Assessment of Tobacco Consumption and Control in India

Abstract

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.

Introduction

The nexus between tobacco consumption and poverty is well-documented; however, the tobacco control measures are uniformly applied, without due consideration for the high-risk target group. In India, nearly 300 million people live in extreme poverty. ¹ About 28.6% of the population consume tobacco. ² Nationally representative surveys and community-based studies have shown that tobacco consumption among the poor has continued. The cyclical relationship between tobacco use among the poor and exacerbation of poverty due to tobacco-related diseases is also well-documented. Health care costs involve not only direct medical costs but also indirect morbidity and mortality costs. ³ India is a low- and middle-income country (LMIC). Government expenditure on health has continuously declined and public spending on health is 1.15% of gross domestic product.^4,5 Health expenditure is mostly out of pocket in India and it also consequently exacerbates the poverty rates due to high out-of-pocket expenditure for treatment of tobacco-related diseases. In India, socio-economic and health inequalities are rampant. ⁶ Tobacco-related diseases are a cause and consequence of poverty. It is not only merely a social and cultural problem but it is also multifaceted and encompasses biomedical, economic, and geopolitical. ⁷ Tobacco use in India is projected to have devastating consequences.

Tobacco control policies have the opportunity to break this vicious cycle. Tobacco control should be a top priority not only merely as a health issue but also as a poverty reduction mechanism. Effective implementation of tobacco control policies provides an opportunity for India to fulfil its commitments to meet the goals – 2030 agenda of Sustainability Development Goal of poverty reduction and good health. Despite all the efforts, tobacco consumption is a major health issue globally, and in India, one-third of the population uses tobacco. ⁸

And to provide targeted intervention, it is necessary to assess the tobacco epidemic and also evaluate the governing policies. The aim of this article is to synthesise the available scientific knowledge on tobacco use in India, with a view to assess the magnitude of the problem, reviewing the tobacco control legislation and its impact at the micro- and macro-level of tobacco control in India. The need for this comprehensive evaluation is to develop a better understanding of tobacco – consumption pattern, control policies, and the gaps that need to be addressed will serve as reference for developing pragmatic tobacco control approach.

Methodology

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 maximise review data. Most of the studies included are those relevant to Indian subcontinent.

Results

Data availability

Nationally representative data on tobacco consumption in India are from National Sample Survey (NSS), National Family Health Surveys (NFHS), and Global Adult Tobacco Survey (GATS-1 and 2)

National Sample Survey organised by National Sample Survey Organization (NSSO) in 1995-1996 was the first nationally representative household survey to collect data on tobacco consumption in the population. Threshold prevalence of tobacco consumption in population then was 51.3% for men and 10.35% for women aged 15 years and above. ⁹ GATS-India provides better understanding of the tobacco products consumed in India.

Surveys conducted did not include institutionalised persons, such as those in hostels, army barracks, hospitals, orphanages, rescue homes, and vagrant houses or other organisations^10,11; persons in institutions have higher prevalence of tobacco and will lead to under estimation of the overall population indicators. Limitation of large studies, such as NFHS, is that one of the household members provides the information, so in NFHS-2, the tobacco use prevalence was under estimated by atleast 5% for smoking among men and 0.5% among women. Most localised studies are based on urban areas. Nationally representative and reliable data on tobacco consumption are scarce in India. There are comparative results between NFHS-3 and NFHS-4 and between GATS-1 and 2.

Forms of tobacco used in India

India has 29 states and 7 union territories with wide cultural differences and habits; tobacco use is ingrained as a cultural practice and resultant addiction. In India, tobacco is used as smoked and smokeless forms. There are myriad forms; in this review, cigarettes, beedis, and smokeless tobacco (SLT) used orally are considered. Cigarettes are available in various types, filtered/unfiltered, length based, and flavoured. Beedi is an indigenous form of tobacco product, made with 0.2 to 0.3 g of tobacco wrapped in temburni leaf and tied with a small string. Beedis contain 3 times more nicotine and 5 times more amount of tar than the regular cigarette, and they are also available in flavours of strawberry, mango, and chocolate. ¹² Smokeless tobacco is a form of tobacco that need not be ignited for use, applied orally and nasally. Oral use of SLT is ubiquitiuous; types and their regional orientation are described elsewhere in detail.^13,14

