Smokeless Tobacco and Public Health in India
Scientific Editors Prakash C. Gupta Monika Arora Dhirendra Sinha Samira Asma Mark Parascondola
Disclaimer: The views expressed in this report are not necessarily those of the Ministry of Health and Family Welfare, Government of India or of the organizations that authors and editors are affiliated to.
Suggested citation: Gupta PC, Arora M, Sinha DN, Asma S, Parascandola M (eds.); Smokeless Tobacco and Public Health in India. Ministry of Health & Family Welfare, Government of India; New Delhi; 2016. Editorial Assistants Cecily S. Ray Manu Raj Mathur Lauren Bartell Message
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viii Smokeless Tobacco and Public Health in India
Contributors
Authors Manu Raj Mathur Swati Srivastava 3K')HOORZ 5HVHDUFK$VVRFLDWH 3XEOLF+HDOWK)RXQGDWLRQRI,QGLD 3+), 3XEOLF+HDOWK)RXQGDWLRQRI,QGLD 3+) 1HZ 3+'+RXVH6HFRQG)ORRU6LULIRUW 'HOKL,QGLD ,QVWLWXWLRQDO$UHD$XJXVW.UDQWL0DUJ VZDWLVULYDVWDYD#SK¿RUJ 1HZ'HOKL±,QGLD PDQXPDWKXU#SK¿RUJ Dhirendra N. Sinha 5HJLRQDO$GYLVRU6XUYHLOODQFH 7REDFFR Gaurav Kumar &RQWURO 7REDFFR)UHH,QLWLDWLYH:RUOG+HDOWK 5HVHDUFK$VVRFLDWH +RXVH,QGUDSUDVWKD(VWDWH0DKDWPD*DQGKL 3XEOLF+HDOWK)RXQGDWLRQRI,QGLD 3+), 0DUJ 1HZ'HOKL,QGLD 1HZ'HOKL±,QGLD *DXUDYNXPDU#SK¿RUJ VLQKDG#VHDURZKRLQW
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ix Contributors
Krishna M. Palipudi Prakash C. Gupta 6HQLRU6HUYLFH)HOORZ 'LUHFWRU &HQWHUVIRU'LVHDVH&RQWURODQG3UHYHQWLRQ +HDOLV6HNKVDULD,QVWLWXWHIRU3XEOLF+HDOWK %XLOGLQJ &+$0 %*UHDW(DVWHUQ&KDPEHUV 5RRP 1&&'3+36WDWLRQ 3ORW1R6HFWRU&%'%HODSXU &KDPEOHH*$86$ 1DYL0XPEDL±,QGLD NULVKQDSDOLSXGL#FGFKKVJRY JXSWDSF#KHDOLVRUJ
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L[ /LVWRI7DEOHV [L[ /LVWRI)LJXUHV[[LLL 3UHIDFH[[YLL ([HFXWLYH6XPPDU\ Chapter 1 +LVWRULFDODQG6RFLRFXOWXUDO2YHUYLHZRI6PRNHOHVV7REDFFRLQ,QGLD 0DQX5DM0DWKXU*DXUDY.XPDU5LFKD:DKL Chapter 2 (FRQRPLFVRI6PRNHOHVV7REDFFRLQ,QGLD 23 6DNKWLYHO6HOYDUDM6DULW.XPDU5RXW%5DYL.XPDU6ZDWL6ULYDVWDYD Chapter 3 6PRNHOHVV7REDFFR8VH$PRQJ Chapter 4 6PRNHOHVV7REDFFR8VH$PRQJ$GXOWVLQ,QGLD .ULVKQD03DOLSXGL3UDNDVK&*XSWD6DPLUD$VPD'KLUHQGUD16LQKD3UDEKDW-KD Chapter 5 'XDO7REDFFR8VHLQ,QGLD 3UDNDVK&*XSWD.ULVKQD03DOLSXGL'KLUHQGUD16LQKD&HFLO\65D\ Chapter 6 'HWHUPLQDQWVRI6PRNHOHVV7REDFFR8VHLQ,QGLD $QNXU6LQJK0DQX5DM0DWKXU.ULVKQD03DOLSXGL0RQLND$URUD Chapter 7 $GYHUWLVLQJDQG0DUNHWLQJRI6PRNHOHVV3URGXFWV %KDYQD%0XNRSDGK\D\&KDQGUD5DPDNULVKQDQ Chapter 8 :RPHQDQG6PRNHOHVV7REDFFR 6SHFLDO&RQVLGHUDWLRQV 6UHHYLG\D6XEUDPRQH\0LUD%$JKL Chapter 9 6PRNHOHVV7REDFFRDQG$OO&DXVH0RUWDOLW\ 0DQJHVK63HGQHNDU3*DQJDGKDUDQ Chapter 10 6PRNHOHVV7REDFFR8VHDQG&DQFHU 6XUHQGUD6KDVWUL3DQNDM&KDWXUYHGL6RXUDY'DWWD$GLWL6KDVWUL Chapter 11 &DUGLRYDVFXODU'LVHDVHVDQG2WKHU+HDOWK&RQVHTXHQFHVRI 6PRNHOHVV7REDFFR8VH 6DOPDQ6DODKXGGLQ6DLOHVK0RKDQ$PEXM5R\.6ULQDWK5HGG\ xvii Contents Chapter 12 2UDO+HDOWK&RQVHTXHQFHVRI6PRNHOHVV7REDFFR8VH 9LMD\0DWKXU7DQXSUL\D*XSWD0DQX5DM0DWKXU3DOXUL5DPD0XUWL Chapter 13 &KHPLVWU\DQG7R[LFRORJ\RI6PRNHOHVV7REDFFR 5DMDQL$%KLVH\6WHSKHQ%6WDQ¿OO Chapter 14 6PRNHOHVV7REDFFR $GGLFWLRQ:LWKGUDZDODQG&HVVDWLRQ 243 5DM.XPDU1LWLQ*RHO Chapter 15 $GYRFDF\DQG3ROLF\0HDVXUHV 0RQLND$URUD'HHSWL6LQJK5DJKDYHQGUD0DGKX6KHNKDU6DONDU Chapter 16 /LWLJDWLRQDQG-XGLFLDO0HDVXUHV $PLW Chapter 17 +HDOWK&RPPXQLFDWLRQIRU6PRNHOHVV7REDFFR&RQWUROLQ,QGLD 1DQGLWD0XUXNXWOD7DKLU7XUN6DQGUD0XOOLQ9LQHHW*LOO0XQLVK3UDYHHQ.6LQKD Chapter 18 6WUDWHJLF3DUWQHUVKLSVDQG,QWHJUDWLRQ 5DMPRKDQ3DQGD0RQLND$URUD'LY\D3HUVDL 5HFRPPHQGDWLRQV $GGHQGXP $SSHQGL[±)DFWVKHHWVRQ6PRNHOHVV7REDFFR3URGXFWVLQ,QGLD $SSHQGL[±6PRNHOHVV7REDFFR,QWHUYHQWLRQ3URJUDPVIRU $SSHQGL[±&RPSLODWLRQRI/LWLJDWLRQV $SSHQGL[±)66$ 6WDWHV¶6WDWXV xviii Smokeless Tobacco and Public Health in India List 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repeatedly countering the tobacco industry’s varied strategies to preserve and enlarge its markets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ation’s Framework Convention RQ7REDFFR&RQWURO :+2)&7& WKHILUVWWUHDW\LQWHQGHG WRFRPEDWWKHJOREDOLsDWLRQRIWKH WREDFFR HSLGHPLF GHILQHV VPRNHOHVV WREDFFR DV ‘WREDFFR WKDW LV FRQVXPHG LQ XQEXUQW IRUP 4 HLWKHURUDOO\RUQDVDOO\’ $FFRUGLQJWRWKH,QWHUQDWLRQDO$JHQF\IRU5HVHDUFKRQ&DQFHU ,$5& The agent termed ‘smokeless tobacco’ includes a large variety of commercially or QRQFRPPHUFLDOO\DYDLODEOHSURGXFWVDQGPL[WXUHVWKDWFRQWDLQWREDFFRDVWKH SULQFLSDOFRQVWLWXHQWDQGDUHXVHGHLWKHURUDOO\RUQDVDOO\ZLWKRXWFRPEXVWLRQ 5 S ,Q DQ DWWHPSW WR FRLQ D YDOLG DQG FRPSOHWH GHILQLWLRQ RI VPRNHOHVV WREDFFR IRU WKH ,QGLDQ VXEFRQWLQHQWZHVXJJHVWWKDWLWFDQEHGHILQHGDV All commercial/noncommercial products that contain tobacco, but which are not ignited at the time of their consumption; are either consumed nasally or orally; and may or may not be mixed with other condiments such as sweetening agents, aromatic