Tobacco and Cancer
Tobacco is a major cause of preventable mortality and morbidity around the world. It is responsible for more deaths than those resulting from road traffic accidents, suicides, homicides, maternity mortality and other causes combined. In India nearly half of all cancers in men are associated with tobacco use including mouth (oral cavity), lip and tongue, throat (oropharynx, larynx & hypopharynx), oesophagus, lung and urinary bladder cancer. In women, less than one fifth of cancers at these sites, including oesophagus and oral cavity are tobacco related. In general tobacco related cancers constitute a lower proportion of all cancers among women due to lower prevalence of tobacco consumption compared to men.
Besides cancer, tobacco consumption is also responsible for high blood pressure, heart diseases, peripheral vascular disease, bronchitis and emphysema ultimately leading to COPD, stroke, impotence and male infertility. Consumption of tobacco during pregnancy may lead to placental complications, perinatal death, low birth weight, miscarriage and fetal malformations.
Prevalence of Tobacco Consumption in India
Around the world China is the largest consumer of tobacco where as much as 60 % of the population indulges in smoking followed by USA, UK and Australia. According to epidemiological studies by the Indian Council of Medical Research there are 184 million tobacco consumers in India. Fifty-five thousand children take up this habit every year. Nearly eight lakh deaths in India are tobacco related.
Prevalence of tobacco use among men above 15 years of age varies from 46 – 63% in urban areas and 32 – 74% in rural areas while in women it varies from 2 – 16% in urban areas and 20 – 50% in rural areas. Use of smokeless tobacco is however similar in both men and women. Several studies conducted in India on cancer at various sites have shown that both smoking and smokeless tobacco use (including tobacco with lime and paan with tobacco) lead to elevated risks for oral, oropharyngeal, oesophageal and cervical and penile cancers. Smoking also causes increase in risk for lung, hypopharynx, larynx and stomach cancers as well.
The determinants of tobacco use among the youth are many. Socio-demographic factors such as gender, state and region, and rural versus urban residence are the most important factors. Others include factors affecting social norms, family influence and tobacco use by friends, exposure to advertisements in media and community; access and availability of tobacco products in area of residence; concurrent alcohol and tobacco smoking, levels of awareness about harmful effects of tobacco and attitude towards government tobacco control policies on access and availability of tobacco products to minors; school policies; tobacco control strategies and tobacco industry tactics to attract the youth.
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 and urban populations. Many young people have the misconception that tobacco is good for 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.
Tobacco Habits in India
In India tobacco is consumed in a variety of forms across various regions with a wide variety of products available. It is important to note that all these tobacco forms are equally harmful.
- Smoked Tobacco- cigarette, cigar, bidi, dhumti, chutta, hookah, chillum etc.
- Chewed Tobacco- pan, gutkha, khaini, mawa, pan masala etc.
- Applied forms- snuff, tobacco based toothpaste, creamy snuff.
Anti Tobacco Interventions
Several large community intervention studies have been conducted in India to assess the effectiveness of various communications strategies in persuading individuals to reduce or give up their habits. Some of these studies were also evaluated in terms of the regression of oral precancerous lesions in those who stopped using tobacco, as an indicator of reduction in oral cancer risk. Several primary prevention approaches may include health education and making the public aware of the health hazards of tobacco. Educational institutional and mass media campaigns including the role of NGO’s is very important in this regard by distribution of IEC material to individuals in various establishments.
Tobacco Cessation Clinics
Informal tobacco cessation clinics using counselling have been in operation for a long time in India. With the availability of nicotine replacement therapy, such as nicotine patches and chewing gums, several health facilities have set up tobacco cessation clinics for people who want to quit, but are unable to do so on their own. These clinics employ pharmacological support in addition to behavioural therapy, including include individual or group counselling and rational emotive therapy.
There is prohibition on smoking in public places such as hospitals, dispensaries, educational institutions, conference rooms, air flights, A/C sleeper coaches in trains, sub-urban trains, A/C buses, etc. It disallows the sale of tobacco to persons below 18 years and within 100 meters of educational institutions, government and semi-government offices. Clear health warnings are mandatory on all packages in local languages and in English, along with tar and nicotine content, to inform the public about the risks of using the products. The Cigarette (Regulation of Production, Supply and Distribution) Act 1975 requires that all packages and advertisements of cigarettes carry a statutory warning, “Cigarette smoking is injurious to health”. The Act provides specific instructions related to minimum font size, colour contrast, etc for the warning. Realizing the need for a warning on smokeless tobacco products (classified as food material), the provisions under the Prevention of Food Adulteration Rules, necessitates that every package and advertisement of smokeless tobacco product should have a warning stating that “chewing of tobacco is injurious to health”. Packages of areca nut should also state that “chewing of supari may be injurious to health”.
Community Education on Tobacco
Anti-tobacco education needs to be targeted at decision-makers, professionals and the general public, especially the youth. Efficacy of educational activities in tobacco cessation had amply been demonstrated by various organizations. No Tobacco Day (31st May) activities have been a regular feature since 1988, which generally comprise of educational advertisements in newspapers along with a programmes and workshops on the theme. Tobacco has been included as a topic in books brought about by NCERT. National Cancer Control Programme also stresses on anti-tobacco education, in view of the fact that half of the cancers among men and about one fifth of the cancers among women in India pertain to tobacco related sites. The anti-tobacco community education activities have been initiated in about 60 districts through district level projects for control of cancers. Coverage of the entire country for anti-tobacco education is a formidable job and can not be achieved without active support from Non-Governmental Organizations and mass media. They, however, need support from the health departments for availability of reliable and impartial information on the subject. Support would be needed not only from health related non-governmental organization but also from other related sectors like education, economics, agriculture, welfare, etc.