In the late fifteenth century Columbus while discovering America brought back tobacco with him and introduced it in Europe. Very soon it became the commodity of consumption because of its addictive character. In many countries a significant amount of their economy was based on the import and export of various products of tobacco. However, bad effects were also observed soon after its discovery. King James of England in 16th century commented regarding smoking: “A custom loathsome to the eye, hateful to the nose, harmful to the brain, and dangerous to the lungs.” The Portuguese brought it to India about four centuries ago. Some used tobacco as a medicine, while still others used it to drive away evil spirits. The “boom period” for tobacco industry matched with a sudden spurt in lung cancers and heart attacks. The celebrated studies of Drs. Doll and Peto of Royal College of Physicians in early sixties conclusively established that tobacco consumption was the major cause of rise in lung cancers, strokes, bronchitis and emphysema deaths. Subsequently, thousands of scientific investigations have confirmed the association of smoking with various diseases.
Burden of Smoking
According to a global estimate 12% of women smoke as compared to 48% of man. In Asia more than 60% of men are smokers. Presently tobacco contributes to 4 million deaths per year globally. As per WHO, tobacco kills more people annually than AIDS, alcohol, drugs and accidents put together. It is going to be 10 million tobacco-attributed deaths per year by 2030, with 70% of these deaths are likely to occur in the developing world with India and Chine taking the lead. In India, tobacco kills 8-10 lakh people each year and many of these deaths occur in people who are very young. It has been estimated that an average of five-and-a- half minutes of Life is lost for each cigarette smoked. Deaths attributable to tobacco are expected to rise from 5.4 million in 2005 to 6.4 million in 2015 and 8.3 million in 2030. India, as per WHO projections, will have the highest rate of rise in tobacco-related death during this period compared to all other countries/ regions. Tobacco users lose an average of 20 – 25 years of non-tobacco user life expectancy. In India, in some areas 70% of adults are using tobacco in some form or the other. While smoking among women is relatively uncommon, chewing is much more widespread, particularly in India where in some communities up to half of all adult women regularly chew tobacco. Tobacco use is also common in medical professionals.
In India, smoking of tobacco is mainly in the form of bidi, followed by cigarette, hukah, chilum, chutta, etc. The habit of smokeless tobacco (also referred as tobacco chewing) is also very common. Some common forms of smokeless tobacco include khaini, Mainpuri tobacco, mawa, mishri, zarda, etc.
Tobacco contains more than 4000 chemicals, and about 40 of which can cause cancer. Benzpyrene Nicotine is the principle addictive drug found in tobacco smoke. The nicotine affects a person, slowly making him an addict when the person continues to smoke to maintain nicotine levels in the blood stream. Nicotine produces dependence and tolerance that is why subsequent higher doses are required to produce the same effect. Studies show that sudden cessation of smoking produces withdrawal symptoms. For those who find difficulty in quitting should switch over to low tar low nicotine cigarette or nicotine chewing gum for a while. Other items in smoking include tar, carbon monoxide, ammonia, nitrogen oxides, arsenic, hydrogen, cyanide, phenol, naphthalene, cadmium, urethane, acetone, DDT, butane and radioactive compounds. In India, inferior tobacco is used for making hand-rolled cigarettes and bidis. Filters used in Indian cigarettes are half in length compared to west, causing more tar and nicotine consumption.
Health Impact of Tobacco smoking or use
Approximately 1.157 billion people are estimated to be smoking tobacco (~6 trillion cigarettes), make involuntary inhalation (passive smoking, second hand smokers) of tobacco smoke almost unavoidable throughout the world. Women and children are the victims of tobacco user behavior. In many cultures, it may not be acceptable for a wife to ask her husband to stop smoking. In the rural northern India where majority of men smokes either hukkah or bidi, enjoy social sanction for their smoking behavior. Understanding such social interpersonal and group behavior is beneficial in preventive intervention.
WHO estimates that approximately 700 million, or almost half of the world’s children are exposed to ETS and is considered a substantial public health threat for children (WHO,1999). Any measure that directly promote prevention and control of smoking or tobacco use would be beneficial. However, it is unlikely that the home, where an individual spends his personal life, will ever become the subject of legislation to minimize environmental exposure to tobacco. Interventions to reduce the exposure of women and children in the home need to cause changes in the smoking behavior of men – fathers and husbands.
