Background: Tobacco kills over 1 million people annually in India. Tobacco is consumed in various forms across all age groups, gender, and geographic area. To tackle this major public health issue various tobacco prevention and cessation policies and interventions are introduced and implemented by the government.
Aim: The objective of this review is to analyze the success of different tobacco interventions implemented in different states and to assess the awareness of these policies among the population
Methods:
The current review is a result of syntheses of 22 articles.
Database searched: Ovid Medline was searched for papers with results from different tobacco prevention/cessation intervention programs in different states in India. The search was divided into 3 categories; Location (India and 29 states and 7 union territories), use of tobacco (smoking, pan chewing, tobacco chewing, smokeless tobacco, bidi, cigarette smoking and reverse smoking) and tobacco use cessation (tobacco control, tobacco prevention, smoking prevention, intervention programs, tobacco cessation smoking cessation, health policies, health education). The MeSH terms used for the search were India, smoking, tobacco use cessation
Article selection: articles were screened based on title and abstract and further based on full text.
Results:
The majority of the interventions included the school-based health program Project Mytri (Mobilizing Youth against Tobacco Related Initiatives) and the community-based program Project ACTIVITY (Advancing Cessation of Tobacco in Vulnerable Indian Tobacco Consuming Youth) show a significant effect on tobacco use outcomes, especially in young adults. The most successful interventions were the ones with continued support from the government and/or NGOs in sustaining the tobacco quit rate. The least successful ones involved Project EX-India and interventions implemented poorly without any framework and follow-ups.
Conclusion: Tobacco use can be controlled by school and community-based interventions, and teachers and community leaders can be trained to make sure there is continued implementation of the strategy. Interventions focusing pregnant women should be explored as most of the current interventions focus on teenagers and men. Intersectoral involvement is required to tackle this major public health issue.
Introduction
The current population of India is 1,364,200,311 and counting out of which only 33.6% live in urban areas and the rest are the rural population and the Indian population is equivalent to 17.74% of the total world. Every year tobacco kills 1 million people, as of now there are 267 million tobacco users in India out of which 20.4% are men and 1.9% are women above 15 years of age (WHO 2018). It is estimated that by 2020 1.5 million deaths will be due to tobacco consumption. Tobacco use prevention and cessation is particularly difficult in India due to consumption of tobacco in various forms and very less support and resources available to control tobacco.
1.2 Various forms of tobacco
India is the 2nd largest tobacco producer after china producing approximately 800 million kgs of tobacco annually. Tobacco production comes under state jurisdiction, yet the 6 sectors of the Union ministry control/has a hand in tobacco production namely agriculture, finance, commerce, labour, industry, and rural development. Tobacco is grown in the following 13 states in India: Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Karnataka, Madhya Pradesh, Maharashtra, Odisha, Tamil Nadu, Telangana, Uttar Pradesh, and West Bengal. The most widely cultivated form of tobacco is the Flue-Cured Virginia (FCV) tobacco accounting for almost 40% of the tobacco production and India is the 3rd largest country to produce FVC tobacco after China and Brazil. The other non-FCV tobacco cultivated are LS Burley, air/sun-cured, and oriental tobaccos. Central Tobacco Research Institute (CTRI) conducted a study which outlined that no other single crop will make as much profit as tobacco and growing 2 types of crops together can be a solution to tobacco cultivation and gradually substituting tobacco cultivation ex: tobacco and red kidney beans, tobacco, and garlic have been proven successful. India varies in the tobacco production pattern because of the various forms it is consumed, only 10% of tobacco is consumed in the form of cigarettes and the rest 90% is consumed in other forms namely bidi(sun-dried tobacco flakes are rolled in dried leaves) mishri(a powdered tobacco paste rubbed on gums), paan(betel leaf filled with areca nut, lime and other spices with or without tobacco) and gutkha(areca nut mixed with chewable tobacco). Cigarette smoking had reduced and use of tobacco in other forms has increased from 1980 to 2017 and there is a 33% increase in overall tobacco consumption.
