Despite the widespread awareness of the associated harms, tobacco usage continues to be one of the most serious health challenges in India. Being one of the world’s largest producers and consumers, India has over 267 million adults using tobacco in various forms. Contrary to the popular belief cigarettes and bidis are not the most heavily used tobacco products. India actually faces a more acute health burden due to smokeless tobacco (SLT) products such as gutka, paan, paan masala, khaini and zarda. Over the years, India has come up with several policies on tobacco regulation in the country. But most of these have failed to address the issue of regulating the usage of SLTs. There are gaps in policy implementation and comprehensive changes are needed to close them.
Dual Burden of Smoking and Smokeless Tobacco in India
Tobacco use contributes to over 9.5 per cent of total deaths in India. India today faces a dual burden of both smoked and smokeless tobacco consumption. According to the Global Adult Tobacco Survey (GATS) conducted in 2016–17, the total prevalence of smoking tobacco use in the country is 10.38 per cent, SLT usage is 21.38 per cent. While dual usage is still prevalent in rural regions, it has increased dramatically in urban areas.
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Why are SLTs massively consumed?
In comparison to smoked tobacco products, SLTs are more readily available in the market due to the variety in number. Moreover, most SLTs can be found in the market at very cheap rates. Zarda, gutka, different kinds of masalas are sold in the market at extremely low prices of below Rs 5. These prices make SLTs extremely affordable for people to buy, even more than once a day. Also, SLT use is increasing as a result of greater societal acceptance, curiosity and culture. Media advertisements have a huge role to play in bringing these into popular culture. Celebrities are roped in for promoting paan masalas and various forms of SLTS. The star value of these celebrities overshadows the health risks of consuming the products.
SLT and Social Determinants
Gender, age, location, socioeconomic status and literacy levels are all important social and demographic determinants that affect levels of SLT consumption. According to a study conducted in 2015, SLT use in India is highest among the poor, followed by middle-class and then the rich. There is a clear identification that the economically weaker population is more vulnerable to health burdens associated with SLT. They are the ones who generally can’t afford health treatments, putting them at further risk of adverse outcomes and death. Tobacco use, particularly SLTs, is very common among women. In 2018, India’s all-cause mortality due to SLT use was estimated to be 368,127 people, with women accounting for approximately three-fifths of these deaths. SLT, as well as tobacco dual-use, is highest in the 25-44 age group. There is a definite need for prevention efforts that focus on young adults to avoid both immediate and long-term damages.
Health Risks Associated with SLT
Tobacco, both smoked and smokeless, has a lot of deleterious effects on the human body. It multiplies the risk of mouth, throat and pancreatic cancer. Using SLT increases the risk of death from heart attacks and strokes. On top of this, SLT causes damage to one’s teeth and gums. When SLT is used during pregnancy, it can result in foetal brain damage, stillbirth and poor birth weight in the newborn.
Need for Comprehensive Changes
India is a signatory to the “World Health Organisation Framework Convention on Tobacco Control”, the first treaty ever signed under the WHO’s auspices. This was enacted in 2005. A National Tobacco Control Programme has been implemented by the union government. Although the programme has been successful in adopting some strategies to reduce tobacco-related harm, there is still much more work to be done. The government’s strategy is similar to the WHO’s, which focuses on reducing demand while increasing supply. However, implementation is lacking. This can be accomplished by raising product costs and taxes, regulating cigarette packaging content and labelling smokeless tobacco products. Furthermore, in the case of SLT, education, communication, training and public awareness have been disregarded. Awareness campaigns around it can help.
Allocating resources to assist people who want to quit smoking is a vital step. Supporting farmers who rely on tobacco for their livelihoods in their transition to other sources of income is another critical one. SLT products, unlike cigarettes, are generally unregulated, and many of these precautions are yet to be adopted. Outright bans that do not reduce demand for certain products do not produce the desired results. For instance, banning gutka led to consumers shifting to alternative tobacco products. An approach which combines reducing demand (via education, increased pricing, de-addiction, health warning on packaging) and throttling supply (via crop substitution, content regulation, product substitution) is key to tobacco control in India.
The tobacco industry is one of the most dominant in the country, with a significant market share. It is critical that we do not allow the tobacco industry to block tobacco-control legislation. The country has put a lot of emphasis on minimising the harm caused by cigarettes, but it has lagged in terms of harm caused by gutkha, betel quid with tobacco, and zarda. We must recognise that smokeless tobacco is the most commonly used form of tobacco, and we are not doing enough to avoid the dangers it causes.
Mahek Nankani is Assistant Programme Manager, The Takshashila Institution. Harshit Kukreja is Research Analyst, The Takshashila Institution. The views expressed in this article are those of the authors and do not represent the stand of this publication.
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