Preventing Tobacco Related Disease in India: Smokeless Tobacco Use
Public Health Issue: As chronic disease prevention becomes a more prevalent topic in public health, the global tobacco epidemic may be in the forefront of one’s mind. It is estimated that annually, tobacco is responsible for 7.2 million deaths worldwide. By global comparisons, India ranks second in tobacco production and third in tobacco utilization. These high levels of consumption significantly contribute to increasing number of tobacco related illness like tuberculosis, respiratory disease, and cardiovascular disease.2,4 In 2017, around 900,000 deaths in India were related to smoking tobacco and another 300,000 were related to smokeless tobacco, totaling over 1 millions deaths per year. ,4,6 Projections estimate that the number of deaths from tobacco related illness will continue to rise by 3% each year. The Indian government, with assistance from the World Health Organization, has been attempting to combat the increasing number of deaths from tobacco related illness.1,2,3,6 However, smokeless tobacco is more commonly used in India than cigarettes, and utilization rates continue to climb each year.1,5,11 With increasing numbers of smokeless tobacco users and the growing health burden, one may wonder if the current policies are enough to address the epidemic of smokeless tobacco use in India.
Methods: References for this analysis were gathered using the PubMed search engine. Search parameters used to collect literature included the terms “India,” “tobacco,” “smokeless,” and “policy.” Other search parameters included “smokeless” and “adolescents.” Of the over 250 titles the search provided, further filters were used to limit the results to articles from the last ten years. From these results, nine articles were chosen as the evidence for this analysis as they offered a wide range data on the dynamic topic of tobacco related policy in India. Additionally, a slightly older article was used to provide a framework and historical context to tobacco related illness in India, and the difficulties in adherence to anti-tobacco legislation.
Agreement: The literature reviewed agreed that tobacco related deaths are a prevailing problem in India and that smokeless tobacco is becoming more commonly used in India.2,3,6 Several articles agree on several factors that contribute to the growing number of smokeless tobacco users. In India, tobacco smokers begin much later in life when compared to other countries.10 The research shows that smokeless tobacco products are heavily used by adolescents as gateway into a lifetime of tobacco use.2,3,6 It is suggested that the ease and cost effectiveness of smokeless tobacco and flavored tobacco are factors that influence the frequent use of these products by adolescents.2,3,6 Additionally, studies show that ease of accessibility of smokeless tobacco products at point of sale shops contributes significantly to adolescent use.2,3,6, . Despite regulations aimed at preventing the sale of tobacco products near schools, and with age limitations, adolescents are still using tobacco at increasingly high rates.
The literature addresses a lack of compliance to the regulations set out by the Indian government. The 2003 Cigarettes and Other Tobacco Products Act sets out several parameters that include: banning tobacco sale within 100 yards of schools and educational institutions, banning sales to minors (under 18 years of age), requiring displays in point-of-sale institutions to state the ban to sale of minors and health warnings in local languages.3,7,11 According to several studies, signage compliance is the leading violation. Signs are often over the legal size regulations.2,3 Although these bans apply to all tobacco products, smokeless tobacco products often goes unregulated.2,3,6 Many signs inside point-of-sale locations contain messages than can be confusing to consumers as many smokeless tobacco products have similar names as products containing no tobacco.2,3 It has been suggested that advertisements for these products not containing tobacco are often used by point of sale advertisements for the smokeless tobacco products as a way around the ban.3
In additional to poor compliance, the articles reviewed also agree that when addressing tobacco use in specific populations, it is important to consider the socio-cultural factors that determine tobacco consumption.5,6 It was suggested in many articles that the current legislation in India is based on research completed in develop countries and did not take into consideration the social determinants of tobacco use in India.6 Specifically, tobacco use in adolescents can be tied to what they see in the media, what they see at home, and what they see in advertisements.5 Many Indians do not begin smoking until later in life suggesting that smokeless tobacco products are how many users begin. Prior to the ban, food products and other products like toothpaste once contained tobacco.1 According to research, one in three homes in India has an adult who uses smokeless tobacco. In rural India, some tobacco products are seen as having medicinal uses.2 This suggests a cultural acceptance of smokeless tobacco. With tobacco use being displayed by older adults, in media, and often encouraged for medicinal purposes, there is common agreement with better regulations for smokeless tobacco products, this alone will not help in decreasing consumption.5,6,8
Disagreement: The reviewed articles agree that tobacco is a large contributing factor to noncommunicable, chronic disease in India. Some articles praise the efforts of the currently tobacco legislation, but others disagree with its potential effective. Despite the known widespread use of smokeless tobacco products in India, it has been suggested that the current policies to address tobacco use were based upon research and data for cigarette smoking.1,2,3 Because of this focus many cessation programs are also focused on smoking tobacco and have been seen as ineffective in India.4 Not only do the regulations not pay specific attention to smokeless tobacco, but they also were based on research conducted in high income countries.9 In these countries, anti-tobacco regulations have seen positive results. However, the transfer of programs ideas to low- and middle-income countries do not always yield the same results. Some suggest that this may be due to influence by tobacco producers on the legislation.1,5,9,11
Gaps: It has been suggested and noticed through this analysis that very limited operational research has been completed on the issue of smokeless tobacco use in India , Operational research may be the key to addressing incomplete and ineffective policy. Through operational research questions may be addressed to the root causes of pervasive smokeless tobacco use.4 Operational research would also aid in addressing research gaps between effective programs in high income countries and their lack of success in low- and middle-income countries.9 Through proper operation research, socio-cultural factors of smokeless tobacco use in India may be addressed in order to add quantative evidence to improve the currently structure of tobacco use interventions.
Summary: The use of smokeless tobacco is becoming an increasingly pervasive problem in India. There is widespread agreement from researchers that smokeless tobacco is a gateway into other tobacco use. There is debate on the effectiveness of the current Cigarette and other Tobacco Act. Some say that it does not sufficiently address the increased use of smokeless tobacco products, and there is also extremely poor compliance with the legislation. A lack operational research is needed to incorporate social and cultural determinants to use in order to effectively influence the rise of smokeless tobacco use.