Patterns and Prevalence of Tobacco Use in India

India is the second largest consumer of tobacco. ⁸ GATS-2 reports that 28.6% of the population consume tobacco in any form, 10.7% smoke, and 21.4% use SLT. ² Khaini (a form of SLT) and beedis are the dominant forms of tobacco consumed in India, at 11% and 8%, respectively. ² Compared with GATS 2010, there has been a 6% decrease in the tobacco consumption recorded in GATS 2017 and also the NFHS-4 has shown decrease in the prevalence rate compared with NFHS-3. ¹⁵ There has been increase in 1 year in the initiation of tobacco use in GATS-2 compared with the previous survey. ² However, between NFHS-3 and NFHS-2, during the gap of 7 years, all forms of tobacco consumption had increased; greatest numbers were seen between 15 and 24 years. ¹⁶ Tobacco consumption annual growth rate is 2% to 3%.^17,18

Smoked form was consumed by 14% of the population. ¹⁹ On an average, Indians smoked about 6.2 cigarettes per day; this is the lowest of all countries, but among women, although the prevalence of cigarette smoking was less, the mean cigarettes per day were quite high, about 7, higher than the average of men, which was 6.1. ²⁰

Beedis accounted for the largest proportion of smoked tobacco consumed in India, ²¹ especially among the lower socio-economic group, they consume beedis 8 to 10 times more than cigarette smoking. ²² Despite greater consumption and higher toxicology associated with beedis, they go unnoticed. One of the historical reasons for the momentum for increased consumption of beedi was in response to the Swadeshi Movement, where imported cigarettes were boycotted and indigenous beedi received greater exposure and its deliberate use increased from cigarettes. ²³ A study that assessed trends in beedi and cigarette smoking in India from 1998 to 2015 showed that cigarettes were displacing beedis among men due to rising income and increased affordability ²⁴ ; this was also significantly noticed among the lower socio-economic status groups. ²⁵

Smokeless tobacco use is documented in 120 countries. ²⁶ India has the largest number of SLT users in the world. Of the 346 million global consumers, India alone has 152.4 million men and 80.8 million SLT consumers, ⁷ and there has been substantial increase in SLT across all age groups. ²⁵ A study analysed 2 nationally representative data in 2005 and 2009 and showed that SLT use continued to increase in the age group of 15 to 49 years. ²⁷ The prevalence of SLT use is higher among men (27%-37%) compared with women (10%-15%). Trends in age-specific standardised prevalence of SLT use in India showed that consumption of SLT increased with age for both the sexes. ¹¹ Moreover, SLT use is considered as a common smoking cessation method and a study showed that 34.4% of smokers switched to SLT use as a cessation method. ²⁷ Its prevalence is explicitly presented in detail elsewhere. ¹⁴

Doctors are exemplars of tobacco cessation and play a crucial role is the success of cessation services and a pivotal role in tobacco control, having opportunity for helping tobacco users to quit and also prevent initiation. However, studies have shown that about 50% in Indian male doctors smoke. ²⁸ Similarly, studies on tobacco consumption in health professional students (medical, dental, nursing, and pharmacy) have shown that the consumption rate is high among them especially male medical students ²⁹ ; this is detrimental not only to the individual but also to the society as it dilutes their ability to deliver effective anti-tobacco counselling in their future clinical practice.

Secondhand smoke

Secondhand smoke (SHS) exposure is a significant problem in India, at both indoor and outdoor. A study has shown that 70% to 80% of the male smokers regularly smoked in home ³⁰ ; 3 in every 10 adults working indoor are exposed to SHS.^2,31 About 23% of adults have reported SHS exposure at public places. ² In NFHS-3, 25% women reported SHS exposure at home. ³¹ Secondhand smoke exposure has a bearing to be future smokers. Although smoke free policies are becoming widespread and there is concomitant downward trend in SHS exposed at work places, especially the organised sectors with warning boards displayed. In home, SHS exposure remains high especially among children.

