tobacco cessation in india

8/8/2019 Tobacco Cessation in India

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Tobacco wa s in t roduced in India by th e

Portu gu ese 400 years ago. Since then t obacco

consump tion continu ed to rise in Ind ia. It has

been estimated that th ere are 1.1 billion smokers

worldw ide an d 182 million (16.6%) of them live

in India1-4. It has been pred icted by the World

Health Organ isation (WHO) that m ore than 500

million p eople alive today w ill be killed by

tobacco by 2030 and tobacco consum ption willbecome the s ingle leading cause of death 5.

How ever, it is an irony that the tobacco use is

the major preventable cause of death w orldw ide

and that the cost-effectiveness of cl inical

smoking cessation interventions have been

reported 6. The International Classification of

Diseases (ICD-10) has recognised that tobacco

depend ence is a d isease7. But the med ical

profession has not taken a serious view of this

fact and has not mad e any serious attemp t to

t reat th e d isease , Tobacco d epend ence.How ever, i t is encouraging to note th at the

WHO and the Government of India (GOI) have

taken the init iat ive for effective tobacco

control8,9.

Tobacco is u sed for sm oking a s well as in

smokeless forms in India. Amon g th e tobacco

users, bidi smok ers constitut e 40%, cigarette

smokers 20% and those using sm okeless forms

40 percent. The prevalence of tobacco use in

1993-94 was 23.2% in m ales (any age) and 4% in

females (any age) in u rban areas, 33.6% in m alesand 8 .8% in females in rura l areas 10. The

National Family Health Survey (India) had

revealed th at individu als with no edu cation

were 2.69 times m ore likely to smoke and chew

tobacco than those wi th pos tg radua te

education 11. This stud y had also shown th at

households belonging to the low est fifth of a

stand ard living ind ex were 2.54 times more

likely to consu me tobacco than th ose in the

highest fifths11. Thus, illiteracy and poverty were

associated with tobacco consumption in India.

EDITORIAL

Tobacco Cessation in India

[Indian J Chest Dis Allied Sci 2005; 47: 5-8]

In a survey of Delhi college students, it has been

observed that 83% of male and 87% fema le

studen ts started smoking for fun and pleasure

and 94 to 98% s tudents w ere aware of the

harmful effects of smoking, the benefits of

qui t t ing and the ban of smoking in pu bl ic

places. Majority felt that education of public will

have an imp act on tobacco cessation (personal

observation).

Despite increasing awareness to the harm ful

effects of tobacco, smoking continu es to be a

s ignif ican t health r isk factor . I t has been

observed that 70% of smokers indicate that they

want to quit12. Stud ies have demonstrated that a

brief physician-delivered intervention (as brief

as three m inutes) for smoking cessation in

pr imary care setting significantly increases

patients smoking cessation rates 13. Smoking

cessation benefits men and w omen at any age

and heal th benef i ts are immediate andsubs tant ia l . Immed iate benefi ts includ e a

decline in carbon m onoxide levels in the blood,

returning of pulse rate and blood p ressure to

normal levels and improvements in the sense of

tas te and smel l14 . In indiv iduals wh o qui t

smokin g before the age of 50 years, the risk of

dy ing in th e next 15 years is half that of a

smoker. Even in persons who qu it at 60 to 64

years of age, the risk of dying is reduced by 10%

compared to regular smokers . Smoking

cessation greatly redu ces the risk for developingcancer. The risk of dying from lung cancer after

10 years in p ersons wh o qu it smoking is 30

35% of that for regular smokers . Smok ing

cessation also reduces the risk of acquiring a

second p rimary cancer. Smokers have twice the

risk of dying from Coronary H eart Disease

(CHD) and stroke compared to non-smokers

and the excess r isk of dying f rom CH D is

redu ced by half after one year of cessation. After

15 years , the CH D r isk is s imi lar to non-

smokers. The risk of dying from stroke also


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returns to non-smokers level in 5-15 years. The

r isk of recurrent hear t a t tacks and

cardiovascular deaths are markedly reduced

(50% or more) after smoking cessation. The rate

of decline in lung fun ction in COPD am ongformer smokers return s to that of never smokers

gradually, and smoking cessation d ecreases the

risk of influenza and p neum onia. The birth

weight of the infant w ill be the same as non -

smokers, if the m other stops sm oking before

becoming p regnant or w ithin 3-4 months of

pregn ancy. Even cessation at later stage of

pregnancy (up to 30 weeks) will lead to higher

birth weight than regular smokers. The average

w eight gain after sm oking cessation is five

pou nd s . H owever , the heal th benef its of smokin g cessation exceed th e risks from th e

weight gain . Smoking cessat ion is a lso

associated w ith concomitant favourable changes

in l ip id prof i le and body fa t depos i t ion .

Smoking cessation redu ces or eliminates th e risk

of passive smoking indu ced d iseases especially

in children: pn eum onia, bronchitis, middle ear

infect ions and exacerbat ions of bron chia l

asthma 14-17. In add ition, person al benefits of

smoking cessation include improved health,

better self-esteem, lower level of perceiveds t ress , good examples for thei r ch i ldren ,

healthier babies, mon ey savings and freedom

from addiction. Our aim shou ld, therefore, be to

help people stop smoking and to p revent people

from beginning to smoke.