1.3 Tax on tobacco products and export
68% of tobacco is produced by unorganized sectors which are not compliant with all the regulations and they pay less tax due to evasion or tax exemption. Taxes on tobacco products is very less in India compared to other countries, a pack of bidi costs just Rs. 4 (USD 0.058) with 9% tax on retail price, and a pack of cigarette costs 60 rupees with 38% tax on retail price which is below (65% to 80% of retail price the rate proposed by World Bank. Taxes are determined on various characteristics like manufacturer (small vs large scale factory, hand-rolled vs machine-rolled bidis), type of cigarette or bidi (length and filter) and taxes differ by state as well. High rates of smoking not only increase the death rate but also increases the burden on the country’s healthcare system. If no interventions/steps are taken, over 38 million bidi smokers and 13 million cigarette smokers will prematurely die from tobacco-related diseases. Increasing tax on tobacco products will significantly reduce smoking rate and increases government revenue. Studies show that 10 % increase in tax on tobacco products can reduce bidi consumption by 9.1% and cigarette consumption by 2.6%. “If India increases its tax rate on bidis from Rs 14 to Rs 98 per 1000 sticks (from 9% to 40% of retail price) and on cigarettes from Rs 659 to Rs 3691 per 1000 sticks (from 38% to 78% of retail price), 18.9 million lives will be saved among Indians alive today. The increase in tobacco tax will provide the government with an additional Rs 183.2 billion (3.9 billion USD) in tax revenue”(9). India generates approximately 6000 crores of revenue from exporting the wide variety of tobacco leaves and products produced.
1.4 Harmful effects of tobacco
Tobacco kills more than 7 million people annually and 10 million premature deaths and will rise up to 1 billion if no interventions or programs are designed to reduce tobacco use. Tobacco use is more prevalent in men population below poverty level in rural areas and uneducated sections of the society according to national family health survey 3 conducted in 2005 to 2006. The types of health-related problems or also as complex as the type of tobacco products used. Tobacco smoking not only leads to death, but it causes disabilities and diseases, In addition to oral cancer tobacco smoking also causes lung cancer oropharyngeal cancer, cancer of stomach pancreas liver kidney urinary bladder, and bone marrow. Apart from cancer tobacco smoking also causes tuberculosis and in bidi smokers, it causes 2.6 times more deaths than in non-smokers. Smoking is also a major cause for cardiovascular diseases in young age and also 48% of deaths are caused by cardiovascular diseases due to smoking in India.
Cigarettes also contain sugar which is added to remove the harshness of tobacco that makes it less appealing to the youth adding sugar adds flavor to cigarettes and hence is more addictive and easier to use. It increases the risk of diabetes, hypertension, and cardiovascular diseases
Second-hand smoking
Tobacco smoking is not only harmful for the smokers but also to non-smokers who are victims of second-hand smoking. second-hand smoking occurs when a person inhales the smoke emitted from cigarettes or bidi tobacco smoke this can occur at home, at public places (restaurants, bars, offices, bus stands, too name a few), and on streets. Second-hand smoking also causes cancer, cardiovascular diseases, asthma and other respiratory diseases, sudden death syndrome in babies to name a few. The smoke emitted gets settled in furniture, clothes, surfaces in the house, and even the objects used by the smoker and is referred to as thirdhand smoke.
1.5 Tobacco control law
The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) binds the countries to implement evidence-based interventions toward tobacco control and cessation and India joined this in February 2004 to implement policies to control tobacco consumption. The FCTC was formulated as a result of the global tobacco epidemic, it stresses on reducing demand and supply of tobacco.
The primary aim of this convention is to protect the present and future generations from declining health, economy, environmental and social impact from tobacco consumption. The protocol consists of articles which consist of regulations for tobacco product production and supply.
