Tobacco contradiction

Life is never free of contradiction,
said Manmohan Singh in his first press conference as India’s prime minister.
The statement is especially true in case of the emerging public health issue of
tobacco consumption. While India’s Ministry of Health and Family Welfare is
running a nationwide ‘National Tobacco Control Programme’ (NTCP), its very own Ministry
of Commerce has a “Tobacco Board”, which has ‘maintaining and improving
existing tobacco markets’ as one of the mandates among others. While Ministry of
Health and Family Welfare’s NTCP aims at creating public awareness against
tobacco use, the Tobacco Board exalts ‘tobacco as a principle cash crop of
national importance’ and applauds tobacco industry as one that makes
significant contribution to National Exchequer by way of excise revenue and
foreign exchange earnings and providing employment to more than 36 million
people. The government of India interestingly runs and also funds some 16
tobacco research institutes for promoting various types of crops and tobacco
products. Clearly, we live in contradictory policy environment.

The World No Tobacco Day was observed last month and it was yet another time to ponder about one of the
important public health challenges of recent times. 

First, let’s understand the
magnitude of it as a public health issue in terms of diseases and death that
occurs because of tobacco use. According to World Health Organisation, every
year the global tobacco epidemic kills nearly 6o lakh people, of which more than
600,000 die from exposure to second-hand smoke. According to the Planning Commission
of India, about 10 lakh tobacco-related deaths occur each year. Compare this
with HIV and AIDS: In 2009, there were 1.72 lakh deaths because of HIV and AIDS
related illnesses. The amount of hype and attention being given to tobacco is
far less than what HIV gets despite tobacco use causing 10 times higher disease
burden compared to HIV/AIDS. 

It is difficult to perceive
tobacco as a big public health issue because its consumption is almost like a
norm in our society. A nationwide survey in the country indicates that in 2010
1 in 2 males and 1 in 5 females used some form of tobacco. Literally, every
other man is a tobacco user in our country and studies show that this trend is
increasing among women. Our young generation, which is most vulnerable to
initiation and use of tobacco, is also facing a challenge. Similar nationwide
survey in 2009 indicates that 1 in 10 students use some form of tobacco and
around 4% smoke cigarettes. One of the reasons of increasing tobacco use among
youth is what they see around and follow. The same survey indicated that 1 in 4
students had people smoke in their home and about 4 in 10 were exposed to smoke
in public places. National Sample Survey Organisation (NSSO) estimated that in
2006, around 10% of households in urban India spent some part of their income on
intoxicants – like liquor and Ganja etc - as compared to 16% in rural
households. Compare this with tobacco consumption: households with non-zero
consumption of tobacco were as high as 40% and 63%, respectively for rural and
urban India. Spending behavior of such a magnitude reflects how common and
widespread the problem of tobacco has become in our society.

We are living in an environment
that is full of contradictions; while we see and hear lot of anti-tobacco
messages in public spaces, radio and televisions, there is also constant onslaught
of tobacco advertisement in all those very places. The above-mentioned survey
also indicated that while around 64% rural people have noticed tobacco
advertisement, only 59% of rural population has noticed anti-tobacco messages
in radio or television. This is despite the fact that advertising of tobacco
products is banned in India. The manufacturers of tobacco products do surrogate
advertising to promote their other products - which are either as harmless as
tea or clothing or less harmful as paan masala under the same or similar brand
name. Does chaini chaini (innocuous non-tobacco mouth freshener) ring a
bell about chaini khaini (a tobacco product)?

Tobacco is more prevalent among
rural and poorer population, who are more vulnerable to its use in absence of
adequate health promotion messages. Not only is the consumption of tobacco high
among rural and poor population, the poor also spend relatively more on tobacco
as compared to their richer counterparts. The NSSO survey indicated that in
Gujarat, while average spending on tobacco as a % of monthly consumption expenditure
per person was 0.76% in urban area, the rural person spent nearly three times
higher at 1.98%. 

The priority for tobacco over
consumption of nutritious items, like fresh fruits, yields starker picture. On
an average, rural Gujarati spends 30% more on tobacco per month as compared to expenditure
on fresh fruits; this is as high as 300% among the poorest economic groups.
While richest segment of the surveyed individuals spent 0.9% of total
consumption expenses on tobacco, the poorest spent around 3%. This priority of
tobacco over fresh fruit is not as stark in urban area. Higher spending on
tobacco over fresh fruits across almost all income categories in rural area and
for poorest categories is one example which clearly shows that people are voting
by their feet and setting their priorities clear.

It is this norm like menace that needs
urgent attention, especially in a state like Guajrat where tobacco is a major
cash crop.  The Socio-economic Review
2012-13 clearly indicates that not only tobacco crop yield is increasing over
last two years, but also both total area in which tobacco is being produced and
production of tobacco in 2010-11 was highest in more than a decade. 

Tobacco not only affects the
user’s health, it has certain economic side effects as well. In second-hand
smoke, also called passive smoking, smoke originating from a smoker affects a
non-smoker family member, friend or even a nearby stranger, who has no
intention to smoke or promote smoking. The ash remnants of smoking products
like bidi, cigarette or hookah can remain on surface for a long time and can
enter non-smoker’s body – especially the toddlers and young children; this
phenomenon is called third-hand smoke. Thus, tobacco consumption has these
negative externalities which need to be addressed and compensated against. What
makes it a difficult menace to tackle is the fact that tobacco consumption is
prevalent across states, across gender and by and large across age. Not only early
initiation is a problem, easy access to information about tobacco and tobacco
products affects the initiation and use. And there is wide variety of choice of
tobacco products which are not so costly as well. 

Since last few years sincere
efforts have been taken to address this problem. While Government of India has put
in place the Cigarettes and Other Tobacco Products (Packaging and Labelling)
Act, there are efforts to substantiate government efforts by public health
institutions like Public Health Foundation of India (PHFI). The Strengthening
of Tobacco Control Efforts through innovative Partnerships and Strategies
(STEPS) project of PHFI is being implemented in six districts of Gujarat in
partnership with the Gujarat government. Various activities under this project
include; a) Community mobilization, which has rural focus and reaches out to the
community, b) Youth empowerment, which reaches out to school going youth to
limit early initiation of tobacco, c) Health system aiming at capacity building
of healthcare providers in assisting the tobacco cessation efforts, d) Indian
language print media that reaches out to media to increase anti-tobacco
coverage, and e) Policy component that does both downstream  and upstream advocacy for larger changes in
implementation of the anti-tobacco law. 

It is an uphill task to address
the tobacco problem and it is harder because the selling and consumption is
very common in our society. However, there is always a beginning. In this case
such a beginning has been made and efforts are ongoing towards making everyone respect
their own health and make informed decisions about it.