Thirdhand smoke

Is the fraction of tobacco smoke that persists in indoor environments after smoking. ³² This remains even after most of the airborne components of the smoke have cleared. ³³ Children are at increased risk, when exposed to thirdhand smoke (THS) toxicants due to their exploratory behaviour and metabolic activity. ³² Dust ingestion was identified as the dominant (80% of the total intake) source of exposure to indoor semi-volatile environmental pollutants in toddlers. ³⁴ This is of enormous importance in India as houses especially in urban slums are compact with poor ventilation. Nicotine is the main component in THS. Oxidants in the tobacco smoke cause local and systemic inflammation. ³² Thirdhand smoke causes significant DNA damage in human cells. ³² Small children are particularly vulnerable as they are exposed to THS/toxicants via inhalation, ingestion, and dermal contact. And also, there is increased risk of cancer in children (1-16 years). ³⁵

Determinants of Tobacco Consumption

The NSS and many other nationally representative surveys and community-based studies have shown the socio-economic, cultural, demographic, religion, and caste-based correlates of tobacco consumption and also showed that smoking and smokeless forms of tobacco are significantly higher in the rural areas, among uneducated poor people, and the socially disadvantaged castes of Indian society. Tobacco consumption among the poor is continuing and questions the penetration of tobacco control policies. ²⁵ Beedis, the cheapest indigenous smoking tobacco, are common among the scheduled caste and uneducated rural adults. ³⁶

Marriage can also be seen as an important factor, the influence of husbands and also they being the sources for purchasing tobacco; a study showed that wives of polyusers were 3 times more polyusers than wives of non-users. ³⁷ However, in NFHS-3, antenatal tobacco use was comparatively high among single mothers than married. ³¹ Antenatal tobacco use is a significant health problem in India. In NFHS-3, 9% women reported antenatal tobacco use; moreover, 12% of them were in the reproductive age group. ³¹ It affects not only the users but also the foetus that carries the disease burden. A study showed that awareness on the adverse health effects among rural pregnant tobacco consumers was poor. ³⁸

There are also disparities in tobacco market at tobacco retailers by sociodemographic neighbourhood. Neighbourhoods with lower income have more tobacco marketing. There are more inducements to start and continue smoking in lower income neighbourhoods. There has been late realisation on the use of SLT under the purview of National Tobacco Control laws, leading to increasing prevalence of SLT use among the public and the efforts have to be multifolded if the goals set to be met by 2020 and 2025.

India’s expected population growth by 2020 will be about 300 million and will be in the age range of 15-59 years. ²² The innovative marketing strategies target the younger age groups. ³⁹ Children are used by women to purchase tobacco for them, thus exposing children at a very young age resulting in early initiation and addiction. ³⁷

Marketing strategies – increased marketing strategies of the tobacco companies targeting the vulnerable has been focussed and also seen to be changing with the tobacco control laws. They also are into alternate domestic products, enhancing their visibility. Tobacco companies have distributed free cigarettes to adolescents post legislation. ⁴⁰ The appealing innovative products and marketing strategies from the tobacco company lead to increase in smoking experiments and consumption by the youth. ⁴¹ Data suggest that tobacco marketing is effectively targeted towards younger people and anti-tobacco messages are not understood by all sub-populations. ⁴² A study on schoolchildren aged 13 to 15 years shows that 1 in 5 non-smokers reported about chance of smoking by next year. ⁴³ Surrogate advertisements influence young minds. ⁴⁴

Price of the tobacco products has also been a crucial determinant. Beedis are consumed 8 times more than the cigarettes as the unit price of beedi is less (Rs 0.4) compared with cigarettes (Rs 3.1); although SLT is consumed in highest amount, such a correlation has not been possible and all studies are on the cigarettes and beedis. ¹⁹ Studies in developed countries have shown increased taxes as an important factor that can help cessation, but from Indian context, the prices are cheap, affordable, and there are also shift in the type of product consumed.

Tobacco Burden

Economic and Social Burden

Economic and social costs are least considered among the stakeholders. Moreover, cigarettes and beedis are available in wide varieties and forms giving an option to choose the cheapest ¹⁹ for the unaffordable class. Expenses incurred in tobacco use substitute the basic needs of food and education. Treatment of tobacco-related diseases are high due to increased out of pocket expenditure and exacerbating poverty3. Health care expenditure involves direct medical costs (16%) and indirect morbidity costs (84%) as well as productivity loss due to premature mortality. The financial burden due to tobacco-related disease was US$22.4 billion in 2011-2012.^3,7 Of all the states, Uttar Pradesh, West Bengal, and Andhra Pradesh have higher expenditure3 The economic burden was highest for women (29%) due to SLT use. ⁷

