indian burden dr jagdish kaur
TRANSCRIPT
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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
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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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