spices, areca nut (supari), and lime. SMOKELESS TOBACCO PRODUCTS COMMONLY USED IN INDIA 0\ULDG YDULHWLHV RI VPRNHOHVV WREDFFR SURGXFWV DUH XVHG LQ ,QGLD 7DEOH JLYHV D EULHI RYHUYLHZ RI WKHVH GLIIHUHQW WREDFFR SURGXFWV FODVVLI\LQJ WKHP EDVHG RQ WKHLU PRGH RI FRQVXPSWLRQ )RUGHWDLOHGGHVFULSWLRQVRILQGLYLGXDOVPRNHOHVVSURGXFWVVHHWKHIDFWVKHHWVLQ $SSHQGL[ 13 Chapter 1. Historical and Sociocultural Overview of Smokeless Tobacco in India Table 1.1: Varieties of smokeless tobacco products used in India Smokeless tobacco product Product description For chewing and sucking Products with areca nut %HWHOTXLG SDQ ZLWKWREDFFR 7REDFFRaUHFDQXWsODNHGOLPHFDWHFKXFRQGLPHQWV ZUDSSHGLQEHWHOOHDI *XWND 7REDFFRaUHFDQXWsODNHGOLPHFDWHFKXFRQGLPHQWV .KDUUD 7REDFFRaUHFDQXWsODNHGOLPHFDWHFKXFRQGLPHQWV ORFDOO\PDGH 0DLQSXUL 7REDFFRILQHO\FXWDUHFDQXWVODNHGOLPHSRZGHUHGFORYHVFDUGDPRP.HZDUD HVVHQFHVDQGDOZRRGSRZGHUFDPSKRUSHSSHUPLQW 'RKUD :HWPL[WXUHRIWREDFFRDUHFDQXWVODNHGOLPHFDWHFKX NDWWKD SHSSHUPLQWDQG FDUGDPRP HODLDFKL 0D\EHVROGLQWZRVHSDUDWHSRXFKHVRQHFRQWDLQLQJWREDFFR DQGWKHRWKHUFRQWDLQLQJQRQWREDFFRLQJUHGLHQWV 0DZD 7REDFFRaUHFDQXWVKDYLQJVsODNHGOLPH Products without areca nut .KDLQL 7REDFFRsODNHGOLPH Zarda 7REDFFREOHQGHGZLWKSHUIXPHVDQGIODYRXrs .KLZDP 7KLFNSDVWHRIWREDFFROHDIH[WUDFWZLWKIODYRXULQJVDQGVSLFHV &KHZLQJWREDFFR 7REDFFR UDZILQHO\FXW /RRVHWREDFFROHDI 6WULSRUSLHFHRIDLUFXUHGWREDFFROHDI For application 0LVKUL 5RDVWHGDQGSRZGHUHGWREDFFR *XO 3\URO\sHGWREDFFRSRZGHU *XGDNKX 3DVWHRIWREDFFRDQGPRODVVHV 7DSNHHU%DMMDUVQXII 'U\SRZGHUHGWREDFFRIRURUDORUQDVDOXVH 7REDFFRFRQWDLQLQJWRRWKSRZGHU +HUEDOWRRWKSRZGHUFRQWDLQLQJDVPDOODPRXQWRIWREDFFR8VHGSULPDULO\IRUGHQWDO K\JLHQH &UHDP\VQXIIWRRWKSDVWH 7REDFFREDVHGWRRWKSDVWHZLWKFORYHRLOJO\FHULQHPHQWKROFDPSKRUDVRWKHU LQJUHGLHQWV For gargling 7XLEXU 7REDFFRVPRNHLQIXVHGZDWHU HISTORICAL OVERVIEW OF SMOKELESS TOBACCO The Origins of Tobacco Use 7KH WREDFFRSODQWRULJLQDWHGLQWKH$PHULFDV1DWLYH$PHULFDQVEHJDQWRFXOWLYDWHLWLQDERXW %&( On Christopher Columbus’s travels through the West Indies and the Caribbean in (XURSHDQV ILUVW HQFRXQWHUHG WREDFFR UHSRUWLQJ WKDW WKH\ IRXQG QDWLYHV ZKR ‘GUDQN VPRNH’ $ )UDQFLVFDQ PRQN QDPHG )ULDU 5RPDQ 3DLQH ZKR DFFRPSDQLHG &ROXPEXV RQ KLV VHFRQGYR\DJHWRWKH1HZ:RUOGLQ UHFRUGHGWKHILUVWUHIHUHQFHWRVPRNHOHVVWREDFFRXVH LQWKHZRUOGZKHQKHQRWHGWKDWWKH1DWLYH$PHULFDQVVQLIIHGILQHO\SRZGHUHGWREDFFROHDYHV 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is tobacco’s body, smoke is its ghost and snuff is tobacco’s soul. —%RE6WHYHQV Traditional Use of Betel Quid (Pan) and the Evolution of Smokeless Tobacco Products 7R XQGHUVWDQG WKH VSUHDG RI VPRNHOHVV WREDFFR LQ ,QGLD LW LV LPSRUWDQW WR XQGHUVWDQG WKH WUDGLWLRQRIFKHZLQJSDQZKLFKGDWHVEDFNDWOHDVWyears LQ,QGLDORQJEHIRUHWKHDUULYDORI WREDFFRLQ6RXWK$VLDDQGVWLOOFRQWLQXHVWRGD\ 7KHWUDGLWLRQDOLQJUHGLHQWVLQSDQDUHDUHFDQXW Areca catechu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Historical and Sociocultural Overview of Smokeless Tobacco in India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–PHGLFDO ULWXDO 0RQDUGHV D6SDQLVK GRFWRULQ WKHWK FHQWXU\ZURWHWKDWWREDFFRFRXOGFXUHFRQGLWLRQV LQFOXGLQJKHDGDFKHWRRWKDFKH‘IDOOLQJILQJHUQDLOV’ORFNMDZKDOLWRVLVZRUPVDQGFDQFHr ,QGLDQWUDGLWLRQDOPHGLFLQH$\XUYHGDZDVEDVHGRQWKHFRQFHSWVRIKRWFROGDQGEDODQFHEXW XQOLNH &KLQHVH DQG (XURSHDQ PHGLFLQH LW QHYHU HQFRXUDJHG WKH XVH RI WREDFFR IRU PHGLFLQDO 2 SXUSRVHV 7KHPHGLFDOFRPSHQGLXPYogratnakaraZULWWHQVRPHWLPH EHWZHHQDQG 2 &(DWWULEXWHVERWKSRVLWLYHDQGQHJDWLYHKHDOWKHIIHFWVWRWREDFFRXVH :KLOH VPRNLQJ WREDFFR ZDV UHFRJQLsHG WR KDYH VRPH DGYHUVH HIIHFWV RQ KHDOWK VPRNHOHVV WREDFFRZDVZLGHO\SHUFHLYHGLQPHGLHYDO,QGLDWRKDYHKHDOWKEHQHILWV6PRNHOHVVWREDFFRXVH ZDVEHOLHYHGWRKDYHDQWLVHSWLFSURSHUWLHVDQGWRUHVXOWLQLPSURYHGRUDOKHDOWKUHOLHIIURPWRRWK 2 SDLQEHWWHUGLJHVWLRQDQGLPSURYHGPHPRU\ 7KHVHP\WKVKDYHVXSSRUWHGDQGLQFUHDVHGWKH XVHRIVPRNHOHVVWREDFFRLQ,QGLDIRUJHQHUDWLRQVDQGVRPHRIWKHVHPLVFRQFHSWLRQVVXFKDVWKH EHOLHIWKDWWREDFFRLVKHOSIXOIRUFOHDQLQJWHHWKDUHVWLOOSUHYDOHQWLQUXUDODUHDVDQGVRPHXUEDQ SRSXODWLRQVLQ,QGLDWRGD\ SMOKELESS TOBACCO, RELIGION, AND RITUALS $OWKRXJK ,QGLDQ UHOLJLRXV WH[WV PDNH QR VSHFLILF UHIHUHQFHV WR VPRNHOHVV WREDFFR WKH XVH RI WREDFFRKDV EHHQFRQGHPQHGGLUHFWO\RULQGLUHFWO\LQ DOOWKHPDMRUUHOLJLRXVWH[WV RI,QGLD 3 7REDFFROHDYHVDUHDQLPSRUWDQWHOHPHQWLQ0XULD*RQGWUDGLWLRQ 7KH0XULD*RQGVDWULEH IURP %DVWDU 'LVWULFW LQ &KKDWLVJDUK FRQVLGHU WREDFFR D YDOXDEOH FRPPRGLW\ DQG FRQVXPH LW 3 GXULQJVRFLDORFFDVLRQVDVDQLQGLFDWRURIEURWKHUKRRGDQGXQLW\ SOCIODEMOGRAPHIC PROFILING OF SMOKELESS TOBACCO IN INDIA ,Q ,QGLD DQG RWKHU 6RXWK(DVW $VLDQ FRXQWULHV WKH SUHYDOHQFH DQG SDWWHUQV RI XVH RI WKH QXPHURXVVPRNHOHVVWREDFFRSURGXFWVDYDLODEOHYDU\IURPRQHUHJLRQDQGSRSXODWLRQWRDQRWKHU +LVWRULFDOO\ VPRNLQJ E\ ZRPHQ KDV EHHQ FRQGHPQHG LQ ,QGLDQ FXOWXUH 8VLQJ VPRNHOHVV WREDFFRKRZHYHUKDVEHHQZLGHO\DFFHSWHGZKLFKKDVOHGZRPHQDQG\RXWKWRDFWLYHO\IROORZ WKLV SUDFWLFH &KDUDFWHULVWLFV RI VPRNHOHVV WREDFFR—VXFK DV LWV ORZ SULFH ORZHU GHWHFWDELOLW\ WKDQ VPRNLQJ DQG DGGHG IODYRXUV HJ HODLDFKL DQG FORYH —DSSHDO WR \RXWK DQG ZRPHQ 0DQXIDFWXUHUVKDYHWaNHQDGYDQWDJHRIWKHPLVFRQFHSWLRQVVXUURXQGLQJVPRNHOHVVWREDFFRDQG KDYH ODXQFKHG PDQ\ YDULHWLHV RI 6/7 SURGXFWV PDNLQJ WKHP HDVLO\ DIIRUGDEOH DQG DFFHVVLEOH HYHQE\SRRUDQGYXOQHUDEOHVHFWLRQVRIVRFLHW\ 18 Smokeless Tobacco and Public Health in India 'DLO\DQGRFFDVLRQDOXVHUVRIVPRNHOHVVWREDFFRDPRQJPDOHVDQGIHPDOHVDUHSURSRUWLRQDWHO\ PRUHSUHYDOHQWLQUXUDODUHDVWKDQXUEDQDUHDV&XUUHQWXVHRIVPRNHOHVVWREDFFRLQFUHDVHVZLWK LQFUHDVLQJDJH DPRQJDJHV–\HDUVDQGDPRQJSHRSOH\HDUVDQGROGHU 'DLO\ XVHRIVPRNHOHVVWREDFFRDPRQJPDOHVDQGIHPDOHVKDVEHHQIRXQGWRGHFUHDVHDVHGXFDWLRQDO OHYHOVLQFUHDVH)LJXUHLOOXVWUDWHVWKHLQWHUSOD\RIWKHVHGHPRJUDSKLFIDFWRUV Figure 1.1: Triad of predisposing factors of smokeless tobacco use CONCLUSION 6LQFHWREDFFRZDVILUVWLQWURGXFHGLQ,QGLDVPRNHOHVVWREDFFRKDVEHFRPHWKHGRPLQDQWIRUPRI WREDFFR XVHG LQ WKH FRXQWU\ 6WXGLHV VKRZ WKH ZLGH UDQJH RI DGYHUVH LPSDFWV WKDW VPRNHOHVV WREDFFRKDVIRU LQGLYLGXDOVDQGWKHQDWLRQDVDZKROH)LJXUHGHSLFWVWKHse LPSDFWVDFURVV YDULRXV GLPHQVLRQV RI KHDOWK DQG GHYHORSPHQW 'HWDLOHG GLVFXVVLRQ RI WKH DGYHUVH HIIHFWV RI VPRNHOHVVWREDFFRZLOOIROORZLQVXEVHTXHQWFKDSWHUVRIWKLVUHSRUW 19 Chapter 1. Historical and Sociocultural Overview of Smokeless Tobacco in India Figure 1.2: Impact of smokeless tobacco 20 Smokeless Tobacco and Public Health in India REFERENCES :RUOG+HDOWK2UJDQL]DWLRQ :+2UHSRUWRQWKHJOREDOWREDFFRHSLGHPLF ZDUQLQJDERXWWKHGDQJHUVRI WREDFFR*HQHYD :RUOG+HDOWK2UJDQL]DWLRQ *XSWD3&5D\&66LQKD'16LQJK3.6PRNHOHVVWREDFFR DPDMRUSXEOLFKHDOWKSUREOHPLQWKH6($UHJLRQ DUHYLHZ,QGLDQ-3XEOLF+HDOWK – *XSWD3&5D\&66PRNHOHVVWREDFFRDQGKHDOWKLQ,QGLDDQG6RXWK$VLD5HVSLURORJ\ –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– %RULR*7REDFFRWLPHOLQH WKHWZHQW\ILUVWFHQWXU\—WKHQHZPLOOHQLXP FKDSWHU ,Q 7REDFFRWLPHOLQH >FLWHG$XJ@$YDLODEOHIURP KWWS ZZZWREDFFRRUJUHVRXUFHVKLVWRU\7REDFFRB+LVWRU\KWPO &DPSEHOO+:K\GLGWKH\QDPHLW" 1HZ 21 Chapter 1. Historical and Sociocultural Overview of Smokeless Tobacco in India &KDXGKXUL6.&KDXGKXUL63ULPLWLYHWULEHVLQFRQWHPSRUDU\,QGLD9RO 1HZ'HOKL 0LWWDO3XEOLFDWLRQV *RYHUQPHQWRI,QGLD 0LQLVWU\RI$JULFXOWXUH 'LUHFWRUDWHRI(FRQRPLFVDQG6WDWLVWLFV'HSDUWPHQWRI $JULFXOWXUHDQG&RRSHUDWLRQ$JULFXOWXUDOVWDWLVWLFVDWDJODQFH. 1HZ'HOKL $YDLODEOHIURP KWWS HDQGVGDFQHWQLFLQODWHVWBKWP 6XGDUVKDQ50LVKUD1*HQGHUDQGWREDFFRFRQVXPSWLRQLQ,QGLD$VLDQ-:RPHQV6WXG – 3DQFKDPXNKL$7REDFFRLQDQFLHQW,QGLDQOLWHUDWXUH:RUNLQJSDSHU1R'KDUZDG &HQWUHIRU 0XOWL'LVFLSOLQDU\'HYHORSPHQW5HVHDUFK 6LQKD'1*XSWD3&3HGQHNDU068VHRIWREDFFRSURGXFWVDVGHQWLIULFHDPRQJDGROHVFHQWVLQ,QGLD TXHVWLRQQDLUHVWXG\%0- – &KDWWRSDGKD\\D$+DUPIXOHIIHFWVRIWREDFFRQRWLFHGLQKLVWRU\%XOO,QGLDQ,QVW+LVW0HG+\GHUDEDG – *HOO$1HZFRPHUVWRWKHZRUOGRIJRRGV FRQVXPSWLRQDPRQJWKH0XULD*RQGV,Q 0LOOHU'HGLWRU &RQVXPSWLRQ FULWLFDOFRQFHSWVLQWKHVRFLDOVFLHQFHV/RQGRQDQG1HZ 22 Chapter 2 Economics of Smokeless Tobacco in India 6DNKWLYHO6HOYDUDM6DULW.XPDU5RXW2 %5DYL.XPDU36ZDWL6ULYDVWDYD 3XEOLF+HDOWK)RXQGDWLRQRI,QGLD1HZ'HOKL 2,QGLDQ,QVWLWXWHRI3XEOLF+HDOWK%KXEDQHVZDU 3,QGLDQ,QVWLWXWHRI3XEOLF+HDOWK1HZ'HOKL 24 Smokeless Tobacco and Public Health in India INTRODUCTION ,Q FRQWUDVW WR WKH UHVW RI WKH ZRUOG WKH FRQVXPSWLRQ RI VPRNHOHVV WREDFFR 6/7 LQ ,QGLD LV VXEVWDQWLDOO\KLJKHUWKDQWKDWRIVPRNHGWREDFFR%HFDXVHRIWKHLQFUHDVLQJGHPDQGSURGXFHUV DUH PDQXIDFWXULQJ GLYHUVH FDWHJRULHV RI VPRNHOHVV SURGXFWV 6/7 SURGXFW SUHIHUHQFH YDULHV DFURVV SRSXODWLRQ JURXSV IRU LQVWDQFH \RXWKV WHQG WR SUHIHU JXWND ZKLOH JXOJXGDNKX LV SULPDULO\XVHGE\ZRPHQIRUFOHDQLQJWHHWK7KHVL]HQDWXUH DQGVWUXFWXUHRIWKH6/7LQGXVWU\ in India—LWV JURZWK WUHQGV DQG LWV FRQWULEXWLRQV WR HPSOR\PHQW WUDGH UHYHQXH DQG IRUHLJQ H[FKDQJHHDUQLQJV—VKRXOG EHH[DPLQHGFDUHIXOO\LQRUGHUWRGHVLJQVXLWDEOHVWUDWHJLHVWRFXUE LWVJURZWK ECONOMIC BURDEN 7KHHFRQRPLFEXUGHQRIWREDFFRDWWULEXWDEOHGLVHDVe LVVXEVWDQWLDO2QHVWXG\ LQ HVWLPDWHG WKDWWKHWRWDOGLUHFWDQGLQGLUHFWFRVWDWWULEXWDEOHWRWKUHHPDMRUWREDFFRUHODWHGGLVHDVHVLQ,QGLD 2 3 ZDV86ELOOLRQ 7KLVDPRXQWLQFUHDVHGE\LQ $QRWKHUVWXG\ REVHUYHG WKDWWKHGLUHFWPHGLFDOFRVWVRIWUHDWLQJWREDFFRUHODWHGGLVHDVHVLQ ,QGLDLQ DPRXQWHGWR 86 PLOOLRQIRUVPRNHGWREDFFRDQG86PLOOLRQIRU6/7,QGLUHFWFRVWVRIXVHZHUH 86 DQG86IRUVPRNLQJDQG6/7UHVSHFWLYHO\ $FFRUGLQJWRWKDWVWXG\WKHFRVWRI WREDFFR XVH waV DERXW KLJKHU WKDQ WKH WRWDO WD[ UHYHQXH IURP WREDFFR DQG FRQVLGHUDEO\ H[FHHGed H[SHQGLWXUHVRQWREDFFRFRQWUROE\WKH*RYHUQPHQWRI,QGLD 7KH WREDFFRDWWULEXWDEOH FRVW RI WXEHUFXORVLV ZDV WKUHH WLPHV KLJKHU WKDQ WKH H[SHQGLWXUH Rn 3 WXEHUFXORVLVFRQWUROLQ,QGLD ,WKDVDOVREHHQHVWLPDWHGWKDWDFFRXQWLQJIRUGLUHFWH[SHQGLWXUHRQ WREDFFRZRXOGLQFUHDVHWKHUXUDODQGXUEDQSRYHUW\UDWHVE\ DIIHFWLQJPLOOLRQSHRSOH 4 DQG DIIHFWLQJ PLOOLRQ SHRSOH UHVSHFWLYHO\ 6LQFH WKH SRRU XVH WREDFFR DW KLJKHU UDWHVWKDQRWKHUJURXSVUDWHVRIWREDFFRUHODWHGLOOQHVVDQGWKHUHVXOWLQJHFRQRPLFEXUGHQZRXOG 5 EHJUHDWHUDPRQJWKHSRRU 7KRVHZKRXVHWREDFFRDOVRKDYHDKLJKHUULVNRIERUURZLQJDQG VHOOLQJDVVHWVGXULQJKRVSLWDOLsDWLRQWKDQ RWKHUV 7KHHYLGHQFHWKHUHIRUHLQGLFDWHVWKDWWKHSRRU DUHSDUWLFXODUO\YXOQHUDEOHWRWKHHFRQRPLFFRVWRIWREDFFRXVH TOBACCO CULTIVATION IN INDIA ,QGLD SURGXFHV VHYHUDO W\SHV RI WREDFFR ZKLFK EHORQJ WR WZR ERWDQLFDO VSHFLHV Nicotiana tabacum and Nicotiana rustica. 