31st May, 2023- World No Tobacco Day: “We need food, not tobacco”.

Tobacco Use is Leading Cause of Preventable Death

• Introduction and Overview

Tobacco kills up to half of its users. Tobacco kills more than 8 million people each year. More than 7 million of those deaths are the result of direct tobacco use while around 1.2 million are the result of non-smokers being exposed to secondhand smoke. Over 80% of the world's 1.3 billion tobacco users live in low- and middle-income countries. In 2020, 22.3% of the global population used tobacco, 36.7% of all men and 7.8% of the world’s women. To address the tobacco epidemic, WHO Member States adopted the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2003. Currently 182 countries have ratified this treaty. The WHO MPOWER measures are in line with the WHO FCTC and have been shown to save lives and reduce costs from averted healthcare expenditure.

Tobacco use is leading cause of preventable death. This global tobacco epidemic kills more people than tuberculosis, HIV/AIDS and malaria combined. According to the World Health Organization (WHO) estimates, globally, there were 100 million premature deaths due to tobacco in the 20th century, and if the current trends of tobacco use continue, this number is expected to rise to 1 billion in the 21st century.

“Tobacco products” means products entirely or partly made of the leaf tobacco as raw material which are manufactured to be used for smoking, sucking, chewing or snuffing”. Tobacco use is a major risk factor for many chronic diseases, including cancer, lung disease, cardiovascular disease and stroke. Globally, tobacco use is one of the biggest public health threats. It leads not only to loss of lives but also has heavy social and economic costs.

India is the second largest consumer of tobacco globally, and accounts for approximately one-sixth of the world’s tobacco-related deaths. The tobacco problem in India is peculiar, with consumption of variety of smokeless and smoking forms. Many of these products are manufactured as cottage and small-scale industries using varying mixtures and widely differing processes of manufacturing Understanding the tobacco problem in India, focusing more efforts on what works and investigating the impact of sociocultural diversity and cost-effectiveness of various modalities of tobacco control should be our priority.

In India, beedi smoking is the most popular form of tobacco smoking. Cigarette smoking is the second most popular form of tobacco smoking. Paan with tobacco is the major chewing form of tobacco. Dry tobacco areca nut preparations such as paan masala, gutka and mawa are also popular and highly addictive. Tobacco dentifrice is popular, especially in some areas, and children also use it.

• Epidemiology

Tobacco kills more than 8 million people each year. More than 7 million of those deaths are the result of direct tobacco use while around 1.2 million are the result of non-smokers being exposed to secondhand smoke. Over 80% of the world's 1.3 billion tobacco users live in low- and middle-income countries.

Nearly 275 million adults (15 years and above) in India (35% of all adults) are users of tobacco, according to the Global Adult Tobacco Survey India, 2016-17. The most prevalent form of tobacco use in India is smokeless tobacco and commonly used products are khaini, gutkha, betel quid with tobacco and zarda.

In India, This figure is made up of 164 million smokeless tobacco users, 69 million smokers, and 42 million people using both smoking and smokeless forms of tobacco. In India, 53.9 million men and 11.1 million women, 48.6 million of rural population and 16.5 million of urban population consume gutkha. The dependency on tobacco and damage of health due to gutkha consumption is recognized as a life threatening disorder with the health consequences. The increased use of gutkha has led to the highest incidence of oral cancer in India.

• Health hazards  

Smoking causes cancer, heart disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis. Smoking also increases risk for tuberculosis, certain eye diseases, and problems of the immune system, including rheumatoid arthritis. Tobacco is a killer, it increases your chance of dying. Smoking 1 cigarette can take 11 minutes off your life. Smoking is not only a killer, but a serious cause of illness. Smoking affects fertility. It gives you bad breath.

• Secondhand Smoke Exposure

Second-hand tobacco smoke is the smoke emitted from the burning end of a cigarette or from other smoked tobacco products (such as bidis and water-pipes) and the smoke exhaled by the smoker. More than 4000 chemicals have been identified in tobacco smoke and there is no safe level of exposure to second-hand tobacco smoke.

Based on the scientific evidence, the Conference of the Parties to the WHO Framework Convention of Tobacco Control (WHO FCTC) has concluded that 100% smoke-free environments are the only proven way to adequately protect the health of people from the harmful effects of second-hand tobacco smoke. Smoke-free laws protect the health of non-smokers and are popular, as they do not harm business and they encourage smokers to quit.

Today, about half of all children between ages 3 and 18 years in this country are exposed to cigarette smoke regularly, either at home or in places such as restaurants that still allow smoking. Compared to children who are not exposed, children exposed to secondhand smoke.

• Youth and Smoking

Nearly all tobacco use begins during youth and progresses during young adulthood. More children age 18 or younger smoke their first cigarette. Nearly 9 out of 10 smokers start before the age of 18 and almost all start smoking by age 26. Every adult who dies early because of smoking is replaced by two new young smokers.

• Smokeless Tobacco

The term smokeless tobacco is used to describe tobacco that is consumed without heating or burning at the time of use. Smokeless tobacco can be used orally or nasally. For nasal use, a small quantity of very fine tobacco powder mixed with aromatic substances called dry snuff is inhaled. This form of smokeless tobacco use, although still practiced, is not very common in India.

The oral use of smokeless tobacco is widely prevalent in India; the different methods of consumption include chewing, sucking and applying tobacco preparations to the teeth and gums. Smokeless tobacco products are often made at home but are also manufactured. Recently, a variety of smokeless tobacco products have been produced industrially on a large scale, commercially marketed and are available in small plastic and aluminium foil packets. the use of smokeless tobacco, including gutkha, is a prevalent and dangerous practice that poses serious health risks, especially for oral cancer. Despite being banned by Indian states since 2012, gutkha remains widely used and available. Gutkha is a mixture of areca nuts, slaked lime, catechu, tobacco, added flavourings, and sweeteners.

