Introduction Tobacco consumption patterns and its health implications for India



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MOBILE TOBACCO CESSATION CLINIC – a necessary step towards public health.

Introduction

Tobacco consumption patterns and its health implications for India

Tobacco has been recognized as a universal demerit good and it is well acknowledged fact that tobacco use in any form is potentially harmful from both economic and human development considerations. It is estimated that by 2030, it would account for the death of about 10 million people per year; half of them aged 35–69. This is a matter of serious concern for the developing countries, where more than 82% of the world smokers reside [1]. India, where nearly 17% of the smokers in the world reside [2], is no exception to this tobacco menace. The consequence of this prevalent practice in the form of increased morbidity and mortality is truly overwhelming. The tobacco problem is India is more complex than probably that of any other country in the world, owing to the diverse patterns of tobacco consumption and a large consequential burden of tobacco related disease and death.


Government of India has enacted various legislations to curb tobacco use in recent times. But despite such measures the use of tobacco is still widespread in India. This has raised a number of policy relevant questions:

  • What is the pattern of tobacco consumption across various regions and social groups?




  • Is it the poor or the rich, who consume more of tobacco and are thereby susceptible to various health issues and hence bear the consequent costs?

It would not be possible to make a significant impact on tobacco control unless we are aware of the prevalence of tobacco consumption at various levels and its associated health implications in India. Subramanian et al. [3], etc. analyzed the pattern and distribution of tobacco consumption and health behaviour of households in India. These studies concluded that prevalence of tobacco use was higher among poor, less educated, scheduled caste (SC) and scheduled tribe (ST) populations*.
*(SCs and STs are historically marginalized and the most deprived section in Indian society. SCs are a constitutionally declared collection of castes, which suffered from the practice of untouchability. Whereas, STs constitute the tribal population, which may be also referred to as the indigenous groups.)

Tobacco economy in India
Following are some important features of the tobacco economy in India:
• India is the second largest producer and fourth largest exporter of tobacco in the world [4];
• Tobacco in India generates nearly Rs. 20 billion of income per annum at the farm, state and central government levels [5];
• In India an estimated 65% of all men and 33% of all women use some form of tobacco [2];
• Approximately 3.5 million people are engaged in tobacco cultivation in India [6].
The above statistics depict a flourishing tobacco industry in India.


Epidemiologic dimension of tobacco related diseases in India.
• Around 9-lakh people die in India every year due to tobacco related diseases (The Hindu, June 5 2001);
• Tobacco related cancers account for nearly half of all cancers among men and one-fourth among women [2];
• India has one of the highest rates of oral cancers in the world;
• Oral cancer accounts for one-third of the total cancer cases in India, with 90% of the patients being tobacco chewers (http://www.cdc.gov/tobacco/who/india.htm);
• An estimated 8.3 million cases of coronary artery diseases and chronic obstructive airway diseases are attributable to tobacco every year [2];
• The cost of tobacco related diseases in India amounts to 270 billion rupees every year and it far outweighs the economic gains from tobacco [7].

Consumption patterns (Indian scenario)
According to the 55th round (1999–2000) of the National Sample Survey (NSS) in India, 54% of tobacco consumers consume bidi, 15% consume cigarettes and 30% consume different chewing tobacco products.
(Both bidi and cigarette are two commonly used smoking tobacco products in India, bidi being the most popular. Bidi is much cheaper compared to cigarette and is used mostly by relatively poorer individuals. Bidi contains only a small amount of tobacco (0.15–0.25 g) compared to 1 g in cigarette. But it delivers as much as 45–50 mg of tar and 1.74–2.05 mg of nicotine compared to 18–28 and 1.55–1.92 mg of tar and nicotine respectively in Indian cigarette. Pan (betel–quid chewing) is a smokeless tobacco, which consists of betel leaf, areca nut, slaked lime, catechu and tobacco [7]. Many households use a combination of products. For example, households who consume bidi may also consume cigarette or some other tobacco products such as pan, tobacco leaf, zarda, etc)
The relative consumption of bidi and smokeless tobacco (pan) is more in rural areas than in urban areas. This could be because of the low unit value of the bidi and the low income of the rural population. Per capita number of cigarettes consumed is more in urban India than in rural India. One obvious reason could be the higher price of cigarette and relatively higher purchasing power of urban population.
In India, it has also been noted that general government expenditure on health as a percentage of total expenditure on health constitutes just 18% and the remaining 82% is private expenditure [8]. Moreover, nearly all the private spending in India is out-of-pocket at the point of service use, which is an inefficient way to finance health care that leaves people highly vulnerable [9]. Thus higher prevalence of tobacco use among the poor leads to further decline of the prevalent inequality in the poor income countries by way of an increased expenditure on tobacco-related diseases.
Thus the differential pattern in consumption clearly indicates that the target population for tobacco counselling and prevention need to be indivualized and address these issues. In addition the tobacco consumption habit of the urban household is showing a declining trend on the whole. Thus the need of the hour is to reinforce our efforts towards rural and semi urban population and devise strategies that target these subset of population, where media, advertisements and even health care may not be easily accessible.
Tobacco Cessation clinics
Considering the adverse health consequences, the potential addictiveness associated with tobacco and the health benefits accruing from tobacco cessation, health researchers have developed various models for tobacco cessation.
Tobacco Cessation Clinic (TCC), is an initiative by The World Health Organization (WHO) and the Ministry of Health, Government of India. The activities formally began with starting of 13 Tobacco Cessation Clinics in various states across India in 2002. Thereafter five more Tobacco Cessation Centers were established in other states.

The services offered at the clinic includes, individual intervention in the form of behavioural counselling, medication, and nicotine replacement therapy. At large, the Centres also intend to create awareness among the general public about the ill effects of tobacco. The awareness programs include exhibitions, preparation of information booklets/manuals aimed at specific populations (eg: consumers of tobacco/clinicians/general public), training programs on tobacco cessation for various professionals etc.


Need for cessation clinics – Rationale and Benefits
The tobacco cessation clinics were set up in diverse settings (cancer treatment centres, psychiatric centres, medical colleges and non-governmental organizations [NGOs]) to help people stop tobacco use.
Currently with an estimated 250 million tobacco users aged 10 years and above in India, the number of cessation centres is evidently inadequate. In addition, as mentioned earlier the prevalence of tobacco use is higher in rural population compared to that in urban areas; 73% of the population lives in rural India.
Since the year 2002, 34,741 cases were registered across the eighteen TCCs in India. 92 per cent of those registered in the TCCs were men, and 8 per cent were women. 65 per cent of those registered used smokeless forms, and 35 per cent used smoking forms or both (smoking and smokeless forms of tobacco). The mean age of those seeking tobacco cessation services was 37 years.[10] Tobacco cessation services have been found to be feasible in Indian settings, with overall quit rate at 6 weeks being approximately 16%. This clearly showed that there was scope for further improvement.
Tobacco cessation is essential to reduce the mortality and morbidity related to tobacco use. It has been projected that by 2050, if the focus is only on prevention of initiation and not cessation, the result will be an additional 160 million deaths among smokers. The majority of tobacco-related deaths that can be prevented over the next 40 years will be among current smokers who can be persuaded to quit, according to projections by the WHO . They are guaranteed to bring health gains for the population for a relatively modest expenditure, and in the long term they reduce smoking-related health care costs, thereby releasing resources for other needs.
Cost-effectiveness analysis have shown that smoking cessation treatment compares favourably with routine medical interventions such as the treatment of hypertension or hypercholesterolaemia or preventive interventions such as papanicolaou smears. With conservative assumptions, smoking cessation interventions are considerably more cost-effective than many medical interventions. The widespread disaffection with smoking among smokers, combined with their tendency to be deluded about how easy and quick it will be to stop, justifies extra urgency in promoting chances to stop.[11]
Tobacco cessation will provide the most immediate benefits of tobacco control and maximize the advantage for a tobacco user who quits the habit. It is also established that a majority of smokers (as many as 70%) desire to quit, but only 30% actually try each year, and only 3%. 5% actually succeed in quitting.
A recent meta-analysis of 7 studies by the Clinical Practice Guideline Panel reported an abstinence rate of 8% when no cessation advice was given, compared with 10% with cessation advice. In some more severely dependent individuals, pharmacological interventions may have to be used. When used alone, they can produce quit rates of about 25% but when combined with behavioural interventions the quit rates can go up to 35%. Tobacco (nicotine) dependence treatment involves a mix of pharmacological and non-pharmacological interventions. Smoking cessation clinical practice guidelines was originally published by the Agency for Healthcare Research and Quality (AHRQ)
A tobacco cessation intervention at an individual level is usually undertaken after a thorough assessment of the intensity of use. The Fagerstrom Test of Nicotine Dependence is a commonly used instrument for this purpose. Depending on these variables, intervention programmes can be individually tailored. It has been estimated that less intensive interventions such as simple advice by a concerned physician can produce quit rates of 5%.10% per year in some individuals.
Psychosocial interventions
The initial goal of psychosocial intervention is to increase motivation, initiate a quit attempt and help the patient quit for a short period. The main goal of psychosocial intervention in tobacco cessation is sustained abstinence, change of lifestyle and improved quality of life.
Three types of counselling and behavioural therapies have been found to be especially effective, and are recommended for all patients who are attempting tobacco cessation:
. Providing practical counselling (problem solving/ skills training)

