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| | | Year : 2007 | Volume : 18 | Issue : 1 | Page : 2-5 | | | Tobacco control in India | | | Preetha Elizabeth Chaly
Department of Preventive and Community Dentistry, Meenakshi Ammal Dental College and Hospital, Alapakkam Main Road, Maduravoyal, Chennai - 95, India
Click here for correspondence address and email | Date of Submission | 17-Feb-2006 | | Date of Decision | 09-Oct-2006 | | Date of Acceptance | 16-Oct-2006 | | |      | |  Abstract | | | Portuguese introduced tobacco to India 400 years ago. Ever since, Indians have used tobacco in various forms. Sixty five per cent of all men and 33% of all women use tobacco in some form. Tobacco causes over 20 categories of fatal and disabling diseases including oral cancer. By 2020 it is predicted that tobacco will account for 13% of all deaths in India. A major step has to be taken to control what the World Health Organization, has labeled a 'smoking epidemic' in developing countries. India's anti-tobacco legislation, first passed in 1975, was largely limited to health warnings and proved to be insufficient. A new piece of national legislation, proposed in 2001, represents an advance including banning smoking in public places, advertising and forbidding sale of tobacco to minors. Preventing the use of tobacco in various forms as well as treating nicotine addiction is the major concern of dentists and physicians. The dental encounter probably constitutes a "teachable moment" when the patient is receptive to counseling about life- style issues. Both policy makers and health professionals must work together for achieving a smoke free society for our coming generations. Keywords: Tobacco, tobacco cessation, tobacco industry, tobacco legislation, tobacco use How to cite this article:
Chaly PE. Tobacco control in India. Indian J Dent Res 2007;18:2-5 |
| Introduction | |  |
Tobacco was introduced to the world by Christopher Colombus, who discovered tobacco among the treasures of the New World in 1492. Later the followers of Colombus, the Portuguese and the Spanish sailors carried it to all the parts of the world in the late 15th century.
"Chewing tobacco is tobacco's body, smoke is it's ghost and snuff is tobacco's soul". The American-Indians were apparently the first to use tobacco in various forms. They chewed, smoked and sniffed it through their nostrils. Tobacco was smoked in pipes for ceremonial and medicinal purposes and as a symbol of goodwill that is the "peace pipe". They used tobacco to relieve toothache, to treat ulcers and skin wounds, diseases of the lungs, spleen and womb, insect bites, as an antifatigue agent and as a tooth- whitening agent. These medicinal properties that the American Indians believed tobacco possessed, was the main reason for its introduction in into Europe.
Initially Europeans heralded it as a medical marvel. It wasn't long however before smoking was recognized as a health hazard. In 1604, King James I of England issued the first official condemnation of tobacco, "A counterblast to tobacco" in which he warned his subjects that the "habit of smoking tobacco is disgusting to sight, repulsive to smell, dangerous to brain and noxious to the lung". Since then a lot of reports have been published on the effect of tobacco.
| Tobacco use in India | | |
The Portuguese introduced tobacco to India 400 years ago and established the tradition of tobacco trade in their colony of Goa. Two hundred years later the British introduced commercially produced cigarettes to India and established tobacco production in the country.
Present scenario of tobacco use in India
In 1997, World Health Organization (WHO), reported the prevalence tobacco habits in India to be, Bidis (34%), Cigarettes (31%), Chewing tobacco (19%), Hookah (9%), Cigars-cheroots (5%), and Snuff (2%).[1]
But the data reported by cancer patients aid association of India in 2004, reveals the prevalence to be cigarettes (20%), bidis (40%) and the remaining 40% is consumed as chewing tobacco, pan masala, snuff, gutkha, masheri and tobacco toothpaste. These two statistics reveals the changing pattern of tobacco consumption in India.
16.6% of the smokers live in India. Sixty-five per cent of all men and 33% of all women use tobacco in some form. 35% of men and 3% of women smoke.[2]
| Health consequences of tobacco consumption | | |
The use of tobacco is harmful to general health, as it is a common cause of addiction, preventable illness, disability and death. The use of tobacco causes an increased risk of oral cancer, periodontal disease, oral mucosal lesions and other deleterious oral conditions and it adversely affects the outcome of oral health care including esthetics. It has been scientifically proved that tobacco causes over 20 categories of fatal and disabling diseases including cancer, cardiovascular and chronic respiratory diseases.