Exposure to environmental tobacco smoke (ETS) is strongly associated with a number of adverse effects, such as reduced birth weight, lower respiratory illnesses, chronic respiratory symptoms, asthma, middle ear disease and reduced lung function, sudden infant death syndrome, cancers, child’s poor neuro-psychological development and physical growth. Babies of smoking mothers are more likely to be hospitalized for bronchitis and pneumonia during first year of their life. Active cigarette smoking is considered to: a) Increase the risk of cardiovascular disease by promoting atherosclerosis; b) Increase the tendency to thrombosis; c) Cause spasm of the coronary arteries, aneurysms, thrombo-angiitis obliterans, dry gangrene etc. d) Increase the likelihood of cardiac arrhythmias; and e) Decrease the oxygen carrying capacity of the blood.
75% of tobacco related cancers are found in mouth, pharynx, and esophagus. Tobacco consumption can also lead to carcinoma of lungs, urinary bladder, kidney, pancreas and cervix. 50% of malignancies in males and 23% in females have been found to be related to tobacco use. The high incidence of oral cancer in India is attributed to the practice of chewing tobacco with betel leaf. A pipe smoker is more likely get lip cancer, a cigarette smoker lung cancer and a bidi smoker throat cancer. Causation of cancers causing effect of nicotine is due to its effect Heart attacks and average a male smoker suffers an attack 7- 8 years earlier than while in female smokers it is earlier by 16-19 years. Tobacco smoke paralyses the cilia which reduces their ability to remove phlegm, thus resulting in bronchitis and emphysema. Affected persons cough frequently and are very breathless. Cigarette smoking has been shown to accelerate gastric emptying which results in gastroduodenal ulcers and their delayed healing. Impotency, lower sperm counts with more abnormal sperms are also found with tobacco users.
It is found that wherever ban is imposed on smoking at workplace the blood cotinine (a derivative of Nicotine) levels of workers were lower. Similarly lower levels of nicotine and respiratory infections were found in children staying in smoke free home and day care center. There is a need to enact and enforce of Clean Indoor Air Legislation including working place so that workers can be protected. Caregivers and parents should be educated for health effects of smoking particularly passive smoking. Public should be told about the benefits of smoke free home. These homes are smell better and visitors appreciate more about clean home environment. Smoke free homes are healthier.
At the individual level, smokers need to learn about their smoking harms that damage not only to them but also their families. At the community level, programs are needed to (i) make smoking at home unacceptable, particularly in the presence of children (ii) draw on governmental and nongovernmental resources including mass media (iii) tap governmental action for public places and work environment, housing and building quality improvement for increasing exchange of indoor air with outdoor air.
Indeed, the awareness regarding the health hazards of tobacco use is increasing. There is a discussion on the comprehensive legislation in the Parliament, litigation by NGOs and their demand for stricter legislation for tobacco control, and surveys indicating the will of community for legislative action. These indicate that social environment is conducive for major activities for tobacco control. Decision-makers in different ministries/ departments at center are aware of the problem, but logistic aspects are still major impediments for successful program.
1. Framework Convention on Tobacco Control (FCTC): FCTC was initiated in view of tobacco being a public health tragedy of the first order and problem existing in every country. A working Group to FCTC discussed the issues from public health point of view, after which the Intergovernmental Negotiating Body has completed the process of negotiations. India is the signatory of the convention.
2. Indian Parliament has enacted a Comprehensive Anti-Tobacco legislation titled “The Cigarette and their tobacco products (Prohibition of advertisement & Regulation, Trade, and Commerce, Production, Supply, and Distribution) Act 2003. The important provisions are as follows: a) prohibition of smoking in a public place; b) prohibition of direct and indirect advertisement of cigarette and other tobacco products; or sale to a person below the age of 18 years or near educational institutions; etc.
3. There is a plan to disseminate information through the mass media or by health label warnings through the Act and also through program. In this direction government has initiated many projects:
a) A collaborative project of ICMR and All India Radio (Radio DATE - acronym for Drugs, Alcohol, and Tobacco Education) was in the form of 30 weekly episodes of 20 minutes each.
4. The Directorate General of Health Services constituted a Expert committee to examine the scientific literature on health hazards of pan masala-containing tobacco. Based on this report, the Central Committee on Food Standards recommended a ban on chewing tobacco.
5. A Tobacco Control Cell has been established in the Department of Health, New Delhi, since August 2000, under Deputy Secretary (Public Health), with the aim of coordination of activities related to tobacco control, with the help of a 7 members Advisory Board. The current activities initiated through this cell include educational programs through mass media and schools, strategy papers for alternate crops and bidi workers, advocacy workshops for non-health sectors, and establishment of tobacco cessation clinics.