. Providing social support as part of the treatment (intra-treatment social support)



. Providing help in securing social support outside of treatment (extra-treatment social support ).

Self-help approaches
The two basic modalities of psychosocial interventions, i.e. brief and extended, have the commonality of being therapist mediated. A third and novel approach in psychosocial intervention is self-help approaches include self-help material and self-help groups.
Self-help material: Written manuals are the most common forms of self-help material, although computer and video versions are also available. The major goals of self-help materials are to increase motivation and impart cessation.
Self-help groups: These mostly operate on the principles laid down by the world.s largest selfhelp group, i.e. the Alcoholics Anonymous (AA). Several organizations such as Nicotine Anonymous have outlined how to apply the 12- step model to quit smoking.

Pharmacotherapy
Current recommended pharmacotherapy for nicotine cessation consists of nicotine replacement therapy (NRT) and the use of the atypical antidepressant bupropion. Extensive randomized, double-blind, placebo controlled clinical trials have established the efficacy and safety of NRTs and bupropion in the treatment of nicotine dependence, by increasing the quit rates by approximately 1.5.2-fold, irrespective of the setting
Since the problem of tobacco in India is complex, in view of the varied nature of tobacco use, the government has realized that the control of tobacco can effectively be carried out only with a multisectoral approach, involving the various concerned sectors. Strategies for different sectors are being identified for effective tobacco control in the community, which would help in planning the national strategy for tobacco control in India.
Tobacco cessation cannot succeed as an isolated programme. It has to be designed and implemented as part of a comprehensive tobacco control strategy. This must include the preventive, curative and rehabilitative aspects of care. A bold step in this regard is the setting up of TCC but this endeavour must be extended. Capacity-building strategies for the identification and management of tobacco use and disorders related to its use must be made available through the existing health care facilities. There must be a provision for adequate therapeutic interventions, including the availability of replacement therapies for tobacco dependence.
More often than not, tobacco interventions address mainly men who are smokers. It is important that cessation activities also address chewers, both men and women, as well as women smokers. Other groups such as the elderly, adolescents and patients with psychiatric illness may require special interventions.
Education regarding tobacco awareness and cessation should be imparted first to educators for effective prevention of tobacco initiation. With the expanding network of NGOs at every district level, the cessation movement should be able to take giant strides.
The major challenge for India in the twenty-first century is to make early tobacco use cessation treatment available to all tobacco users, evolve treatments that are culturally relevant and appropriately tailored to individuals and the population, and view tobacco cessation in the wider picture of prevention activities.[11]