In India, in 1990, 1.5% of total deaths were tobacco related. Tobacco consumption is growing at a rate of 2-3% per annum. By 2020, it is predicted that it will account for 13% of all deaths in India.[2]
Smokeless tobacco is an important etiological factor in cancers of the mouth, lip, tongue and pharynx. India has one of the highest rates of oral cancer in the world. 65% of all cancers in men and 33% of all cancers in women are tobacco-related. Annual incidence of oral cancer is said to be 10 per 1,00,000 of males.[2]
| India's Tobacco Industry and Market | | |
India is world's third largest tobacco growing country. The liberalization of trade has contributed to a growth in tobacco consumption. Bidi manufacturing is the largest tobacco industry in India. In 1998, a total of 858 billion bidis were sold in India and sales are projected to reach 1031 billion by 2007. Gutkha and panmasala have become increasingly popular with young people. These mixtures, containing arecanut and flavoured additives are sold in colorful small sachets for as low as half a rupee. The four Indian tobacco companies are Indian Tobacco Company, Godfrey Phillips Ltd. Tobacco, Golden Tobacco and National Tobacco. These companies face significant competition from the unorganized bidi manufacturers, which are largely protected from high taxes because of their status as small-scale industry.
| Tobacco Legislation in India | | |
India has a short history of tobacco-related legislation. The first national level bills were introduced not to curtail but to build a foundation for the tobacco industry and enable it to be competitive in the international market. Only recently has there been significant impetus to come up with a multifaceted national control measure.
At central level
The legislation dates back to 1975 when the Tobacco Board Act was introduced to develop the tobacco industry, which facilitated regulation of production and curing of tobacco, fixed minimum prices and provided subsides to tobacco growers. Again in 1975, Cigarettes Act of 1975 was passed. It was India's first national level anti- tobacco legislation and prescribed all packages to carry the warning "Cigarette smoking is injurious to health". Prevention and Control of Pollution Act was introduced in 1988, which included smoking in the definition of air pollution. The Motor Vehicles Act of 1988 made it illegal to smoke or spit in a public vehicle.
The Cable Television Networks Amendment Act of 2000 prohibited the transmission of tobacco commercials on cable television across the country. In February 2001, Indian prime minister Vajpayee's union cabinet introduced Cigarettes and other Tobacco Products Bill. This was a multifaceted anti-tobacco legislation to replace the Cigarettes Act of 1975. According to this bill, smoking in public places would be outlawed, sale of tobacco to people under 18 years of age would be prohibited, tobacco packages required to have warnings and it also prohibited tobacco companies from advertising and sponsoring sports and cultural events.[2]
This bill covers most tobacco products like cigarettes, cigars, bidis, cheroots, pipe tobacco, hookah tobacco, chewing tobacco, panmasala and gutkha. A first time offender will result in a fine of rupees 200 and a second time offender will result in a fine of rupees 1,00,000 and imprisonment for up to three years.
At state level
Delhi was the first to impose a ban on smoking in public. In 1996, Delhi Prohibition of Smoking and Non- Smokers Health Protection Act was passed. This act prohibited sale of cigarettes 100 meters from the school building and to minors. The offender was fined a sum of rupees 100. But it was difficult to enforce this act and had little real impact, the key problem being lack of manpower to enforce the law. In 1999, Kerala High Court came out with a judgement prohibiting smoking in public places, including parks and highways and Goa banned smoking in public places through anti-tobacco legislation. For the past three years, Tamil Nadu and Andhra Pradesh have banned the marketing and sales of gutkha.[2]
Additional steps that could be taken to curb the demand include increasing tax on all tobacco products, control smuggling, closure of all advertising avenues and creation of an infrastructure for enforcement of laws.
| Role of Health Professionals | | |
The major goal for the members of health profession is to use their knowledge and skills to contribute to control what the WHO, has labeled a 'smoking epidemic' in developing countries.[1]
Prevention against the diseases that come with tobacco usage is based primarily on public and individual education to drop the habit or preferably not to begin in the first place. Some of the steps to be taken as suggested by WHO include:[1]
1. Preventing children from becoming addicted to tobacco
More than 80% of adults who use tobacco, started using it before the age of 18 years and it easily produces nicotine dependency, the risk of which is underestimated. Action should be taken to educate people about the use of tobacco focussing not only on primary prevention, that is not only on discouraging young people from taking up the habit but also on providing help and support for those who wish to quit smoking. Family doctors, can play a pivotal role in this endeavor. Prohibition on offering free samples of tobacco products and prohibition of sale of single cigarettes will help in preventing children from getting into the habit of using tobacco.
2. Providing effective protection from involuntary exposure to tobacco smoke
In indoor locations, it is necessary either to prohibit smoking entirely or to restrict smoking to a few separately ventilated smoking areas. Many jurisdictions have laws that ban or restrict smoking in public places, workplaces and transit vehicles.
3. Providing effective programme of health promotion and health education
These include the celebration of no tobacco days, use of paid media advertising, school-based and community-based health promotion programmes and sponsorship of cultural, sporting and community events.
4. Effective smoking cessation progamme
The best smoking cessation strategies will include the training of all health professionals, including doctors, nurses, pharmacists and dentists, in the technique of providing smoking cessation counseling and advice. It would also be desirable to make available a broad range of smoking cessation strategies, including group counseling, physician advice and where appropriate nicotine replacement therapy like chewing gum or replacement therapy patches (Nicorette 15 mg).
