occur. Mutations in particular regions of crucial genes, like RAS orMYC oncogenes or TP53 or CDKN2A tumor-suppressor genes, may result in loss of normal cellular growth-control regulation and tumor development. Nicotine and carcinogens can also bind directly to some cellular receptors, leading to activation of the serine threonine kinase AKT (protein kinase B), protein kinase A and other factors. These lead to decreased apoptosis, increased angiogenesis and increased cell transformation. Tobacco products may also activate protein kinase C (PKC), activator protein 1 (AP1) or other factors, thereby enhancing carcinogenesis.
Tobacco and cancer in India
Tobacco addiction is an established risk factor for cancers of the lung, head and neck (oral cavity, pharynx, larynx), nasopharynx, esophagus, stomach, pancreas, liver, kidney, bladder, and cervix, and leukemia (IARC, 2012). Globally approximately 6.7 million smoking-related cancer cases are diagnosed every year of which 4.3 million cases are from developing countries .Even the frequency of newly diagnosed lung, stomach, liver, head and neck, esophagus, cervical, and nasopharyngeal cancers and leukemia cases are more in developing countries than developed countries. Cigarette smoking confers a 15- to 30-fold increase of lung cancer, a 10-fold increase of laryngeal cancer, a 4- to 5- fold increase of both oral cavity and oropharyngeal cancers, a 1.5- to 5-fold increase of esophageal cancer, a 2- to 4-fold increase of pancreatic cancer, and a 1.5 to 2.5-fold increase of nasopharyngeal, stomach, liver, kidney, cervix cancers, and leukemia. In terms of global cancer mortality, tobacco smoking accounts for 42% of oral and oropharyngeal cancer, 42% of esophageal cancer, 13% of stomach cancer, 14% of liver cancer, 22% of pancreatic cancer, 70% of trachea, bronchus, and lung cancers, 2% of cervical cancer, 28% of bladder cancer, 9% of leukemia, 21% of all cancers
The tobacco-related cancers constitute 56.4% and 44.9% of cancers in males and females, respectively. The top five or six cancers in men are all tobacco-related cancers which include lung, oral cavity, larynx, oesophagus and pharynx whereas in women, these are cancers of cervix, oral cavity, oesophagus and lung. Case control studies conducted in India on cancer at various sites have shown that both smoking and smokeless tobacco use (including tobacco with lime and paan with tobacco) cause elevated risks for intra-oral, oropharyngeal, oesophageal and cervical cancers, and cancer of the penis. They have shown that smoking in India causes elevated risks for cancer of the lungs, hypopharynx, larynx and stomach. Associations with smokeless tobacco are suggested for cancers of the oral cavity, esophagus, and the pancreas .The attributable fraction of tobacco-related cancer incidence for smokeless tobacco varies considerably by region and sex. In India oral cavity cancer cases that are attributed to smokeless tobacco are estimated to be 52.5% in men and 51.6% in women. The tobacco habit varies regionally within India that dictates difference in gestation period and molecular phathophysiological characteristics of oral precancerous and cancerous lesion (website reference on tobacco habits in India). Areca nut, an indispensable component of gutka, causes oral submucous fibrosis and is a precursor to oral cancer. Unlike smoking with gutka use, oral submucous fibrosis develops within a very short period of time
National tobacco control program
There is no doubt that from view of public health point, this highly toxic industrial product needs strict control measures. The Government of India enacted ‘Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COTPA) to prohibit the consumption of cigarettes and other tobacco products, which are injurious to health. To strengthen the implementation of the tobacco control provisions under COTPA and policies of tobacco control mandated under the WHO FCTC, the Government of the India piloted National Tobacco Control Programme (NTCP) in 2007–2008.
The main components of the NTCP were:
National level
i. Public awareness/mass media campaigns against tobacco; ii. Establishment of tobacco product testing laboratories iii. Mainstreaming the program components as part of the health care delivery mechanism under the National Rural Health Mission framework; iv. Mainstream Research and Training on alternate crops and livelihoods in collaboration with other nodal Ministries; v. Monitoring and Evaluation including surveillance e.g. GATS India
State level
i. Tobacco control cells with dedicated manpower for effective implementation and monitoring of anti tobacco laws and initiatives
District level
i. Training of health and social workers, SHGs, NGOs, school teachers etc; ii. Local IEC activities; iii. Setting up tobacco cessation facilities; iv. School Programme; v. Monitoring tobacco control laws
The Ministry of Health and Family Welfare, Government of India under the proposed National Tobacco Control Programme currently has 19 Tobacco Cessation Centres (TCCs) in diverse settings across India. These centres function under the District Tobacco Control Cell and comprise cancer treatment centres, psychiatric centres, medical colleges and NGOs .
Other tobacco control strategies initiated by the government:
The other prime initiatives that have been taken by Government of India for tobacco control include –(i)A national level inter-ministerial task force has been set up with stakeholder ministries and representatives from other states and civil society; (ii) A Steering Committee has been formed under the chairmanship of Secretary (Health) to look into specific instances of violation of Section 5 at national level. Monitoring Committees have also been formed at state level; (iii) In 2008, the Ministry of Health and Family Welfare initiated a pilot project for developing alternative cropping systems to replace bidi and chewing tobacco with Central Tobacco Research Institute (CTRI), Rajamundhry; (iv) The Ministry of Labour has launched a pilot programme for skillbased vocational training of bidi workers especially women and minors; (v) Tobacco control initiatives are being integrated with other national health programs.e.g National Mental Helath Program(NMHP), National Cancer Control Program(NCCP) etc .
Recommendations for tobacco control in future
The National Action Plan and Monitoring Framework for Prevention and Control of Non Communicable Diseases in India developed by Ministry of Health and Family Welfare aims to achieve a 20% reduction in current tobacco use by 2020 and 30% by 2025. A comprehensive study on the economic burden of tobacco related diseases was supported by the Ministry of Health & Family Welfare, Government of India, WHO Country Office for India and was developed by the Public Health Foundation of India (PHFI) in 2014. According to the report the total economic costs attributable to tobacco use from all diseases in India in the year 2011 amounted to Rs. 1,04,500 crores. The massive direct medical costs of tobacco attributable diseases amounted to Rs.16,800 crore and associated indirect morbidity cost was of Rs. 14,700 crore. The cost from premature mortality is Rs. 73,000 crores, indicating a substantial productive loss to the nation. Therefore in order to reduce the tremendous economic burden and the concurrent losses of the nation the following tobacco control efforts has been recommended by the report-
(i) Comprehensive tobacco control policy; (ii) Tobacco taxation policy; (iii) Treatment for tobacco dependence; (iv) Prohibition of sale and manufacture of all forms of smokeless tobacco products/chewing tobacco; (v) Enhancing public awareness; (vi) Implementation of the WHO framework convention on tobacco control and tobacco control laws.
Conclusion
The tobacco problem in India is complex due to the varied nature of tobacco use. Cessation in Indian settings needs a multi disciplinary approach which should include preventive, curative and rehabilitative care. Mass awareness activities in India should address adult and youth smokers as well as chewers. Educational interventions are very necessary in schools and colleges due to the large number of tobacco addicted children and teenagers. Effective tobacco control in India is dependent on balanced implementation of demand and supply reduction strategies by the Government and stakeholder departments as well as on synergism of government policies and tobacco control initiatives by non government organisations.
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