7KRXJKWKHFRXQWU\JURZVERWKVSHFLHVWKHODUJHVWDUHDXQGHU FXOWLYDWLRQLVSODQWHGLQN. tabacum0RUHWKDQQLQHN. tabacum YDULHWLHVDUHJURZQLQGLIIHUHQW UHJLRQVRIWKHFRXQWU\LQFOXGLQJFLJDUHWWHWREDFFR 9LUJLQLDIOXHFXUHG ELGL FKHZLQJKRRNDK FLJDU FKHURRW VQXII QDWX DQG EXUOH\ WREDFFR 7REDFFR KDV EHHQ JURZQ LQ ,QGLD VLQFH WKH 3RUWXJXHVH LQWURGXFHG LW WKH HDUO\ V ,W ZDV ILUVW JURZQ LQ WKH VWDWH RI *XMDUDW DQG ODWHU VSUHDGWRRWKHUDUHDVRIWKHFRXQWU\ 7KHPDLQWREDFFRJURZLQJVWDWHVDUH$QGKUD3UDGHVK.DUQDWDND7DPLO1DGX*XMDUDW3XQMDE 8WWDU3UDGHVK$VVDP%LKDU2ULVVDDQG:HVW%HQJDO7KUHHVWDWHV$QGKUD3UDGHVK.DUQDWDND DQG*XMDUDWFRQWDLQRIWKHWRWDOODQGDUHDIRUJURZLQJWREDFFR $QGKUD3UDGHVKDFFRXQWV IRURIWKHWRWDOODQGXQGHUWREDFFRFXOWLYDWLRQIROORZHGE\.DUQDWDNDZLWKDQG*XMDUDW ZLWK ,Q DGGLWLRQ WR WKH RYHUDOO UHGXFWLRQ LQ ODQG DUHD FXOWLYDWHG LQ WREDFFR WKH DPRXQW RI WREDFFR SURGXFHGIOXFWXDWHGEHWZHHQ DQG ,Q KHFWDUHVRIODQGZDVXVHG IRUJURZLQJWREDFFRZLWKDWRWDOSURGXFWLRQRIWRQQHV 7DEOH 7KHDUHDGHFOLQHGWR 25 Chapter 2. Economics of Smokeless Tobacco in India KHFWDUHV LQ EXW SURGXFWLRQ GLG QRW GHFOLQH SURSRUWLRQDOO\ ZKLOH WKH FXOWLYDWHG DUHD GHFOLQHG E\ SURGXFWLRQ GHFOLQHG E\ RQO\ LQGLFDWLQJ LQFUHDVHG SURGXFWLYLW\GXULQJWKHSHULRG%RWKDUHDDQGSURGXFWLRQGHFOLQHGVKDUSO\LQGXHWRD FURS KROLGD\ LQ $QGKUD 3UDGHVK $UHD XQGHU FXOWLYDWLRQ LQFUHDVHG DJDLQ DIWHU EXW UHPDLQHGVPDOOHUWKDQWKHDUHDXVHGIRUJURZLQJWREDFFRGXULQJWKH V2QDYHUDJH KHFWDUHVRIODQGZDVXVHGIRUWREDFFRFXOWLYDWLRQGXULQJ –DQGWKLVGHFOLQHGWR KHFWDUHV GXULQJ WKH \HDUV – +RZHYHU WKH DYHUDJH \LHOG SHU KHFWDUH LQFUHDVHG IURP NJVGXULQJ –WRNJVGXULQJ– Table 2.1: Area and production of tobacco in India Area Production Yield Year (000 hectares) (000 tons) (kg/hectare) 524 Average (1990 to 2000) Average (2000 to 2008) Source: *RYHUQPHQWRI,QGLD0LQLVWU\RI$JULFXOWXUH'LUHFWRUDWHRI7REDFFR'HYHORSPHQW Area Grown and Crop Production in India 8QOLNHRWKHUPDMRUWREDFFRJURZLQJFRXQWULHVLQWKHZRUOGLQ,QGLDWREDFFRIRUGLIIHUHQWW\SHV RISURGXFWV ELGL, FLJDUKRRNDKFKHZLQJDQGVQXII DVZHOODVW\SHVRIWREDFFR 9LUJLQLDQDWX LVJURZQLQVSHFLILFDUHDVRIWKHFRXQWU\7REDFFRWREHXVHGLQ6/7SURGXFWVLVPDLQO\JURZQLQ 7DPLO 1DGX *XMDUDW %LKDU :HVW %HQJDO DQG 8WWDU 3UDGHVK DFFRUGLQJ WR WKH 'LUHFWRUDWH RI 7REDFFR'HYHORSPHQW*RYHUQPHQWRI,QGLD 2IWKHWRWDOODQGDUHDRQZKLFKWREDFFRLVJURZQ 26 Smokeless Tobacco and Public Health in India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able 2.2: Land area of various tobacco crops in India (000 hectares) (percent) Smokeless Chewing Snuff varieties Smoked Year Total varieties varieties (chewing + varieties snuff) 5 5 33 4 27 Chapter 2. Economics of Smokeless Tobacco in India Smokeless Chewing Snuff varieties Smoked Year Total varieties varieties (chewing + varieties snuff) Average (1990 to 2008) Source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able 2.3: Production of various types of tobacco crops (000 tonnes) (percent) and yield per hectare (kg/hectare) Smokeless tobacco varieties Smoked tobacco Total tobacco Chewing Snuff production Year varieties varieties Production Yield Production Yield (smoked + (000 tonnes) (kg/hectare) (000 tonnes) (kg/hectare) smokeless) 352 353 452 2 254 2 28 Smokeless Tobacco and Public Health in India Smokeless tobacco varieties Smoked tobacco Total tobacco Chewing Snuff production Year varieties varieties Production Yield Production Yield (smoked + (000 tonnes) (kg/hectare) (000 tonnes) (kg/hectare) smokeless) 2 2 524 2 2 433 2 2 342 2 2424 2 2 Source: *RYHUQPHQWRI,QGLD0LQLVWU\RI$JULFXOWXUH'LUHFWRUDWHRI7REDFFR'HYHORSPHQW SLT MANUFACTURE Categories of SLT Manufacturers 7REDFFR PDQXIDFWXULQJ LQ ,QGLD OLNH PRVW ,QGLDQ PDQXIDFWXULQJ IDOOV LQWR WZR FDWHJRULHV UHJLVWHUHGRURUJDQLsHGDQGXQUHJLVWHUHGRUXQRUJDQLsHG8QGHUWKH%LGLDQG&LJDU:RUNHUV$FW RI WREDFFR SURGXFW IDFWRULHV ZLWK RU PRUH ZRUNHUV RU DW OHDVW ZRUNHUV SOXV HOHFWULFLW\DUHUHTXLUHGWREHUHJLVWHUHG7KH$QQXDO6XUYH\RI,QGXVWU\ $6, LVWKHPDLQVRXUFH RIGDWDIRUDOOUHJLVWHUHGPDQXIDFWXULQJ7KHXQUHJLVWHUHGPDQXIDFWXULQJVHFWRULVWUDFNHGE\WKH 1DWLRQDO 6DPSOH 6XUYH\ 2UJDQLsDWLRQ 1662 WKURXJK WKH FRXQWU\ZLGH (FRQRPLF &HQVXVHV XQGHUWDNHQE\WKH&HQWUDO6WDWLVWLFDO2UJDQLsDWLRQ &62 166GDWDDUHFROOHFWHGSHULRGLFDOO\ ZKLFKFDQUHVXOWLQJDSVLQGDWDRQWKHXQUHJLVWHUHGVHFWRU %RWK WKH 1662 DQG &62 VXUYH\V GHILQH WKH 6/7 LQGXVWU\ XVLQJ WKH 1DWLRQDO ,QGXVWULDO &ODVVLILFDWLRQ 1,& 7DEOHGHVFULEHVWKHILYHGLJLWFODVVLILFDWLRQRIWREDFFRPDQXIDFWXULQJ DFFRUGLQJ WR 1,& ZKLFK IXUWKHU FDWHJRULsHV WKH WREDFFR LQGXVWU\ LQWR WKUHH PDMRU FDWHJRULHV WREDFFR OHDI SURFHVVLQJ VPRNHG WREDFFR PDQXIDFWXULQJ DQG VPRNHOHVV WREDFFR PDQXIDFWXULQJ:LWKLQWKHVHWKUHHFDWHJRULHVDUHQLQHVXEJURXSV'DWDDUHDQDO\sHGIRUWKH\HDUV DQGXVLQJERWK$6,DQQXDOGDWDDQG166GDWD 29 Chapter 2. Economics of Smokeless Tobacco in India Table 2.4: Structure of the tobacco manufacturing industry as defined by the National Industrial Classification (NIC), 2004 NIC 2004 Broad classification Process or product codes 7REDFFRVWHPPLQJUHGU\LQJHWF 7REDFFROHDISURFHVVLQJ RIWREDFFROHDI %LGLV 6PRNLQJWREDFFR &LJDUHWWHVDQGFLJDUHWWHWREDFFR SURGXFWV &LJDUVDQGFKHURRWV 6QXII Zarda 6/7 &DWHFKX NDWKD DQGFKHZLQJOLPH SURGXFWV 3DQPDVDODDQGUHODWHGSURGXFWV &KHZLQJWREDFFRDQGRWKHUWREDFFR SURGXFWV Source: 1DWLRQDO,QGXVWULDO&ODVVLILFDWLRQ Estimating the Size of India’s SLT Industry The size of India’s smokeless tobacco industry can be estimated using the gross value added *9$ DSDUDPHWHUWKDWLVGHILQHGDVWRWDORXWSXWVPLQXVWRWDOLQSXWVRIDQLQGXVWU\,QJHQHUDO WRWDORXWSXWVDUHWKHVXPRIWKHYDOXHVRISURGXFWVDQGE\SURGXFWVSURGXFHGE\DQLQGXVWU\DQG LQFRPHIURPVHUYLFHVYDOXHRIHOHFWULFLW\JHQHUDWHGDQGVROGDQGVDOHYDOXHRIJRRGVVROGLQWKH VDPHFRQGLWLRQDVSXUFKDVHG7RWDOLQSXWVDUHWKHVXPRIWKHYDOXHVRIZRUNGRQHE\RWKHUVRQ PDWHULDOV VXSSOLHG DOO UHSDLU DQG PDLQWHQDQFH RSHUDWLQJ DQG QRQRSHUDWLQJ H[SHQVHV and LQVXUDQFHFKDUJHV 7DEOH VKRZV WKH *9$ IRU registered and unregistered manufacturing RI YDULRXV 6/7 SURGXFWV DW WKUHH SRLQWV EHWZHHQ DQG 7KH *9$ IRU 6/7 SURGXFWV UHJLVWHUHG DQG XQUHJLVWHUHGVKRZHGDGHFOLQLQJWUHQGRYHU\HDUV%HWZHHQDQGWKH *9$GHFOLQHGDOPRVWIURP5V PLOOLRQLQLQDEVROXWHWHUPVWRMXVWXQGHU 5VPLOOLRQLQ%\WKH *9$LQFUHDVHGWR5V PLOOLRQEXW VWLOOIHOOVKRUWRILWVOHYHO 7KH FRQWULEXWLRQ RI unorganised/unregistered manufacturing WR *9$ LQFUHDVHG PRUH WKDQ WLPHV IURP WR JURZLQJ IURP LQ WR LQ $OWKRXJK WKH VKDUH RI XQUHJLVWHUHG PDQXIDFWXULQJ GHFOLQHG WR E\ D GHFOLQH WKHXQRUJDQLsHGVHFWRUFRQWLQXHVWRFRQWULEXWHDODUJHVKDUHRIWKHVPRNHOHVVLQGXVWU\ 7KLVWUHQGPLUURUVFRQGLWLRQVLQWKH,QGLDQHFRQRP\DVDZKROHZKHUHWKHXQRUJDQLsHGVHFWRU KDVDGRPLQDQWVKDUHLQWKHWRWDOHPSOR\PHQW ,QWHUPVRIWKHFRQWULEXWLRQRIspecific SLT productsEHWZHHQDQGWKH*9$RI]DUGD VKRZVDULVHLQDEVROXWHYDOXHDVZHOODVLQYDOXHUHODWLYHWRRWKHUVPRNHOHVVSURGXFWVFDWHJRULHV 2YHUDOOKRZHYHUWKH*9$RIVPRNHOHVVSURGXFWVGHFOLQHGRYHUWKHVH\HDUVZKLFKFRXOGEH DVVRFLDWHG ZLWK LPSOHPHQWDWLRQ RI WREDFFR FRQWURO ODZV HVSHFLDOO\ WKH EDQV RQ DGYHUWLVHPHQW DQGSURPRWLRQVDVZHOODVWKHEDQRQVDOHDQGSURGXFWLRQRIJXWNDDQGSDQPDVDOD 30 Smokeless Tobacco and Public Health in India Table 2.5: Gross value added of the SLT industry (in Rs millions) (percent) for both unregistered and registered manufacturing 2000-01 2005-06 2010-11 Unreg- Unreg- Unreg- Registered Total Registered Total Registered Total istered istered istered Type of product 6QXII 3 Zarda 3 &DWHFKX NDWKD DQGFKHZiQJOLPH 3DQPDVDODDQG 4 2 3 UHODWHGSURGXFWV &KHZLQJWREDFFR 2 DQGRWKHUWREDFFR 2 SURGXFWs Total SLT 2 Share of registered & unregistered (%) Share in total tobacco (%) Sources: (VWLPDWHGIURPWKHXQLWOHYHOUHFRUGVRIWKH$QQXDO6XUYH\RI,QGXVWU\ $6, UHJLVWHUHGXQLWV DQG1DWLRQDO6DPSOH6XUYH\ 166 GDWD XQUHJLVWHUHGXQLWV EMPLOYMENT PATTERNS IN THE SLT INDUSTRY 7REDFFRPDQXIDFWXULQJLVDQLPSRUWDQWVRXUFHRIMREVLQ,QGLDSURYLGLQJHPSOR\PHQWWRDODUJH QXPEHU RI ZRUNHUV WKH PDMRULW\ RI ZKRP DUH HPSOR\HG LQIRUPDOO\ 7KH WREDFFR ZRUNIRUFH FRQVWLWXWHVZRUNHUVHPSOR\HGLQDJULFXOWXUHPDQXIDFWXULQJDQGWUDGHUHODWHGDFWLYLWLHV,Q,QGLD LQSHRSOHZHUHHPSOR\HGLQYDULRXVWREDFFRUHODWHGDFWLYLWLHVLQFOXGLQJ 2 FXOWLYDWLRQPDQXIDFWXULQJDQGWUDGHFRQVWLWXWLQJDURXQGRIWRWDOHPSOR\PHQW $SSUR[LPDWHO\RIWKHWREDFFRZRUNIRUFHLVHPSOR\HGLQWKHPDQXIDFWXULQJVHFWRUIROORZHG E\DOPRVWHTXDOVKDUHVLQWUDGHDQGFXOWLYDWLRQ VHH7DEOH ,QWKHPDQXIDFWXULQJVHFWRUWKH ELGLLQGXVWU\HPSOR\VDPDMRUFKXQNRIWKHWRWDOZRUNIRUFH7RWDOWREDFFRHPSOR\PHQWGHFOLQHG PDUJLQDOO\ DERXW EHWZHHQ DQG $FURVV WKH WKUHH VHFWRUV WKH JUHDWHVW GHFOLQHZDV VHHQLQ WKHWUDGHVHFWRUZKHUH HPSOR\PHQW IHOOIURP WR 'XULQJWKHHDUO\VWREDFFRWUDGHZDVDPDMRUHFRQRPLFDFWLYLW\DFFRXQWLQJIRUDVKDUH RI WKH WRWDO WREDFFR ZRUNIRUFH FRPSDUHG WR D VKDUH LQ VKRZLQJ WKDW LQFUHDVLQJ QXPEHUVRISHRSOHZHUHHPSOR\HGLQZKROHVDOHDQGUHWDLOWREDFFRWUDGHGXULQJWKLVSHULRG7KH VLJQLILFDQWGHFOLQHLQHPSOR\PHQWLQWREDFFRWUDGHE\OLNHWKHGHFOLQHLQWKH*9$RI the tobacco industry, could be attributed to India’s implementation of tobacco control laws. 31 Chapter 2. Economics of Smokeless Tobacco in India Table 2.6: Structure of employment in the tobacco industry in India Numbers of workers (thousands) % change, 2004- 2004-2005a 2011-2012b 2005 to 2011- 2012 Activity Rural Urban Total Rural Urban Total &XOWLYDWLRQ 52 0DQXIDFWXULQJ 7UDGH $OOWREDFFRDFWLYLWLHV % share of workers, by activity Activity Rural Urban Total Rural Urban Total &XOWLYDWLRQ 0DQXIDFWXULQJ 7UDGH $OOWREDFFRDFWLYLWLHV RIDOOHPSOR\PHQW Sources: a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able 2.7: Employment in SLT manufacturing 2011–2012 % of total By type of product 6QXII Zarda &DWHFKX NDWKD DQGFKHZLQJOLPH 3DQPDVDODDQGUHODWHGSURGXFWV &KHZLQJWREDFFRDQGRWKHUWREDFFRSURGXFWV Total employment in SLT manufacturing Total tobacco manufacturing employment Source: (VWLPDWHGIURPWKHXQLWOHYHOUHFRUGVRIWKH1DWLRQDO6DPSOH6XUYH\ 166 – %HFDXVH PRVW DFWLYLWLHV LQYROYHG LQ 6/7 PDQXIDFWXULQJ LQFOXGLQJ SDFNDJLQJ DUH GRQH E\ PDFKLQHV 6/7 PDQXIDFWXULQJ LV QRW ODERXU LQWHQVLYH 7KLV LV RQH RI WKH UHDVRQV IRU WKH ORZ 32 Smokeless Tobacco and Public Health in India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axes on SLT Products )RUVPRNHOHVVSURGXFWVSDUWLFXODUO\JXWNDDFRPSRXQGHGOHY\VFKHPHLVDSSOLFDEOHLQZKLFK GXW\LVLPSRVHGRQWKHEDVLVRIWKHFDSDFLW\RIWKHPDFKLQHLQVWDOOHGE\WKHPDQXIDFWXUHU7KUHH W\SHV RI GXWLHV—%DVLF ([FLVH 'XW\ %(' $GGLWLRQDO 'XW\ RI ([FLVH $'( DQG 1DWLRQDO &DODPLW\&RQWLQJHQF\'XW\ 1&&' —DUHLPSRVHGRQ6/77KH%('RQFKHZLQJWREDFFRSDQ PDVDODFRQWDLQLQJWREDFFRDQGVQXIILVRIWKHYDOXHRIWKHSURGXFW7KLVKDVQRWFKDQJHG IURP WR VHH 7DEOH +RZHYHU WKH UDWH UHSUHVHQWV DQ LQFUHDVH RYHUSDVW\HDUV WKHWD[UDWHwas LQLQFUHDVHG WRLQ and WKHQ WR LQ 33 Chapter 2. Economics of Smokeless Tobacco in India Table 2.8: Tax rate on smokeless products (percent) 2010-2011 to 2011-2012 2012-2013 Product categories ADE on ADE on BED pan NCCD Total BED pan NCCD Total masala masala &KHZLQJWREDFFR SUHSDUDWLRQVFRQWDLQLQJ FKHZLQJWREDFFR 3DQPDVDODFRQWDLQLQJ WREDFFR 6QXIIRIWREDFFRDQG SUHSDUDWLRQFRQWDLQLQJVQXII RIWREDFFR 7REDFFRH[WUDFWVDQG HVVHQFH Zarda-sFHQWHGWREDFFR Notes: %(' %DVLF([FLVH'XW\$'( $GGLWLRQDO'XW\RI([FLVHRUKHDOWKFHVVDSSOLHGWRSDQPDVDODDQGRWKHUWREDFFRSURGXFWVIRU 1DWLRQDO5XUDO+HDOWK0LVVLRQ1&&' 1DWLRQDO&DODPLW\&RQWLQJHQF\'XW\ ,QDGGLWLRQWRWKHDERYHDQHGXFDWLRQFHVVDWDQGDVHFRQGDU\DQGKLJKHUHGXFDWLRQFHVVDW RQDJJUHJDWHGXWLHVRIH[FLVHDUHFKDUJHG Source: -DLQ YDULRXV\HDUV 7KH1&&' ZDVLQWURGXFHGE\WKH)LQDQFH$FWRIWRSURYLGHILQDQFLDOUHVRXUFHVIRUQDWXUDO GLVDVWHUV7KH*RYHUQPHQWRI,QGLDLPSRVHG1&&'DWWKHUDWHRIRQFKHZLQJWREDFFRSDQ PDVDODDQGVQXIIWREDFFRDQGWKLVdid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xcise Revenue from Tobacco Products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mokeless Tobacco and Public Health in India $V D VKDUH RI WRWDO WREDFFR H[FLVH UHYHQXH FKHZLQJ WREDFFR ZDV RQ DYHUDJH GXULQJ WKH V DQG LQFUHDVHG WR LQ WKH VXEVHTXHQW GHFDGH ,Q PRQHWDU\ WHUPV WD[ UHYHQXH IURP FKHZLQJWREDFFRURVHIURP5VPLOOLRQLQ WR5VPLOOLRQLQ D ILYHIROG LQFUHDVH DQG LW FRQWLQXHG WR ULVH DPRXQWLQJ WR 5V PLOOLRQ LQ 5HYHQXH IURP RWKHU WREDFFR SURGXFWV XQPDQXIDFWXUHG WREDFFR ZKROO\ RU SDUWO\ VWHPPHG SUHSDUDWLRQVFRQWDLQLQJFKHZLQJWREDFFR]DUGDVFHQWHGWREDFFRVQXIIHWF VKRZVDQLQFUHDVLQJ WUHQG RYHU WKH VDPH \HDUV JURZLQJ IURP RQ DYHUDJH GXULQJ WKH V WR GXULQJ WKH V ,QVSLWHRIFKDQJHVLQWKHSDWWHUQRIUHYHQXHFROOHFWLRQIURPYDULRXVWREDFFRSURGXFWV ZLWK LQFUHDVLQJ VKDUH RI UHYHQXH IURP FKHZLQJ WREDFFR DQG RWKHU SURGXFWV WD[ UHYHQXH IURP FLJDUHWWHV PDNHV XSWKH ODUJHVW VKDUHRIWKHWRWDO5HYHQXHIURPVPRNHOHVV WREDFFR JUHZDW D KLJKHUUDWHDIWHUZKHQJRYHUQPHQWLQFUHDVHGWKHEDVLFH[FLVHGXW\ Table 2.9: Excise revenue from different tobacco products (in Rs millions) (percent) Cigarettes and Excise revenue cigarillos of tobacco Chewing Year Bidis Others * from all tobacco or tobacco tobacco products substitutes | 2 Average share (1990-2000) 35 Chapter 2. Economics of Smokeless Tobacco in India Cigarettes and Excise revenue cigarillos of tobacco Chewing Year Bidis Others * from all tobacco or tobacco tobacco products substitutes Average share (2001-2010) ,QFOXGHVXQPDQXIDFWXUHGWREDFFRZKROO\RUSDUWO\VWHPPHG SUHSDUDWLRQVFRQWDLQLQJFKHZLQJWREDFFR ]DUGDVFHQWHGWREDFFR VQXII SUHSDUDWLRQVFRQWDLQLQJVQXII WREDFFRH[WUDFWVDQGHVVHQFH FXWWREDFFR Source: *RYHUQPHQWRI,QGLD0LQLVWU\RI)LQDQFH'LUHFWRUDWHRI'DWD0DQDJHPHQW 7KH ILYH\HDU QRPLQDO DYHUDJH JURZWK UDWHV RI H[FLVH UHYHQXH LQGLFDWH WKDW FLJDUHWWHV KDG WKH PRVWFRQVLVWHQWSHUIRUPDQFHEHWZHHQ DQG 7DEOH ,QWKHILUVW\HDUVDQGWKH ODVW\HDUVRIWKLVSHULRGUHYHQXHIURPFLJDUHWWHVJUHZDWDQGKDGDVLPLODUJURZWKUDWH 7D[ UHYHQXH IURP ELGLV JUHZ WKH OHDVW UHIOHFWLQJ WKH ORZ WD[ UDWH RQ ELGLV 5HYHQXH IURP FKHZLQJWREDFFRIOXFWXDWHG—GHFOLQLQJEHWZHHQDQGDQGWKHQJURZLQJ RQ DYHUDJH DW EHWZHHQ DQG +RZHYHU UHYHQXH IURP WREDFFR SURGXFWVDVDZKROHLQFUHDVHGWRGXULQJWRZKLOHWKHRYHUDOOFHQWUDO H[FLVHUHYHQXHGHFOLQHGWRDOPRVWKDOIRIZKDWZDVDFKLHYHGLQWKHSUHYLRXV\HDUVDVDUHVXOW RIWKHHIIHFWVRIWKHJOREDOHFRQRPLFVORZGRZQRQWKH,QGLDQHFRQRP\ Table 2.10: Annual average growth rate in revenue from tobacco products versus total central excise revenue (percent) Cigarettes and cigarillos Chewing All tobacco Total central Year of tobacco or tobacco Bidis tobacco products excise revenue substitutes WR WR WR – WR