Considering the social and economic impact

of tobacco consum ption, sm oking cessation

interventions are am ong the m ost cost effective

of al l medical interventions6. A supp ortive

environm ent for tobacco cessat ion can be

created by changing the commu nity norms,banning sm oking in workp laces, mass med ia

campaign and increasing the cost of cigarettes to

promote tobacco cessation, in addition to clinic-

based smoking cessation progra mm es. The

importance of pu blic health approach to tobacco

control at a minimal cost should be emp hasized.

The t rea tment of tobacco depend ence and

smoking cessation method s include behavioural

and ph arm acological therapies for smoking

cessation. Behaviou ral interven tions such a s

physician advice, self-help materials especially

individu ally tailored m aterials and proactive

telephone calls from a Counsellor, behaviour al

and psychological interventions, mass m edia

communication campaigns, telephone quit

l ines/ Internet-based services , quit and wincompetitions and smoke-free places are helpful6.

Treatment of n icot ine dependence has to

add ress the problem of tobacco-withdr aw al

symp toms. The p harm acologic agents that are

used for sm oking cessation includ e nicotine

replacement med ications and non -nicotine

medicat ions . The n icot ine replacement

med ications are transd ermal p atches, nicotine

gum s, nicotine lozenges, nicotine sub-lingua l

tablets, nicotine oral inh aler and nicotine nasal

spray6, 18. The non-nicotine medications that aredescribed include bup ropion hyd rochloride,

clonidine an d nortriptyline. Population-based

interventions to complement individual-based

behavioural or p harm acological interventions

are also essential19, 20. There is also a need to

prioritize cessation strategies according to our

national circum stances and resources available.

It is also to be emphasized that there is a need

for capacity building for smoking cessation and

treatmen t of tobacco dep end ence. Socia l

suppor t for qui t t ing , t ra in ing of heal thprofess ionals and in tegrat ion of smoking

cessat ion in o ther heal th programmes are

essential for successful imp lementa tion of

tobacco cessation programmes6, 19. The adop tion

of a WHO Framework Convention on Tobacco

Control (WH O FCTC) by the World H ealth

Assembly on 24th May 1999 is an imp ortan t

landmark to achieve comprehensive tobacco

control worldw ide21. Ind ia is the 7th coun try

that has ra t i f ied the WHO FCTC on 5 th

February 200422. In add ition, the WHO TobaccoFree Initiative encourages countr ies to d evelop

and strengthen strategies for tobacco control

measures. Thou gh, on a small scale in a coun try

like India, the Ministry of Health and Family

welfare , Governm ent of Ind ia has taken a

posit ive s tand and has op ened 13 Tobacco

Cessation Clinics all over India. In ord er to

strengthen th e tobacco control measur es, the

Governm ent of Ind ia has passed an anti-tobacco

legislation, The Cigarettes and Other Tobacco

Produ cts (Prohibition of Adv ertisement and

Tobacco Cessation in India V.K. Vijayan and Raj Kumar 6 ,


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2005; Vol. 47 The Indian Journal of Chest Diseases & A llied Sciences 7

Regulation of Trade and Comm erce, Production,

Sup ply an d Distribution) Act 2003, wh ich has

come in to force on 1st May 2004, and this Act

replaces the Cigare t tes (Regula t ion of

Produ ction, Sup ply and Distribution) Act of19759. Salient features of this new Act include

proh ibition of the ad vertisemen t of all tobacco

prod ucts and provision for its regulation in

trade and commerce, prohibition of smoking in

pu blic places, proh ibition of selling tobacco

products to persons below the age of 18 years,

identification of nicotine and tar contents on the

packets, ind ication of warn ing on the package in

English as well as in Ind ian languages and total

ban on sponsoring any sport/ cultural events by

cigarettes and other tobacco products com-pan ies . Smoking in pu bl ic p laces is mad e

pu nishable w ith a fine of up to Rs.200 w hile

advertisement of tobacco prod ucts w ill attract

imp risonment of up to tw o years or a fine of

Rs.1000 or both in case of first conviction. In th e

case of second or sub sequent conviction, the

imprisonment wou ld be up to five years and a

fine of Rs.50009.

In our country, the tobacco cessation

programm es will have to add ress the issues of

bidi smoking a nd smokeless forms of tobacco.Bidi man ufacturing is a cottage ind ustry in India

wi th many ch i ld ren and women ac t ive ly

engaged in its production23. In ad dition, Ind ia is

the w or lds th i rd larges t tobacco grow ing

indu stry with a great impact on the economy 3.

More than 400,000 hectares of land are

harv ested for tobacco and nearly 3.5 million

peop le are estimated to be engaged in full-time

tobacco man ufacturing 24. While imp lementing

tobacco control measures in India an d other

developing countr ies, we will have to take thesefactors into account.

V.K. Vijayan1 and Raj Kumar2

Director1 and Senior Lecturer2

Vallabhbhai Patel Chest Institute

University of Delhi, Delhi 110 007, India

E-mail: [email protected]

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Tobacco Cessation in India V.K. Vijayan and Raj Kumar 8 ,

tobacco cessation in india

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