6. The National Anti-Cancer Program provides support through health care and community empowerment.
Smoking behavior is dangerous to self and community because it causes direct exposure and environment pollution. A large amount of tobacco of total production is consumed in the form of cigarettes, biddis and pan masala. Developed nations have realized its devastating effect and almost ban in their countries but shifted their market to developing nations. India must realize that cost of treatment of health effects of tobacco use is more than revenues generated by it for the country. It is also understood that tobacco use is a behavioral problem and can be solved by positive behavior change at the individual, community, country and international level. It is quite impossible for any country to achieve health for all if smoking behavior is not change. Health Professionals should come forward and realize their role to help people in changing this behavior. They are in an excellent position that allows them to have a prominent role on tobacco control. They reach a high percentage of the population and have the opportunity to help people change their behavior and they can give advice, guidance and answers to questions related to the consequences of tobacco use, they can help patients to stop smoking and forewarn children and adolescents of the dangers of tobacco. That is why this year on World No Tobacco Day which is celebrated on 31st May 2005 focuses on the Role of Health Professional on Tobacco Control.
Myth 1: Tobacco is only an issue for affluent people and affluent countries.
Reality: Smoking is declining among males in most high-income countries. In contrast, it is increasing in males in most low- and middle-income countries and in women worldwide. Within individual countries, tobacco consumption and tobacco-related disease burdens are usually greatest among the poor.
Myth 2: Governments should not discourage smoking other than making its risks widely known. Otherwise, they would interfere with consumers’ freedom of choice.
Reality: First, many smokers are unaware of their risks, or they simply underestimate or minimize the personal relevance of those risks, even in high-income societies where the risks are relatively widely known. Second, most smokers start when they are children or adolescents -- when they have incomplete information about the risks of tobacco and its addictive nature -- and by the time they try to quit, many are addicted. Third, smoking imposes costs on non-smokers. For these reasons, the choice to smoke may differ from the choice to buy other consumer goods and governments may consider interventions justified.
Myth 3: Smokers always bear the costs of their consumption choices.
Reality: Not necessarily so. They do impose certain costs on non-smokers. The evident costs include health damage, nuisance and irritation from exposure to environmental tobacco smoke. In addition, smokers may impose financial costs on others (such as bearing a portion of smokers’ excess healthcare costs) . However, the scope of these costs is difficult to measure and they vary in place and time, so this report makes no attempt to quantify them In high-income countries, smokers’ healthcare costs on average exceed non-smokers’ in any given year. It has been argued that, because smokers tend to die earlier than nonsmokers, their lifetime health care costs may be no greater than those of nonsmokers; however, recent reviews in high-income nations conclude that smokers’ lifetime healthcare costs do indeed exceed nonsmokers’, despite their shorter lives. If healthcare is paid for to some extent by the public sector, smokers will thus impose their costs on others.
Myth 4: Tobacco control will result in permanent job losses for an economy..
Reality: Successful control policies will lead to only a slow decline in global tobacco use (which is projected to stay high for the next several decades). The resulting need for downsizing will be far less dramatic than many other industries have had to face. Furthermore, money not spent on tobacco will be spent on other goods, generating alternative employment. Studies for this report show that most countries would see no net job losses and that a few would see net gains if consumption fell.
Myth 5: Tobacco addiction is so strong that simply raising taxes will not reduce demand; therefore, raising taxes is not justified
Reality: Scores of studies have shown that increased taxes reduce the number of smokers and the number of smoking-related deaths. Price increases induce some smokers to quit and prevent others from becoming regular or persistent smokers. They also reduce the number of ex-smokers returning to cigarettes and reduce consumption among continuing smokers. Children and adolescents are more responsive to changes in the price of consumer goods than adults-that is, if the price goes up, they are more likely to reduce their consumption. This intervention would therefore have a big impact on them. Similarly, people on low incomes are more price-responsive than those on high -incomes, so there is likely to be a bigger impact in developing countries where tobacco consumption is still increasing. Models developed for this report show that tax increases that would raise the real price of cigarettes by 10 percent worldwide would cause 40 million smokers alive in 1995 to quit and prevent a minimum of 10 million tobacco-related deaths.
Myth 6: Governments will lose revenues if they increase cigarette taxes, because people will buy fewer cigarettes.
Reality: Wrong. The evidence is clear: calculations show that even very substantial cigarette tax increases will still reduce consumption and increase tax revenues. This is in part because the proportionate reduction in demand does not match the proportionate size of the tax increase, since addicted consumers respond relatively slowly to price rises. Furthermore, some of the money saved by quitters will be spent on other goods which are also taxed. Historically, raising tobacco taxes, no matter how large the increase, has never once led to a decrease in cigarette tax revenues.