Source: *RYHUQPHQWRI,QGLD0LQLVWU\RI)LQDQFH'LUHFWRUDWHRI'DWD0DQDJHPHQW 7KHVKDUHRIWKHWREDFFRH[FLVHUHYHQXHLQWKHRYHUDOOWD[UHYHQXHRIWKHFHQWUDOJRYHUQPHQWKDV GHFOLQHGRYHUWKH\HDUV7REDFFRWD[UHYHQXHPDGHXS RIJURVVWD[UHYHQXHLQ DQG KDG GHFOLQHG WR E\ )LJXUH 7KH GHFOLQH EHJDQ LQ DQG UHDFKHGLWVORZHVWSRLQWLQ7KHVKDUHRIFKHZLQJWREDFFRLQJURVVWD[UHYHQXHZDV 36 Smokeless Tobacco and Public Health in India OHVVWKDQGXULQJWKLV\HDUSHULRGDQGGHFOLQHGDIWHU2QDYHUDJHWREDFFRWD[HV DFFRXQWHG IRU RI JURVV WD[ UHYHQXH DQG FKHZLQJ WREDFFR DFFRXQWHG IRU MXVW RI JURVVWD[UHYHQXHEHWZHHQDQG$OWKRXJKUHYHQXHIURPWREDFFRSURGXFWVVKRZHGDQ DEVROXWH LQFUHDVH GXULQJ WKH GHFDGH EHIRUH LWV VKDUH LQ WRWDO FHQWUDO JRYHUQPHQW WD[ UHYHQXHGHFOLQHG7KLVGHFOLQLQJVKDUHFRXOGEHDWWULEXWHGWRWKHJUHDWLQFUHDVHLQWD[UHYHQXH WKDWUHVXOWHGIURPJURZWKLQWKH,QGLDQHFRQRP\DVDZKROHGXULQJWKHODVWRQHGHFDGH Figure 2.1 Share of tobacco in gross tax revenue of Government of India (%) Sources: 7REDFFRWD[GDWD *RYHUQPHQWRI,QGLD0LQLVWU\RI)LQDQFH'LUHFWRUDWHRI'DWD0DQDJHPHQW &XVWRPVDQG&HQWUDO([FLVH *URVVWD[UHYHQXH GDWD *RYHUQPHQWRI,QGLD0LQLVWU\RI)LQDQFH&RQWUROOHU *HQHUDORI$FFRXQWV INTERNATIONAL TRADE IN SLT PRODUCTS IN INDIA Export Earnings from Tobacco (Both Unmanufactured and Manufactured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hapter 2. Economics of Smokeless Tobacco in India Table 2.11: Export earnings of tobacco in India (includes both unmanufactured and manufactured) Value of tobacco exports Value of SLT exports Share of SLT in total Year (Rs million) (Rs million) tobacco exports (%) 0DU 0DU 0DU 0DU 0DU Average Annual Growth Rate (AAGR) (%) 0DU 0DU 0DU 0DU 0DU AAGR (%) 0DU 0DU 0DU 0DU 0DU AAGR (%) – 0DU 0DU 0DU 0DU 0DU AAGR (%) $YHUDJHVKDUHLQ\HDUV Source: *RYHUQPHQWRI,QGLD0LQLVWU\RI&RPPHUFH'LUHFWRUDWH*HQHUDORI&RPPHUFLDO,QWHOOLJHQFHDQG6WDWLVWLFV YDULRXV\HDUV Export Earnings from SLT (Both Unmanufactured and Manufactured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mokeless Tobacco and Public Health in India PLOOLRQ FRQVWLWXWHGRIWRWDOH[SRUWHDUQLQJVIURPYDULRXVW\SHVRI6/77KLVLQFUHDVHGWR RIWRWDO6/7H[SRUWHDUQLQJV 5VPLOOLRQ E\WKHHQGRI0DUFK7KXVH[SRUW HDUQLQJVIURPFKHZLQJWREDFFRLQFUHDVHGHLJKWIROGGXULQJDVSDQRI\HDUVDQGWKHDYHUDJH DQQXDO FRQWULEXWLRQ RI FKHZLQJ WREDFFR ZDV RI WRWDO 6/7 H[SRUWV GXULQJ WKH \HDUV ,QGLDQ PDQXIDFWXUHUV EHJDQ WR H[SRUW WZR YDULHWLHV RI 6/7 SURGXFWV—VQXII DQG SUHSDUDWLRQV FRQWDLQLQJFKHZLQJWREDFFR—LQ Table 2.12: Export of varieties of SLT in India (in Rs millions) (percent) Tobacco for manufacturing of chewing tobacco Tobacco partly Products Tobacco not Chewing Zarda- Products Total SLT or wholly contain-ing Year stemmed or tobacco scented Snuff contain- ing export stemmed or chewing stripped products tobacco snuff earnings stripped tobacco 0DUFK 1$ 2 1$ 0DUFK 1$ 1$ 0DUFK 1$ 1$ 0DUFK 1$ 1$ 0DUFK 1$ 1$ 0DUFK 1$ 1$ 0DUFK 1$ 1$ 332 0DUFK 1$ 1$ 0DUFK 1$ 1$ 0DUFK 5 1$ 1$ 0DUFK 1$ 1$ 0DUFK 345 53 1$ 1$ 0DUFK 1$ 1$ 0DUFK 0DUFK 0DUFK 0DUFK 0DUFK 5 0DUFK 39 Chapter 2. Economics of Smokeless Tobacco in India Tobacco for manufacturing of chewing tobacco Tobacco partly Products Tobacco not Chewing Zarda- Products Total SLT or wholly contain-ing Year stemmed or tobacco scented Snuff contain- ing export stemmed or chewing stripped products tobacco snuff earnings stripped tobacco 0DUFK Source: *RYHUQPHQWRI,QGLD0LQLVWU\RI&RPPHUFH'LUHFWRUDWH*HQHUDORI&RPPHUFLDO,QWHOOLJHQFHDQG6WDWLVWLFV Exports of SLT to Different Regions of the World 'DWD RQ H[SRUWV RI 6/7 WR GLIIHUHQW UHJLRQV RI WKH ZRUOG DV GHILQHG E\ WKH :RUOG +HDOWK 2UJDQL]DWLRQLQGLFDWHWKDWPRVW6/7H[SRUWV PRUHWKDQ JRWRWKH(DVWHUQ0HGLWHUUDQHDQ 5HJLRQ IROORZHG E\ WKH :HVWHUQ 3DFLILF DQG $PHULFDQ 5HJLRQV 7DEOH 6PRNHOHVV SURGXFWVDUHH[SRUWHGWRERWKORZ DQGKLJKLQFRPHFRXQWULHVRIWKHZRUOG Table 2.13: Export of manufactured and unmanufactured SLT, by World Health Organization Regions of world (in Rs millions) (percent) March March March March March March March Annual WHO Region 2004 2005 2006 2007 2008 2009 2010 Average $IULFD 52 $PHULFD 6RXWK(DVW$VLD 4 (XURSH (DVWHUQ 0HGLWHUUDQHDQ :HVWHUQ3DFLILF 8QVSHFLILHG Total Source: *RYHUQPHQWRI,QGLD0LQLVWU\RI&RPPHUFH'LUHFWRUDWH*HQHUDORI&RPPHUFLDO,QWHOOLJHQFHDQG6WDWLVWLFV 7KH 8Qited Arab Emirates (UAE), Afghanistan, and Iran are the largest markets for India’s FKHZLQJWREDFFRH[SRUWV7KHKLJKHVWVKDUHRIH[SRUWVZHQWWR8$(XSIURPLQ 7DEOH ,QWKHVHFRQGKLJKHVWVKDUHRIFKHZLQJWREDFFRH[SRUWVZHQW WR$IJKDQLVWDQ followed by Iran, Canada, and Saudi Arabia. Of the top 10 countries importing India’s chewing WREDFFRSURGXFWV$XVWUDOLDUHFHLYHGWKHVPDOOHVWDPRXQW OHVVWKDQ RIWRWDOFKHZLQJWREDFFR H[SRUWV,QWKHUHZHUHPLQRUFKDQJHVLQWKH H[SRUWWRWRSFRXQWULHV$IJKDQLVWDQZKLFK KDGWKHVHFRQGKLJKHVWVKDUHLQEHFDPHWKHWKLUGZLWKDVKDUHLQWKHWRWDOH[SRUWVDQG QHZH[SRUWGHVWLQDWLRQVZHUHDGGHGLQFOXGLQJ0DOD\VLD6LQJDSRUHand 1HSDO 