Need for Mobile Clinics In Areas of Poor Accessibility
Despite having health posts, regional and district hospitals in India, there is still poor accessibility to health care. As high as 75% of Indian population is rural and people have limited access to health care and travelling to a smoking cessation clinic far away is not practicable.
A more accessible service should encourage more people to utilize the service and benefit from it. Mobile clinical service was useful in reaching the hard to reach population in other settings. In addition, constructing cessation clinics is costly and subsequently finding appropriately qualified personnel to man them is difficult as some may not want to remain in a particular village or post long term. Several organisations do use mobile health clinics to access target groups with the inability to access health care. By extrapolating this strategy towards cessation clinics we may be able to reach a wider set of tobacco consuming population, especially those with poor accessibility.
A recently published paper by Abdullah et al (BMC Geriatrics, 2008) has successfully shown the feasibility of this approach. This programme was set up in Hong Kong, mainly targeted towards the elderly smoking population with limited accessibility to cessation clinics. The mobile team included a coordinator and 3 trained smoking cessation counsellors. The mobile smoking cessation programme included health talks, assessment of clients' smoking status and nicotine dependence level, provision of individually tailored behavioural counselling, prescription of nicotine replacement therapy, NRT (patch only),and arrangements for follow up (telephone and on-site). In this program a social worker, if available, was invited in each of these centres to act as the contact person. These social workers were trained on basic smoking cessation skills. The quit rates achieved (28%) with this approach were similar to the quit rates from adult smokers clients attending tobacco clinics and double the quit rates for the elderly population attending cessation clinics (10%), clearly demonstrating its utility value. This study has important public health implications. First, this is the first study to report promotion of smoking cessation programme through mobile service targeting the elderly smokers. Second, the low cost of the programme suggests that a mobile service could be promoted to attract more smokers in addition to the elderly. Finally, it would be useful to test the effectiveness and cost effectiveness of mobile smoking cessation service for other vulnerable population groups (such as pregnant women and young people) with limited accessibility.[12]
A similar approach using the mobile clinics was also utilized by the Anti-Smoking Awareness Society (Kafa), a non-profit group which tours Jeddah with promising results. The clinic also targeted educational institutes, government offices and private sector establishments. Kafa’s mobile clinic had, in the last four years, succeeded in helping more than 2,000 people quit smoking.
Hence there is sufficient evidence that mobile cessation clinics would be an optimal way for a better outreach. This could be a viable model, with the current scenario and prevailing tobacco habits in India.

Tobacco burden among the youth in India
Tobacco is used by the youth all over India with a wide range of variation among states.

  • Two in every ten boys and one in every ten girls use a tobacco product.

  • There is no statistical difference in rural-urban current tobacco use among students aged 13-15 years.

  • Many youth have the misconception that tobacco is good for the teeth or health.

  • Initiation to tobacco products before the age of 10 years is increasing.

  • States having higher levels of curricular teaching have a low prevalence of tobacco use by students. [11]

The Global Youth Tobacco Survey (GYTS), supported by the WHO and the Centres for Disease Control and Prevention (CDC), conducted during the years 2000- 2004, is the first survey that provides data on youth (13-15 years) for national and international comparison with standardized methodology.


Survey reveals that among 13-15 year old school going children, the current use of any tobacco product varies from 3.3% in Goa to 62.8% in Nagaland [13].
In this survey ‘ever tobacco use’ (ever consumed any tobacco product) was reported by one-fourth of students (25.1%); the prevalence ranged from 4.0% (Himachal Pradesh) to 75.3% (Mizoram).

  • 17.5% were current users of tobacco in any form (range: 2.7%–63%);

  • 14.6% were current smokeless tobacco users (range: 2.0%–55.6%);

  • 8.3% were current smokers (range: 2.2%–34.5%).

(GYTS 2000–2004)

The GYTS results revealed that over 68.5% (average) of students who smoked wished to quit smoking.


In Karnataka among college students, although female students interviewed were non-smokers, several suggested that in the future, smoking might be an acceptable behaviour among college going females [14].
The above data clearly indicates that the marketing effect of tobacco industry is overriding prevention strategies and our initiatives towards tobacco control were adjudged to have failed.