The cigarettes and other tobacco products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act, 2003 or COTPA, 2003 is the principal law which governs the tobacco control in India. This law prohibits smoking in public places and is subject to fine of up to 200 rupees to protect non-smokers from secondhand smoking produced by tobacco products. This law provides rules and regulations for trade and commerce in, and production, supply, and distribution of cigarettes and tobacco products and restrict advertisement of tobacco products if manufacturers do not follow this regulations of production of products related to warnings on the package can be first conviction up to 2 years or fined up to 5000 and up to 5 years in subsequent convictions. Sale of tobacco products are prohibited within a 100meter radius from educational institutions and to any person below the age of 18. Advertisement of any form of tobacco products is prohibited. All tobacco products must display pictorial (skull or scorpion) and written (smoking kills, tobacco causes cancer, and sales of tobacco products is prohibited to a person under the age of 18 years is a punishable offense) warning on the packages.
2. Method
2.1 Search strategy
The current review is a result of syntheses of 22 articles found via Ovid Medline search which was divided into 3 categories; Location (India and 29 states and 7 union territories), use of tobacco (smoking, pan chewing, tobacco chewing, smokeless tobacco, bidi, cigarette smoking and reverse smoking) and tobacco use cessation (tobacco control, tobacco prevention, smoking prevention, intervention programs, tobacco cessation smoking cessation, health policies, health education). The MeSH terms used for the search were ‘India’, ‘smoking’, and ‘tobacco use cessation. Articles were screened based on title and abstract and further based on full text. The keywords were combined with ‘and’ and ‘or’ to retrieve a total of 22 articles were selected
2.2 Inclusion and exclusion criteria
To analyze the success of the interventions only those articles which included smoke and/or smokeless tobacco products usage, tobacco intervention programs implemented in India, articles specifically reporting results in India, interventions which were actually implemented and not just described, and articles not specifically reporting results in India, Incomplete studies, no outcomes mentioned or irrelevant outcomes and articles only explaining intervention programs were excluded.
3. Interventions
3.1 School-based interventions
In the year 2007-2008, the National Tobacco Control Programme (NTCP) was launched by the National Tobacco Control Cell (NTCC) at the Ministry of health and family Welfare (MoHFW) to spread awareness about harmful effects of tobacco use and support people trying to quit tobacco, but this programme did not include any cessation support for schools. Adolescents is the most vulnerable stage in life and most adult smokers start tobacco use in childhood or adolescents therefore it is very important to target interventions at this age group to prevent the use of tobacco. It is very easy to influence young adults through movies, propaganda, innovative advertisements, and peer pressure. The factors which influence and encourage young adults to start tobacco use must be understood to prevent them from initiating tobacco consumption. Indian judiciary has passed laws to prohibit sell of tobacco products within a 100m radius of educational institutions and selling tobacco to anyone below the age of 18 is a punishable offense.
3.1.1 Tobacco-free teacher/tobacco-free society
Teachers are a major role model for their students and for the community as they are a source of knowledge and wisdom and children spend most of their time in schools and are easily influenced by teachers hence school-based interventions involving aiming teachers is an important factor in preventing tobacco usage among the youth. The Indian state of Bihar has rates of tobacco use in the country, it was found that 78% of school teachers in Bihar used tobacco by the Global School Personnel Survey in 2000. A school-based intervention was developed and tested by the Bihar School Teachers Study and was called the Tobacco-free teacher/tobacco-free society program which focused on cessation support, educational and tobacco control policies. The study was conducted in 2 waves 2009-2010 and 2010-2011 and was a collaboration between the Healis-Sekhsaria Institute for Public Health in Mumbai and Patna, India, and the Dana-Farber Cancer Institute and Harvard School of Public Health, Boston, Massachusetts.
A total of 72 schools were randomized into intervention and control groups and 3 surveys in each wave were collected at baseline, immediate postintervention, and 9 months postintervention, a pilot test was conducted in 2 schools and modified accordingly.