5. Prominent health warnings on tobacco product packing
Warnings to be used on all kinds of tobacco products. Strong uncompromising messages such as "Smoking Harms Your Family", "Smoking Causes Cancer", "Cigarettes are Addictive", "Smoking Causes Heart Disease" and "Tobacco smoke causes fatal lung disease in non-smokers", are displayed in black on white or white on black format occupying 20% or more of the largest surfaces of packages of tobacco products.
6. Progressive elimination of tobacco advertising
Includes general prohibition of use of names of tobacco products, trademarks and logos in advertising. It also includes prohibition of sponsoring of cultural events or contests by tobacco importers, manufacturers, wholesalers and retailers or their agents.
7. Financial measures to discourage tobacco consumption
Studies have shown that for every 10% increase in the price of tobacco products, consumption can be expected to decline by 2-8%.[1] The two key target groups are the adolescents and people of lower socioeconomic status. Tobacco taxes can serve many useful purposes like reducing consumption, increasing government revenue.
| Role of Dentist in Tobacco Control Measures | | |
The scope of preventive dentistry is constantly expanding and can be as far reaching as a professional's imagination, sense of responsibility and efforts. Dentists have been recognized as "ideally positioned to counsel against the use of cigarettes and smokeless tobacco products." They can relay specific information concerning the oral ill effects of tobacco use. The dental encounter probably constitutes a "teachable moment" when the patient is receptive to counseling about life-style issues. Because of his expertise in dental and oral matter a dentist makes a unique and important contribution to the smoking withdrawal programme. Oral health professionals should integrate tobacco use, prevention and cessation services into their routine and daily practice. They should participate in lectures, demonstrations and assist in group discussions.
Recommendation for brief interventions in a dental office settings for patients who use tobacco
A four-step approach referred to as the "four A's" in dental office setting will help patients in tobacco cessation.[3] The dentist will first ASK the patients about tobacco use (frequency, whether attempts were made to quit and if he is interested in quitting). Following which he will ADVISE tobacco using patients to quit, citing appropriate reasons specific to the individual and concentrating on any of the patient's current dental problems that may be aggravated by smoking (stained teeth). Next step is to ASSIST those who are interested in quitting by helping the patient select a quit date, provide self-help materials, consider prescribing nicotine gum, transdermal patches, especially for highly addicted patients. Last but not the least he should ARRANGE patient follow-up services by setting a follow-up visit within one to two weeks after the quit date, having an office staff member call or write to the patient within seven days after the initial visit, reinforcing the decision to stop and reminding the patient of the quit date and setting a second followup within one to two months.
Strategies to be used by dental students to assist their patients to quit smoking
All oral health institutions and all continuing education providers should integrate tobacco-related subjects into their programmes. It has been argued that the professional skills required by the dentists to provide smoking cessation counseling to their patients ideally should be learnt during the dental curriculum and reinforced within continuing education.[4] Dental schools should have a curriculum addressing relevant counseling techniques. The strategy could include the following like asking patients if they smoke, counsel smoking patient about the oral effects of smoking related to their own health, advise smoking patients to quit, provide written information and self-help material about how to quit smoking, suggest nicotine replacement therapy to patients who wish to give up smoking and arrange follow-up visits to discuss smoking.
Barriers mitigating provision of smoking cessation counseling
- Many smoking patients do not have the motivation to quit.
- Health professionals do not have sufficient skills to provide smoking counseling.
- Dentists do not consider smoking counseling part of the their professional role.
- Dentists do not have time to provide smoking cessation counseling during clinical consultations.
- A myth among dentists that giving unwanted smoking cessation counseling may upset the dentist-patient relationship.[4]
| Conclusion | | |
Humans have used tobacco for 1000 years. Tobacco in its various forms has provided powerful and immediate satisfaction to its users. These gratifications are pharmacological, psychological, emotional and social in nature. Once introduced, its use seldom has been eliminated even by legal or religious prescription. The use of tobacco kills millions of people and ruins the health of millions more. Clearly, preventing the use of tobacco in various forms as well as treating nicotine addiction is the major concerns of dentists and physicians. Today, we the members of the health profession along with policy makers should help in achievement of a smoke-free society so that we can protect the health of the coming generations.
| References | | |
| 1. | WHO. Tobacco or health: A global status report. WHO publication: Geneva; 1997.  | | 2. | Shimkhada R, Peabody JW. Tobacco control in India. Bull World Health Organ 2003;81:48-52. [PUBMED] [FULLTEXT] | | 3. | Watt RG, Daly B, Kay EJ. Prevention. Part 1: Smoking cessation advice within the general dental practice. Br Dent J 2003;194:665-8. | | 4. | Rikard-Bell G, Groenlund C, Ward J. Australian dental students' views about smoking cessation counseling and their skills as counselors. J Pub Health Dentist 2003;63:200-6. [PUBMED] |
Correspondence Address:
Preetha Elizabeth Chaly
Department of Preventive and Community Dentistry, Meenakshi Ammal Dental College and Hospital, Alapakkam Main Road, Maduravoyal, Chennai - 95
India
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DOI: 10.4103/0970-9290.30913 PMID: 17347536
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