Disease Burden

Tobacco is an important risk factor for non-communicable diseases; the total burden of NCDs is expected to rise from 40% in 1990 to 75% by 2030. ⁴⁵ Tobacco affects every part of the body. In India, the burden of cardiovascular diseases, respiratory diseases, tuberculosis, and cancers is very high. Noteworthy of mentioning here is oral cancer; India has highest oral cancer rates in the world. ⁹ Tobacco is responsible for 90% of oral cancer cases ⁴⁶ and 52% caused using SLT consumption; this needs to be specifically mentioned as SLT use in European countries have not seen similar risk. ⁴⁷ Moreover, most of the oral cancer cases are diagnosed in the advanced stages and the disfigurement caused by the treatment further affects the quality of life apart from imposing financial burden. In addition to other health risks as men, women also experience increased risk of infertility, pregnancy complications, premature births, low birth weight infants, and stillbirths. Nicotine is an appetite suppressor, thus tobacco is associated with appetite suppression. ³² Nicotine causes body weight loss. ³² This is very crucial as Indian population is already suffering from nutritional diseases. Secondhand smoke exposure in children also leads to middle ear and respiratory infections, sudden death, and severe asthma. ⁴⁸ Among pregnant women, tobacco use and SHS exposure are detrimental to health. ³¹ Thirdhand smoke is a potential threat to infants and children with smoker at home. ³² A study on tobacco consumption among the elderly has also shown that elderly population also runs risk of cognitive impairment, dementia, muscular degeneration, cataract, hearing changes, and fire-related fatalities. ⁴⁹ Tobacco affects every part of the body and to consider all diseases is beyond the scope of this review.

Associated Mortality

Tobacco is the leading cause for NCDs; mortality due to NCDs accounts to about 63%, and 80% of the deaths due to NCDs occur in LMICs ⁵⁰ and 50% of these deaths occur in the active age group of 30 to 69 years.^51,52 Attributable burden due to tobacco smoking (including SHS) was 6.3 million deaths and 156 million disability-adjusted life year globally. ⁵³ Globally, 80% of the tobacco-related deaths occur in the LMICs, ⁵⁴ and 12% of the deaths in people above 30 years are caused by tobacco (WHO). According to WHO’s estimation, deaths due to tobacco-related diseases will rise from 1.4% in 1990 to 13.3% in 2020. ⁵⁵ According to WHO, if the tobacco consumption continues with the present trend, global tobacco-related deaths may reach 8 million by 2030. ⁵⁶ Projected tobacco-associated mortality in India is estimated to be 1.5 million by 2020. ⁵⁷

A study on the trends in smoking prevalence for 187 countries between 1980 and 2012 found that the age-standardised prevalence of daily smoking declined by 25% globally with an initial rapid decline followed by a much slower decline after 2006 ⁵⁸ ; the study also showed a steady decline in the prevalence of daily tobacco smoking for both the sexes in developing countries. ⁵⁸

Tobacco Control and Challenges in India

Tobacco control efforts can reduce the disproportionate burden that tobacco use imposes on the poor, thereby decreasing the often wider disparities in health outcomes between the rich and the poor. ⁷ There is complicated legislation addressing the various types of tobacco use, enforced to different extents at various administrative levels across the country. ⁵⁹

Legislation

India’s anti-tobacco legislation was first passed at the national level in 1975, the Cigarettes Act ²¹ ; this was largely limited to statutory warning ‘Cigarette Smoking is Injurious to Health’ to be displayed on cigarette packs and advertisements^60,61 but it did not include non-cigarettes ²² and proved to be inefficient. ²¹ The Prevention and Control of Pollution Act of 1981 considered smoking as air pollutant and The Motor Vehicles Act 1988 made smoking illegal in public vehicle. ⁶⁰ The provision of the Prevention of the Food Adulteration Act 1955 was used by the Government of India in 1990 to prescribe health warning stating chewing of tobacco to be injurious.^21,61 In 1992, Central Government banned sale of tooth paste and tooth powder containing tobacco under the Drugs and Cosmetics Act of 1940. ⁶¹ Cable Television Networks Amendment Act of 2000 prohibited the transmission of advertisements on tobacco and liquor throughout the country. ⁶² Cigarettes and Other Tobacco Products Act (COTPA) 2003, a multifaceted tobacco legalisation, replaced the Cigarettes Act of 1975 and also included cigars, beedis, cheroots, pipe tobacco, hookah, chewing tobacco, pan masala, and gutka. ²¹ The COTPA came into force in 2003; according to this, direct and indirect advertisements of tobacco products, smoking in public places, sale of tobacco to minors, and smoking within a radius of 100 yards of educational institutions are all prohibited; it also included mandatory display of pictorial warning and mandated testing of tar and nicotine content of all tobacco products.^61,63 This comprehensive law promulgated tobacco control rules and during 2001-2003 State Governments imposed ban on gutka and pan masala. ⁶³