• Youth and Smokeless Tobacco Gutkha

In India, gutkha has attracted the younger generation more than the older generation. The wider availability of gutkha has even attracted women and made it easier for them to chew tobacco without attracting social sanction. Gutkha and paan masala (areca nut products without tobacco) have been strongly implicated in the recent increase in the incidence of oral submucous fibrosis, especially in the very young, even after a short period of use. The condition has a high rate of malignant transformation, is extremely debilitating and has no known cure. This previously uncommon disease, found mainly among old persons in India, is emerging as a new epidemic mainly among young people (below 35 years). Growth of gutkha use has overtaken that of smoking forms of tobacco.

• Ecological and Environmental Effects of Tobacco Use

Tobacco contributes to deforestation in three ways: forests cleared for cultivation of tobacco, fuel wood stripped from forests for curing and forest resources used for packaging of tobacco, tobacco leaves, cigarettes, etc. Tobacco growing depletes soil nutrients at a much faster rate than many other crops, thus rapidly decreasing the fertility of the soil. Tobacco displaces the indigenous flora and fauna and will thus gradually become a source of pests for other crops. It leads to collapse of the food web, thereby destabilizing the predator prey relationship.

Tobacco requires huge chemical inputs. Such chemicals may run off into water bodies, contaminating local water supplies. High levels of pesticide use may also lead to the development of resistance in mosquitoes and flies. Frequent contact with and spraying of chemicals, and storage of tobacco in residential premises of farmers have adverse health effects. Tobacco is heavily dependent on fertilizers. With increased irrigation, mistimed fertilizer application causes excessive leaching, including that of nitrogen and potassium. In India, an estimated 20,000 children work in tobacco farms and another 27,000 work in beedi-making or packing cigarettes.

Cigarette butts and other tobacco product wastes(TPW) are the most common items picked up in urban and beach cleanups worldwide. TPW contains all the toxins, nicotine, and carcinogens found in tobacco products, along with the plastic non biodegradable filter attached to almost all cigarettes sold in the most countries worldwide. Toxicity studies suggest that compounds leached from cigarette butts in salt and fresh water are toxic to aquatic micro-organisms and test fish. Toxic chemicals have also been identified in roadside TPW. With as much as two-thirds of all smoked cigarettes (numbering in the trillions globally) being discarded into the environment each year, it is critical to consider the potential toxicity and remediation of these waste products.

• Prevention and Cessation

No matter what age a person is, smoking is dangerous to health and can be hard to give up. Nicotine addiction is very powerful and happens quickly. It’s easier to avoid starting to use tobacco in the first place than it is to quit later on. Encourage parents to talk to their kids about reasons to avoid tobacco use, and to protect their children from secondhand smoke exposure.

Public health awareness, raising a mass movement against tobacco, sensitizing and educating all health care professionals for tobacco control and cessation by incorporating the topic in medical undergraduate curriculum, nursing curriculum, various CMEs, conferences, scientific meetings, workshops, etc. is vital.

Quitting tobacco: When tobacco users become aware of the dangers of tobacco, most want to quit. However, nicotine contained on tobacco products is highly addictive and without cessation support only 4% of users who attempt to quit tobacco use will succeed. Professional support and proven cessation medications can more than double a tobacco user's chance of successful quitting.

• Conclusion

In India, Tobacco use is main preventable cause of oral cancer, and premature death due to oral cancer. 60% Indian tobacco users use only smokeless tobacco, as per Global Adult Tobacco Survey (GATS). A combination of areca nut and tobacco has been introduced in India known as Gutkha (chewable tobacco form) which is used as a mouth freshener in most part of India.

Smoking: All forms of tobacco are harmful, and there is no safe level of exposure to tobacco. Cigarette smoking is the most common form of tobacco use worldwide. Other tobacco products include waterpipe tobacco, various smokeless tobacco products, cigars, cigarillos, roll-your-own tobacco, pipe tobacco, bidis and kreteks.

• Key Message

1. Warn about the dangers of tobacco. 
2. Raise taxes on tobacco. 
3. Enforce bans on tobacco advertising, promotion and sponsorship. 
4. Monitor tobacco use and prevention policies. 
5. Protect people from tobacco use.
6. Offer help to quit tobacco use.

• References

1. Report on Tobacco Control in India (New Delhi, India), In: Reddy KS, Gupta PC, Editors, New Delhi, India: Ministry of Health and Family Welfare; 2004. 
2. Jha P, Jacob B, Gajalakshmi V, Gupta PC, Dhingra N, Kumar R, et al. A nationally representative case–control study of smoking and death in India. N Engl J Med 2008;358:1137-47. 
3. A global epidemic of addiction and disease. Tobacco: deadly in any form or disguise. World Health Organization. WHO Tobacco Free Initiative. ISBN 92 4 156322 2 (NLM classification: QV 137) ISBN 978 92 4 156322 World No Tobacco Day 2006. 
4. WHO Report on The Global Tobacco Epidemic, 2011. The MPOWER package, warning about the dangers of tobacco. Geneva: WHO; 2011. 
5. An overview of the tobacco problem in India. Gauravi A. Mishra, Sharmila A. Pimple, Surendra S. Shastri Indian Journal of Medical and Paediatric Oncology | Jul-Sep 2012. 
6. WHO World No Tobacco Day 2023.

Regards and Thanks

Dr. (Prof)Rajendra T. Nanavare

 Chest Physician and 

Ex Medical Superintendent GTB hospital Sewri Mumbai.