The Indian Tobacco Control Act: A Public Health Imperative

1. The Indian Tobacco Control Act: A Public Health Imperative Dr. K.S. Reddy Hony Executive Director, HRIDAY

2. CIGARETTE SMOKE CONTAINS 4000 POISONS

3. 1 tobacco related death every 6 seconds WHAT IS AT STAKE? = 10 million annual deaths by 2030 1 Billion deaths in 21st Century

4. Global Tobacco Toll • Tobacco toll rising globally: 5 million in 2002 to 10 million in 2030- WHO • Developing Countries increasingly vulnerable: 7 million deaths in 2030- WHO • 700 million children worldwide are forced to passively breathe tobacco smoke • 1.69 million due to cardiovascular diseases • 1.47 million due to all tobacco related (0.83 million due to lung cancer) • 1 million due to chronic obstructive pulmonary disease.

5. Health Consequences of Tobacco Use • Tobacco chewing in its various forms is directly responsible for cancers of the oral cavity, oesophagus, pharynx, cervix, penis. • Beedi and cigarette smoking cause oral, pharyngeal, oesophagael, laryngeal, lung, stomach, gallbladder, urinary bladder and penile cancers. • Tobacco use is a major known risk factor for cardiovascular diseases. • Tobacco smoking is responsible for over 82% of chronic obstructive pulmonary disease. • Tuberculosis is a major cause of death in India and it is three times as great among smokers than non smokers. • Men who smoke have a lower sperm count and poorer sperm quality than non smokers • Tobacco use is also associated with oral precancerous lesions such as leucoplakia and other oral mucosal lesions.

6. TOBACCO AND CANCERS • Lung • Mouth (oral) • Throat (Pharynx & Larynx) • Food Pipe (Oesophagus) • Urinary Bladder • Other Sites

8. CARDIOVASCULAR RISKS OF SMOKING 100% Increase in Risk Stroke; CHD; Impotence 300% Increase in Risk Death from undiagnosed CHD > 300 % Increase in Risk Peripheral Arterial Disease 400 % Increase in Risk Aortic Aneurysm

9. OTHER DISEASES • Chronic Bronchitis • Emphysema • Asthma • Cataract • Tuberculosis • Diabetes • Still Birth and Low Birth Weight > 25 Diseases

10. PASSIVE SMOKING (ETS) • Second Hand Smoke increase risk of • Cancer by 30% • Heart attack by 25% in spouse of the smoker • Increased risk of asthma and lung disease in children

11. Economic Effects of Tobacco Use • The total social costs of tobacco products exceed the direct outlay on them, owing to morbidity, mortality and negative externalities associated with the consumption of tobacco products. • The costs inflicted by tobacco consumption extend much beyond the direct users to cover secondary smokers as well as non-users. • The recognition of the costs of tobacco has been obfuscated and made opaque by the unethical tactics and practices by the tobacco lobbies. • Worldwide recognition of the perils of the pandemic of tobacco have led to the recognition of tobacco as a demerit good, i.e. a public ‘bad’.

12. Cost of Tobacco related Cancer

13. ECONOMIC COSTS OF TOBACCO Health Care: Just for 3 diseases (Coronary Heart Disease; Cancer; Chronic Lung Disease) Health Care cost in 2002 – 2003 was Rs. 308.33 Billion (USD 7.2 Billion) Tobacco also has: Environmental costs & Social costs

14. PrevalenceOf Tobacco Use Among The Youth - INDIA Global Youth Tobacco Survey (GYTS) conducted among school going youth (aged 13-15) during 2000-2004 in India: • Ever tobacco use : 25.1% • Current tobacco use: 17.5% • Current smokeless: 14.6% • Current smoking: 8.3% • Current cigarette smoking: 4.2% Results support the need to prevent youth from initiating tobacco habit and provide the evidence base for the provisions of Indian Tobacco Control Act, 2003

15. Differences in prevalence of tobacco use between sixth-grade and eighth-grade students (n=11642) : MYTRI STUDY - (The Lancet, 2006; 367: 589-594

16. Government Initiatives towards Tobacco Control Laws to Curb the Problem • Cigarettes Act is passed with first statutory health warning, 1975 • States like Delhi, Goa and a few more had created their own tobacco control laws • Kerala High Court and Supreme Court had given momentous decisions in favour of tobacco control policies • Prevention and Control of Pollution Act included smoking in the definition of air pollution, Motor Vehicles Act of 1988 made it illegal to smoke in a public vehicle and Cables Television Network Amendment Act of 2000 prohibited the transmission of tobacco commercials on cable TV across the country. • The Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COTPA), a comprehensive tobacco control legislation, comes into force on 1st May 2004 • India ratified FCTC on 5th February 2004.