India became a signatory to the WHO Framework Convention on Tobacco Control (FCTC). Being a signatory to the treaty, the Indian Government has been in the forefront pursuing a proactive and bold strategy for tobacco control and was an elected coordinator of the countries of the WHO South East Asia Region (SEAR). There has been a significant paradigm shift in tobacco control after FCTC signatory.

To implement the tobacco control laws and to fulfil the commitments under the WHO-FCTC, the Ministry of Health and Family Welfare, Government of India, launched National Tobacco Control Programme (NTCP) in 2008 covering 42 districts of 21 states/union territories of India under which the following activities were planned – training and capacity building; information, education, and communication (IEC) activities; tobacco control laws; and reporting survey and surveillance (National Health Portal). Tobacco-related education for schoolchildren has become more extensive. ⁶⁴

Health is a state subject in India ⁴ and based on its own social, economic, political, and cultural situations develops its own standard operating procedures. ⁶⁵ State legislation is increasingly used for tobacco control but lacks uniformity and multipronged strategies to control the demand. ²¹ Under NTCP, the Government is funding every state. ⁶¹ State-level Governments in India has imposed different types of tobacco control legislation, to cite a few, (1) the Delhi Government was the first to impose a ban on smoking in public places under Delhi Prohibition of Smoking and Non-Smokers Health Protection Act ⁶⁶ and (2) Rajasthan levies a highest tax on all tobacco products.

Tobacco prevention and control policies in India have focussed on awareness and behaviour change. ²⁵ Building an enforcement infrastructure in India appears to be essential to the success of tobacco control and is a much needed Government provision. ²¹ This can be reinforced by involving representatives from local self-government bodies, as they are potentially influential, and untapped nexus between the mainstream policymakers and public and their role is tobacco control will be advantageous. ⁶⁷

Implementation of tobacco control policies and surveillance

Tobacco control in India is large and complex. ⁶⁸ Implementation of policies is a major problem. The tribal population in the country is more than 100 million, and there are geographical and infrastructural challenges. ⁴ Studies have shown Scheduled Tribes are the highest consumers of tobacco. Thus, foremost drawback with laws is failure in implementation. The LMICs spend only 1% of the global tobacco control spending. ⁵⁴ This minimum budget and inadequate human resources needed to undertake tobacco control compared with the magnitude of the problem is a major barrier in effective and efficient tobacco control.

Lack of awareness of the potential problems and definite health hazards associated with tobacco consumption and the tactics of the tobacco industry to target the vulnerable population, the women and the youth, bolster the increased tobacco consumption in developing countries. ⁶⁹ Health professionals have a key role in tobacco control but have not been effectively brought into this area (WHO). If we look into GATS 2010 and GATS 2016, advice from health professionals has been inspiring and motivating in cessation. But are they effectively trained? Studies have shown that substantial proportion of health professionals themselves considered that lower levels of tobacco use had limited consequences.^70,71 Among the Indian population, awareness of tobacco being harmful is high after FCTC but personalisation of potential harm and knowledge of more specific consequences of tobacco use were less. ⁶⁸ Although anti-tobacco warning messages are on the packs, these are not understood by all sub-populations, ⁴² as it requires intense health education. Health indicators of Kerala state in India are far ahead of the Indian averages and are also closer to the developed countries^72,73 and also literacy rate is very high. Despite this social structure, prevalence rate is similar to India. ⁷²

Government of India has become increasingly engaged with India’s tobacco problem ⁶⁸ ; however, tobacco control cannot be done in isolation. Implementation of legislation is the prime factor in control. Integrating tobacco control with health programmes will optimise the utilisation of human and financial resources ⁷⁴ and also alleviate major barriers in tobacco control. Establishment of central and state-coordinating mechanisms to monitor, effective enforcement of tobacco control legislation is required. ²²

Tobacco industry contribution

The overall contribution of tobacco industry to India’s large agricultural sector is small. Approximately 3.5 million people are employed in tobacco cultivation, and this represents 0.5% of the agricultural labour force and 0.31% of the total labour force. ⁷⁵ Cigarette manufacturing is a mechanised job and creates fewer jobs. Beedi manufacturing is the largest tobacco industry in India. ²¹ Beedi production and various other forms of tobacco, SLT, production take place as an unorganised sector on the pretext of employment and exploits millions of women and children.