Myth 7: Smuggling and illicit production will undermine the effects of raised tobacco taxes.
Reality: Smuggling is a serious concern. But even in the face of smuggling, the evidence from a number of countries shows that tax increases still increase revenues and reduce cigarette consumption. Furthermore, governments can adopt effective policies to control smuggling. Such policies include prominent tax stamps and local-language warnings on cigarette packs, as well as the aggressive enforcement and consistent application of tough penalties to deter smugglers.
Myth 8: Governments should not raise cigarette taxes because such increases will have a disproportionate impact on poor consumers.
Reality: Existing tobacco taxes do consume a higher share of the poor consumers’ income than of rich consumers. However, policymakers’ main concern should be over the distributional impact of the entire tax and expenditure system, and less on particular taxes in isolation. Poor consumers are usually more responsive to price increases than rich consumers, so it is likely that their consumption of cigarettes will fall more sharply, and their relative financial burden may be correspondingly reduced.
Myth 9: In response to higher cigarette taxes, smokers will switch to cheaper brands or cheaper tobacco products and thus there will be no reduction in overall tobacco consumption.
Reality: This behavior, which is also known as "substitution", establishes a legitimate concern. However, not all smokers will engage in this behavior. Price increases will discourage non-smokers from taking up smoking and induce many smokers to quit or reduce consumption. Consequently, there will be reductions in overall consumption and prevalence. Only a certain portion of smokers will not be affected and some of them manage to maintain their levels of tobacco consumption through substitution. Non-price measures, nicotine replacement therapy and other cessation interventions can help curb tobacco use among this group.
Myth 10: Tax rates for cigarettes are already too high in most countries
Reality: The question of what the “right” level of tax should be is a complex one. The size of the tax depends in subtle ways on empirical facts that may not yet be available, such as the scale of the costs to nonsmokers, income levels, and also on varying societal values, such as the extent to which children should be protected. It also depends on what a society hopes to achieve through the tax, such as a specific gain in revenue or a specific reduction in disease burden. For the time being, a useful yardstick may be the tax levels adopted as part of the comprehensive tobacco control policies of a number of countries where cigarette consumption has fallen. In such countries, the tax component of the price of a pack of cigarettes is between two-thirds and four-fifths of the retail cost. Currently, in the high-income countries, taxes average about two-thirds or more of the retail price of a pack of cigarettes. In lower-income countries, taxes amount to not more than half the retail price of a pack of cigarettes, which are still very much below the level in high-income countries.
Myth 11: Measures to reduce tobacco supply are effective ways to reduce consumption
Reality: While interventions to reduce demand for tobacco are likely to succeed, measures to reduce its supply are less promising. This is because, if one supplier is shut down, an alternative supplier gains an incentive to enter the market. The extreme measure of prohibiting tobacco is unwarranted on economic grounds, unrealistic and likely to fail. Although crop substitution is often proposed as a means to reduce the tobacco supply, there is scarcely any evidence that it reduces consumption, since the incentives to farmers to grow tobacco are currently much greater than for most other crops. However, it may be a useful strategy where needed to aid the poorest tobacco farmers in transition to other livelihoods, as part of a broader diversification program. Similarly, the evidence so far suggests that trade restrictions, such as import bans, will have little impact on cigarette consumption worldwide. Instead, countries are more likely to succeed in curbing tobacco consumption by adopting measures that effectively reduce demand, and applying those measures symmetrically to imported and domestically-produced cigarettes. However, there is one supply-side measure which is key to an effective strategy for tobacco control: action against smuggling. Control of smuggling will improve governments’ revenue yields from tobacco tax increases.
Myth 12: Tobacco controls will simply compound the poverty of rural economies that are heavily dependent on tobacco farming
Reality: The market for tobacco is likely to remain substantial for at least the next several decades and, while any future gradual decline in consumption will clearly cut the number of tobacco-farming jobs, those jobs will be lost over a decades or more, not overnight. Adopting sound agricultural and trade policies can help farmers in poor countries compete fairly for the world market. Governments are justified to prudently help the poorest of tobacco farmers with the adjustment costs of a gradual decrease in demand for their product. Many governments have helped with such adjustment costs for other industries.
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Dr. J Kishore
MBBS, MD, PGCHFWM, PGDEE, MSc, MNAMS, FIPHA, Professor, Community Medicine, Maulana Azad Medical College, New Delhi-2, firstname.lastname@example.org
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