17. The Cigarettes and Other Tobacco Products Act, 2003: Significance to Public Health • Section 4: Ban on Smoking in Public Places • Secondhand smoke (passive smoking) of smoke causes many diseases like lung cancer, respiratory diseases, heart disease, breast cancer, asthma, bronchitis. In some cases, it can trigger severe, even life-threatening reactions in individuals. • Children are the worst affected. It causes sudden infant death syndrome. • People working, especially in the food service industry are affected. • Ban on smoking in public places would prevent damage to the health of non smokers and smokers

18. Contd.. • Section 5: Ban on Advertisements of Tobacco Products • In India children and the youth have been greatly influenced by tobacco advertisements, especially those for cigarettes and gutka which definitely harms their health. • Advertisements and placing of the product at a low height and next to candies at points of sale is a strategy they use to give undesirable exposure and access to children. • A study found that children who had seen sports events being sponsored by a tobacco company were more likely to start smoking. This was during the period when a cigarette company sponsored cricket matches. • Many tobacco industries are promoting tobacco products to target women. • This provision would prevent women and children from being influenced by glamorized advertisements of tobacco products.

19. TRENDS IN WEIGHTED CIGARETTE CONSUMPTION PER CAPITA IN COUNTRIES WITH A COMPREHENSIVE BAN COMPARED WITH NO BAN Source: World Bank Report, 1999

20. Contd.. • Section 6: Prohibition of Sale of Tobacco Products to and by Minors • Many children in India experiment with tobacco at an early age and become addicted thereafter. • Individuals who use tobacco from a young age are more likely to suffer from serious diseases earlier than others and die prematurely • Sale by a minor gives a message to that child, as well as to other children, that it may be all right to use tobacco. • Adolescents out of school are more likely than other youth to sell tobacco. • This would restrict access of tobacco products to youth and children

21. Contd.. • Section 7: Specified Health Warning Labels on all Tobacco Products • Images help smokers visualize the nature of tobacco-related diseases and convey health messages in a clearer way. • Pictorial health warnings are intended to serve as visual cues to prompt smokers to take action to quit. They are designed to shock people into realizing that smoking kills and causes serious illness. • Pictorial warnings also make the health warnings accessible to those who are illiterate. • They are effective tool in conveying health risks to the tobacco users. It also has an impact on intention and ability to quit. • In countries like Brazil, Canada and Thailand many pictorial warnings have helped in decreasing consumption of tobacco products

22. Contd.. • Section 7(5): Every tobacco package to have nicotine and tar contents along with the maximum permissible limits • Nicotine and tar are carcinogens • Nicotine and tar contents along with permissible limits should mentioned on the packages • Having them on the package would help people making an informed choice

23. Contd.. • Increasing Tax and Price of Tobacco Products • Price and tax measures are an effective and important means of reducing tobacco consumption by various segments of the population, in particular young persons. • Implementing tax policies and price policies, on tobacco products would contribute to the health objectives aimed at reducing tobacco consumption. • This measure acts as a demand reduction measure for tobacco products.

24. PRICE INCREASE OF 10% IMPACT ON SMOKERS ALIVE IN 1995 Change in Change in Grouping number of smokers number of deaths (millions) (millions) Low/middle -36 -9 Income High Income -4 -1 World -40 -10 Source: World Bank Report, 1999

25. TOBACCO Evidence is available from many countries (including LMIC) that Taxation Ad Bans Smoke Free Policies Health Warnings ARE EFFECTIVE 48.1% of mortality averted in UK (1981-2000) is attributable to reduced smoking(Unal B et al. Circulation 2004) POWER OF POLICY FOR CHRONIC DISEASE PREVENTION

26. TOBACCO CONTROL POLICIES WORK • Ban on smoking in bars: 80% reduction in salivary cotinine levels of bar staff (BMJ 2005; 331:1117-22) • Graphic warning labels have impact on smoking cessation (Tobacco Control 2003; 12:391-95) • Reduced incidence of admissions for myocardial infarction after public smoking ban (BMJ 2004; 328:977-80)

27. Thank You