To justify tobacco with the revenue from the tobacco, studies have shown that in the year 2011-2012, the estimated cost of economic burden due to tobacco-related diseases was 22.4 billion and the revenue gained from total excise on tobacco was 17% of the estimated economic risk. ³ There has been marked promotion of tobacco products by the industry. ²⁵ The increased market power of tobacco companies poses new challenges for public health. ⁷ The cottage industry uses aggressive marketing and advertising and has established a secure market. ⁷⁶ The unorganised beedi manufacturing is considered as small-scale industry and are largely protected from high taxes unlike cigarette industry. ⁷⁶ The effects of tobacco use in India are projected to be devastating.

Discussion

The tobacco consumption levels in India continue to be increasing. Continuous evaluation of tobacco consumption pattern will help in developing effective tobacco control interventions. Most of the large studies have limitations because one of the members in the household provided information. Community-based studies where data collection is done from each of the participants at different points in time will be a better source of information to understand the trends.

Although the NFHS-4 and GATS-2 have shown relative reduction, India still has the highest number of consumers and burden of tobacco-related diseases. There is greater delay in addressing the issue of SLT problem in India due to the ad hoc amendments made to the national laws in India. ²⁶

Studies have shown that people have widespread understanding of tobacco-related harm but less knowledge about specific consequences of use. ⁶⁸ Moreover, control of NCDs including tobacco control was not an agenda of the global poor ⁷⁷ and was omitted from the ambitious Millennium Development Goals adopted in 2000. ⁷⁴ This systematic omission is also a cause for the present prevalence rate among the disadvantaged sections.

Worksites are important areas for promotion of tobacco cessation as the users are continuously exposed to health warnings and dangers of tobacco use. ⁷⁸ This needs to be considered not only for the organised sector but also for the unorganised sector in India which forms 92% of the workforce which mostly includes the labourers, both rural and urban, in various areas such as agriculture, construction, and industrial; health warning and smoke-free policies will have enormous impact on the tobacco consumption by the poor.

There is no evidence for enhancement of tobacco-related education and prevention or cessation training in medical and dental curriculum or the production of training programmes aimed at current medical and dental practitioners (McKay, 2015). Supplementary education about tobacco will be beneficial to traditional health care providers for the success of these (McKay, 2015). ⁶⁸ It is important because health professionals have a greater role to play; studies have shown that tobacco users have been provided with cessation advice by health professionals, but as the levels of cessation advice have been low, the consumption has continued.^79–81 Government of India plans to implement specialist cessation services as distinct units apart from the existing health services under specially trained professionals. ⁸² This will be a great value addition as studies have shown that additional disease-specific cessation counselling by non-doctor health professional to be efficacious in preventing smoking cessation. ⁸³

Reduction in tobacco consumption will require redoubling efforts to prevent initiation and promote cessation among the large proportion of youth, who currently are tobacco consumers. ⁴³ Cessation counselling conducted for families as a whole will be effective as they influence each other than individually. ³⁷ Tobacco cessation counselling using 5As and 5Rs at speciality and superspeciality health care areas has been efficacious in increasing the cessation rate.^84,85 Integration of tobacco control activites with developmental programmes^22,86 such as poverty alleviation, rural development schemes, women and child development and tribal welfare programmes will lead to extensive and widespread presence of tobacco control activity at the grass root level. And also active engagement of academic institutions, civil societies and research organisations are needed to to make evidence based policy actions. Tobacco cessation counselling can be made part of all health care specialities.

Need for India

Tobacco use contributes to poverty; diversion of household spending from other basic needs such as food and family needs is substituted by expense of tobacco consumption. Illness caused by tobacco leads to increased out-of-pocket spending, and tobacco-related morbidity and mortality are high in the productive age group of 24 to 69 years. Integration of tobacco cessation programmes with health and development programmes can be helpful in overcoming the barriers in tobacco control and decreasing the tobacco-associated burden. For preventing the devastating effect of tobacco, tobacco control policies need to be strictly implemented, and for better penetration of policies, culture-based strategies need to be devised.