Reforms towards rebuilding tobacco free society
The education system can be optimally utilized to spread information, shape attitudes and strengthen skills as relevant to tobacco control. In this context, schools and colleges can be made arenas for public health action intended to prevent primary uptake of tobacco and to promote early cessation among those who have already acquired the habit. School-based tobacco prevention programmes that identify the social influences which promote tobacco use among the youth and teach skills to resist such influences can significantly reduce or delay adolescent smoking.
In contrast to the experience of western countries, where many teacher-led, school-based programmes for tobacco control have not been effective, there is considerable scope for such an approach in the Indian cultural context. In a country such as India, involving teachers in intervention delivery has proven to be very effective as teachers standpoints are given the highest priority by the youth when they are in school. This approach needs to be utilized and scientifically evaluated.
A well designed public education campaign that is integrated with community- and school-based programmes has been demonstrated to lower smoking among young people with effects lasting for a longer time [15]. In addition, it has been observed that; in India, students in whom school-based interventions were carried out were less likely to receive offers, experiment with or intend to use tobacco [16].
It has also been demonstrated that students who were exposed to the media plus school interventions were found to be at lower risk for smoking than those only receiving school interventions. A 1992 study found that a five year intervention involving a media campaign, community programmes, and school-based instruction resulted in significantly lower smoking rates. At the end of high school, just 14.6% of students in the intervention community were weekly smokers, compared to 24.1% of those in the control community. Further to this discussion, a 1997 study found that, in terms of cost per years of life gained, mass media and education campaigns are currently among the most cost-effective methods available to prevent or reduce tobacco use [17].
In 1998 an appeal was signed by over 25,000 school students of Delhi and submitted by the representatives of the Student Health Action Network (SHAN) to the Prime Minister of India. This appeal urged the Prime Minister to initiate measures to usher in a tobacco-free society and to start that process by imposing a comprehensive ban on all forms of tobacco advertising. These youth initiatives show a positive trend and increasing awareness among students, which need to be reinforced and, information on tobacco hazards disseminated to a larger student population both in rural and urban areas.
Yet another dimension to the current tobacco crisis is child labour being utilized for tobacco cultivation. In India, according to a report by an advocacy group, Global March Against Child Labour, New Delhi, an estimated 20,000 children work in tobacco farms and another 27,000 children work in beedi-making or packing cigarettes. Tobacco engages the land for a longer period than other crops, and utilizes labour-intensive practices, irrespective of the farm size. This is also reflected in the high rates of absenteeism from school seen during the tobacco planting, harvesting and curing seasons. Child labour and hired labour exploitation has also been rampant [18].
The present concept of mobile tobacco cessation clinic can be looked as an innovative step forward in reaching the youth population. These mobile clinics and their interventions would primarily target the vulnerable youth sections and empower youth with the knowledge, motivation and skills required to abstain from or abandon the use of tobacco habit. These clinics could also work towards the creation of suitable environments to stimulate, support and sustain healthy lifestyle choices (such as tobacco free norms at schools, worksites, homes, etc.).

References

[1] World Bank. Curbing the epidemic: governments and the economics of tobacco control.Washington, DC, USA:World Bank; 1999.


[2] Shimkhada R, Peabody J. Tobacco control in India. Bulletin of the World Health Organisation 2003;81(1):48–52.
[3] Subramanian SV, Nandy S, Kelly M, Gordon D, Smith GD. Patterns and distribution of tobacco consumption in India: cross sectional multilevel evidence from the 1998–99 national family health survey 2004;328:801–6
[4] Sundaram S. Tobacco amid controversy. Facts for you 2003; 23(6).
[5] ILO. Employment trends in the tobacco sector: challenges and prospects. International Labor Organization. Report for discussion at the Tripartite Meeting on the Future of Employment in the Tobacco Sector, Geneva; 2003.
[6] Rowena J, Gale HF, Capehart TC, Zhang P, Jha P. The supplyside effects on tobacco control policies. Oxford University Press; 2000..
[7] Mudur G. India finalises tobacco control legislation. British Medical Journal 2001;322:386.
[8] UNDP. Human development report. United Nations Development Program; 2004.
[9] Peters DH, Yazbeck AS, Sharma RR, Ramana G, Pritchett LH, WagstaffA. Better health systems for India’s poor. Finding analysis and options. Washington, USA: The World Bank; 2002.
[10] http://www.thaindian.com/newsportal/health1/scaling-up-clinic-based-tobacco-cessation-in-india_100166369.html ( accessed on 23/08/2009)
[11] Reddy KS, Gupta PC. Report on tobacco control in India. Ministry of health & Family welfare, Govt. of India. 2004
[12] Abdullah ASM et al. Effectiveness of a mobile smoking cessation service in reaching elderly smokers and predictors of quitting. BMC Geriatrics 8:25;2008.

[13] The Global Youth Tobacco Survey Collaborative Group.Tobacco use among youth: A cross country comparison.Tobacco Control 2002;11:252.70.


[14] Gavarasana S, Doddi VP, Prasad GV, Allam A, Murthy BS. A smoking survey of college students in India:Implications for designing an antismoking policy.
[15] Vertiainen E. Paavola M, McAlister A, et al. Fifteen year follow-up of smoking prevention effects in the North Karelia Youth Project. American Journal of Public Health 1998;88:81.5.
[16] Reddy KS, Arora M, Perry CL, Nair B, Kohli A, Lytle LA, et al. Tobacco and alcohol use outcomes of a school-based intervention in New Delhi. American Journal of Health Behavior 2002;26:173.81.
[17] Public education reduces tobacco use. Available from URL:

http://www.tobaccofreekids.org/research/factsheets/index.php


[18] Anon. Worst forms of child labor, global march against child labor. Available from URL: http://www.globalmarch.org/worstformsreport/world/worst-form.html.


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