The intervention was framed around 6 themes: emphasizing teachers as role models, improving the understanding of harmful effects of tobacco, motivation to quit, skill building for tobacco quitting, withdrawal coping mechanisms, and promoting maintenance skills.
Intervention was delivered through a health educator and a lead teacher was appointed in each school who were trained to deliver the intervention.
The lead teachers got constant support from the health educators through phone, monthly visits, and a midyear meeting.
The tobacco policy was painted on each school wall in large and bold writing.
The intervention included tobacco cessation through written materials and group discussions
The intervention aimed at increasing the tobacco quit rate post-intervention and after 9 months. About half of the tobacco users quit in the intervention group compared to 15% in the control group.
The difference between the groups were borderline statistically significant but the effect of intervention was statistically significant with p-value of 0.04.
This intervention was one of a kind and the first one to provide evidence-based cessation program at school level, it was successfully implemented by conducting 98% of the meeting and doubled the quit rate in survey takers, and quadrupled quit rate in those who completed the intervention. Though this intervention does not directly impact the youth it does provide enough material and knowledge to teachers to educate children on harmful effects of tobacco and benefits of quitting tobacco.
3.1.2 Project EX-India
Project EX is a teen tobacco cessation program and has a school-based clinic version and a classroom-based intervention program the classroom-based program was adopted to be implemented in India. The program consists of 8 sessions 40 – 45 minutes each and was based on motivation-coping skills-personal commitment model of teen tobacco users. Alternative medicine activities like yoga, meditation, and healthy breathing were a part of the program and non-smokers become a listening ear for smokers and supported those to decided to quit tobacco and trying not to relapse. 4 schools (2 private and 2 public) in Delhi were selected for the purpose of this project.
The following changes were made to adopt the intervention:
2 manuals one for teacher and one for student were translated from English to Hindi for the purpose of implementation of intervention.
Scenarios and case studies were modified by changing the names and characters for example: changing ‘Eddie’ to ‘Sachin’ and ‘girlfriend’ to ‘best friend’.
Original curriculum targeted use of pipe, cigarette, and cigar but it was adopted to include various forms of tobacco popular in India including bidi, gutkha, pan, and mishri.
Currency was changed from dollars to rupees.
No incentives were given to students for participating in the study as done in the United States.
Outcome measures were collected before and after the intervention, at baseline demographic characteristics and tobacco use behavior questions were asked.
Participants were asked to rate which EX curriculum they liked the most out of the total 8 activities: meditation, yoga, breathing exercise, game-is smoking on the menu?, talk shows – cigarettes may be stressing you out, family and friends confront smokers about their habit, quitting smoking: I’ve been there and it does get better and WARNING! Waiting to quit smoking may be hazardous to your peace of mind.
A third questionnaire was asked after 3 months of intervention consisting of tobacco use behavior yes/no and level of tobacco use questions were asked to assess the effect of intervention.
The program did not have any significant cessation effect, but it most definitely had a prevention effect on young adults and was not conducted long enough (at least a year) to see the impact of intervention.
3.2 Community-based interventions
Most of the Indian population lives below poverty line, most are uneducated and unemployed and have limited access to health care thus it makes it even difficult to have access to any kind of tobacco cessation programs. These community-based intervention programs are funded by the government or NGOs with a good intention to prevent tobacco use in non-smokers and encourage tobacco quitting among smokers. A lot of these interventions are very expensive, time-consuming, and need skills like communication, analysis, and decision-making during the process of implementation as it requires dealing with the local population. There is a lack of evidence-based prevention and cessation programs and if immediate actions are not taken to reduce tobacco consumption rate health disparities will further widen.
3.2.1 Project activity (Advancing Cessation of Tobacco Use in Vulnerable Indian Tobacco using Youth)
Project activity was started in 2009 with 14 low-income communities from Delhi to participate in a randomized intervention trial. These communities were slums and resettlement colonies
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Project EX-India: A classroom-based tobacco use prevention and cessation intervention program