Tobacco consumption is a huge public health issue in India and its impact is especially devastating among the poor. Effective tobacco control should be a top priority, both as a health issue and as a method to reduce poverty. Tobacco use is deeply ingrained as a cultural practice and there are a myriad of tobacco types. We reviewed multiple determinants of tobacco consumption including socio-economic status, marriage, population growth, marketing strategies, and price. We also considered the tobacco burden including economic and social costs and adverse health impacts especially those resulting from oral cancer. We then addressed the history of tobacco control legislation in India and challenges in implementation. Tobacco consumption in India is continuing to increase despite tobacco control policy. Needed are more visible and aggressive anti-tobacco campaigns including increased public awareness of tobacco harms and active engagement of worksites and health professionals in promoting tobacco cessation.
Databases searched include PubMed, EMBASE, CINAHL, Google Scholar using key words tobacco use in India, cigarettes, beedis, smokeless tobacco, tobacco control, and legislation policies, and wide probability of these words was used in a variety of combinations. Reports of Government of India and World Health Organization (WHO), news reports from Web sites, names of individual states in India were used with the above key words to obtain state-specific information. The cross references of the selected articles were also considered. Nationally representative surveys conducted by Government of India time to time with tobacco as the component and large-scale and local community-based studies on tobacco were all taken into consideration. Articles reporting findings of empirical studies and were extended to increase use of evidence-based prevention and intervention to maximize review data. Most of the studies included are those relevant to Indian subcontinent.
India is the second largest consumer of tobacco.
Males contributed 91% of the entire economic burden and remaining accounted for the females. SLT accounts for 66% of direct medical costs among the females. SLT has grown at an alarming rate in India, about one-fifth of the world’s total production and cultivation is done by India.
Hazards of tobacco use
Tobacco is deadly in any form either be smoking or smokeless; scientific evidences have proved that tobacco leads to disease, disability, and death. According to the International Agency for Research on Cancer (IARC) monograph, there is sufficient evidence in humans that tobacco smoking causes cancer of the lung; oral cavity; naso-, oro-, and hypo-pharynx, nasal cavity, and paranasal sinuses; larynx; esophagus; stomach; pancreas; liver; kidney (body and pelvis); ureter; urinary bladder; uterine cervix; and bone marrow (myeloid leukemia). Colorectal cancer is seen to be associated with cigarette smoking, although there is insufficient evidence for it to be causal. Ninety percent of all lung cancer deaths in men and 80% in women are caused by smoking. Research has clearly indicated causal associations between active smoking and adverse reproductive outcomes, chronic obstructive pulmonary disease, and cardiovascular diseases. Studies on bidi smoking, the most common form of tobacco smoking in India, provide evidence toward causality of it as carcinogenic substance. Case–control studies demonstrate a strong association of bidi smoking with cancers at various sites, such as oral cavity (including subsites), pharynx, larynx, esophagus, lung, and stomach. The research has indicated the significant trends with the duration and number of bidi smoked with causation of any type of cancer; passive smoking also attributed to diseases related to tobacco consumption.
Prevalence of various smoking tobacco in India
People smoke more tobacco in urban areas as compared with rural mind. With increase in age, smoking prevalence increases, and in India, males smoke more tobacco as compared with females. As compared with the urban area, there is more consumption of bidi and hookah in the rural areas. Daily cigarette smoking is about 6% compared with bidi smoking, which is 10%. In total, 63% of cigarette smokers smoke cigarette every day, whereas 81% of bidi smokers smoke bidi every day. In rural and urban areas, prevalence of daily cigarette smoking is 3% and 5%, respectively, whereas that of daily bidi smoking is 9% and 5%, respectively.
Sociocultural factors influencing tobacco consumption in India
Prevalence studies of tobacco use in India have shown wide variations between urban and rural areas, regions, age, gender, education, and other sociodemographic variables across the country.
There has also been a complex interplay of sociocultural factors that not only influenced the acceptance or rejection of tobacco by sections of society but also determined the patterns of use. In ancient India, smoking tobacco in the joint family was considered as a taboo and was mostly consumed by the dominant male members of the family. The younger members of the family avoid consumption of tobacco products in presence of elder family members. The practice of members of different generations smoking together, in a home setting, is rare even today though modernity has led to some relaxation of these rules.
Now,tobacco prevention and control policies in India have largely focused on awareness and behavior change campaigns, with much weaker implementation of more effective population level interventions, such as taxation increases and the banning of smoking in public places.
Public policy and health promotion interventions (a part of the sociopolitical context) need to have an inequality perspective to have desired impact and accordingly modify tobacco control policies. Uniform population-based approach of health education had worsened social inequalities as major benefits are harnessed by upper economic classes. Tobacco control measures that differentially target the poor include banning of advertisements, raising tobacco prices, work place interventions, free supply of cessation aids, and telephone help lines. Taxation has been reported as the most effective policy measure to curb smoking epidemic in poor. A 10% increase in bidi prices cut down bidi consumption by 9.2%.
All in all, addressing the inequalities in tobacco consumption did not necessitate introducing new set of interventions for tobacco control, but modifying the existing ones. To reduce the mortality and morbidity related to tobacco, there should be suitable policy reformation with interventions like inclusion of large public health programs in relation with NCD program to solve this problem holistically.