40 Smokeless Tobacco and Public Health in India Table 2.14: Top 10 export destinations for chewing tobacco (in Rs millions) (percent) Country March 2004 Country March 2007 Country March 2010 8QLWHG$UDE 8QLWHG$UDE 8QLWHG$UDE (PLUDWHV (PLUDWHV (PLUDWHV 2 $IJKDQLVWDQ Source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te less than 1% of the government’s total tax revenue, and total HPSOR\PHQWLQ6/7SURGXFWLRQUHSUHVHQWVRIWRWDOHPSOR\PHQWLQWREDFFRPDQXIDFWXULQJ$ IDFWRUWKDWPLOLWDWHVDJDLQVWWD[UHIRUPKRZHYHULVWKHKLJKYDOXHRI6/7SURGXFWLRQ,Q 5V PLOOLRQ ZRUWK RI VPRNHOHVV SURGXFWV ZDV SURGXFHG FRQVWLWXWLQJ PRUH WKDQ SHUFHQWDJHRIWKHYDOXHRIWRWDOWREDFFRSURGXFWV7KLVJURZWKUDLVHVFRQFHUQVDERXWWKHJURZWK RI WKH XQRUJDQLsHG VHFWRU ZKLFK PDNHV PRQLWRULQJ SURGXFWLRQ DQG SULFH VWUXFWXUH GLIILFXOW 41 Chapter 2. Economics of Smokeless Tobacco in India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s RI XQPDQXIDFWXUHG WREDFFR ZKLFK GRPLQDWHG WKH H[SRUW PDUNHW GXULQJ V 6WULFW PHDVXUHV DUH QHHGHG WR FXUWDLO H[SRUW GHPDQG VR WKDW LW GRHV QRW ERRVW SURGXFWLRQLQFLUFXPYHQWLRQRIGRPHVWLFODZV 'HPDQG LQ ,QGLD LWVHOI LV D FULWLFDOO\ LPSRUWDQW FRQFHUQ 0RUH WKDQ RQHIRXUWK RI DOO DGXOWV FRQVXPH VRPH IRUP RI 6/7 DQG FRQVXPHUV EHJLQ WR XVH 6/7 DW HDUO\ DJHV EHFDXVH RI WKH DYDLODELOLW\ RI ORZSULFHG SURGXFWV LQ WKH PDUNHW *RYHUQPHQW PHDVXUHV WR FRPEDW GRPHVWLF GHPDQGDUHFULWLFDO &XUELQJWKHVXSSO\RI6/7LVHVVHQWLDOIRUHIIHFWLYHWREDFFRFRQWUROSROLF\LQ,QGLD0HHWLQJWKH JURZLQJFRVWRIWREDFFRUHODWHGGLVHDVHVKDVEHFRPHLQFUHDVLQJO\FKDOOHQJLQJIRUWKHSXEOLFO\ IXQGHGKHDOWKFDUHV\VWHPZKLFKLVDOUHDG\JUDSSOLQJZLWKORZUHVRXUFHDOORFDWLRQHYHQDWWKH SULPDU\ KHDOWK FDUH OHYHO ,Q WKLV FRQWH[W UHVRXUFHV QHHG WR EH FDUHIXOO\ DOORFDWHG DPRQJ WKH health sector’s various competing priorities. To reduce tobaccoUHODWHG KHDOWK FDUH FRVWV WKH SUHYDOHQFHRIWREDFFRXVHPXVWEHUHGXFHGVXEVWDQWLDOO\$PRQJVHYHUDOVXSSO\VLGHPHDVXUHV mentioned in the WHO’s Framework Convention on Tobacco Control (FCTC), controlling SURGXFWLRQDQGUHGXFLQJDUHDVXQGHUWREDFFRFXOWLYDWLRQDUHYLWDO7KHWD[VWUXFWXUHQHHGWREH VLPSOLILHG ZKHUHSRVVLEOHWKHGLIIHUHQWLDOWD[UDWHVKRXOGEHPLQLPLVHGDQGWKHWD[VWUXFWXUH VKRXOGEHDGMXVWHGWRSULFHDQGLQFRPHFKDQJHVSHULRGLFDOO\DVUHFRPPHQGHGE\WKH)&7& Research Priorities 7KRXJKWKHJRYHUQPHQWKDVHQDFWHG OHJLVlaWLRQLQFOXGLQJLQFUHDVLQJWKH WD[UDWHHVSHFLalO\DWWKH VWDWHOHYHOWRFXUEWKHJrRZWKRIVPRNHOHVVWREDFFRXVHLWLVHVVHQWLDOWRH[DPLQHWKHLPSDFWRI WD[LQFUHDVHs RQFRQVXPSWLRQDWWKHSURYLQFLDOOHYHO )XUWKHULQGXVWU\SURILWDELOLW\WDFWLFV and SULFHVWUDWHJ\VKRXOG EHVWXGLHGDQGHYLGHQFHFROOHFWHGRQKRZ6/7PDQXIDFWXUHUVPDQLSXODWH SULFHV LQ RUGHUWR PDLQWDLQ GHPDQG IRUWKHLUSURGXFWV7KH JURZLQJH[WHUQDO GHPDQG IRU6/7 SURGXFWV LV D PDWWHU RI FRQFHUQ DQG H[SRUW SULFHV YROXPH RI WUDGH and WKH SRVVLELOLW\ WKDW H[WHUQDO GHPDQG FRXOG EH D VRXUFH RI UHYHQXH IRU WKH PDQXIDFWXUHUV RXJKW WR EH H[DPLQHG 5HVHDUFKHUV VKRXOG DOVR FRQVLGHU ZKHWKHU GRPHVWLF PHaVXUHV ZLOO EH LQHIIHFWLYH if H[WHUQDO GHPDQGis VXIILFLHQWWRGULYHWKH JURZWKRIiQGXVWU\7KHOLYHOLKRRGFRQFHUQVRIWKHVPRNHOHVV JURZHUV DQG ZRUNHUV HQJDJHG LQ WUDGH DUH LPSRUWDQW LQ ,QGLDQ FRQWH[W +RZHYHU LQVXIILFLHQW HYLGHQFH is DYDilaEOHRQ DOWHUQDWLYHRSWLRQVWKDWFRXOGEH HTXDOO\UHPXQHUDWLYHDQGSURYLGHEHWWHU OLYHOLKRRG RSSRUWXQLWLHV 7DNLQJ LQWR FRQVLGHUDWLRQ WKH VORZ SURJUHVV RQ $UWLFOH RI WKH )UDPHZRUN&RQYHQWLRQRI7REDFFR&RQWURO )&7& HYLGHQFH VKRXOGEHJHQHUDWHGLQWKLVDUHD ACKNOWLEDGEMENTS :HDUHWKDQNIXOWRWKHYDULRXVJRYHUQPHQWDJHQFLHVIRUSURYLGLQJXVWLPHVHULHVGDWDUHODWHGWR ODQGXWLOLVDWLRQDQGSURGXFWLRQWD[UHYHQXHDQGH[SRUWGDWD2XUVSHFLDOWKDQNVDUHGXHWRWKH 'LUHFWRUDWH RI 7REDFFR 'HYHORSPHQW 0LQLVWU\ RI $JULFXOWXUH *RYHUQPHQW RI ,QGLD WKH 'LUHFWRUDWHRI'DWD0DQDJHPHQW&XVWRPVDQG&HQWUDO([FLVH0LQLVWU\RI)LQDQFH*RYHUQPHQW 42 Smokeless Tobacco and Public Health in India RI ,QGLD 1HZ 'HOKL DQG WKH 'LUHFWRUDWH *HQHUDO RI &RPPHUFLDO ,QWHOOLJHQFH DQG 6WDWLVWLFV 0LQLVWU\RI&RPPHUFH*RYHUQPHQWRI,QGLD1HZ'HOKL ZKLFKSURYLGHGGDWDHVSHFLDOO\IRUWKLV FKDSWHU 43 Chapter 2. Economics of Smokeless Tobacco in India REFERENCES 5DWK*.&KDXGKU\ .(VWLPDWLRQRIFRVWRIPDQDJHPHQWRIWREDFFRUHODWHGFDQFHUV5HSRUWRIDQ,&05WDVN fRUFHs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hHDOWKSUREOHPVRIWREDFFRhDUYHVWHUVDQGWheir SUHYHQWLRQ>QRGDWH@ >FLWHG0D\3@ $YDLODEOH IURP KWWS LFPUQLFLQSURMHFWSURMHFWKWP *RYHUQPHQWRI,QGLD 'HSDUWPHQWRI$JULFXOWXUHDQG&RRSHUDWLRQ 'LUHFWRUDWHRI(FRQRPLFVDQG6WDWLVWLFV $JULFXOWXUDOsWDWLVWLFVDWDJODQFH$YDLODEOHIURP KWWS HDQGVGDFQHWQLFLQ$GYDQFHB(VWLPDWHKWP *RYHUQPHQWRI,QGLD0LQLVWU\RI$JULFXOWXUH 'LUHFWRUDWHRI7REDFFR'HYHORSPHQW&KHQQDLYDULRXV\HDUV 1DWLRQDO,QGXVWULDO&ODVVLILFDWLRQ >FLWHG-DQ@$YDilaEle IURP KWWS ZZZPFDJRYLQ0&$GFDHILOLQJ1,&BGHWDLOB MDQ SGI -RKQ505DR5.5DR0*HWDO7KHeFRQRPLFVRIWREDFFRDQGWREDFFRWD[DWLRQLQ,QGLD 3DULV ,QWHUQDWLRQDO 8QLRQ$JDLQVW7XEHUFXORVLVDQG/XQJ'LVHDVH *RYHUQPHQWRI,QGLD0LQLVWU\RI6WDWLVWLFVDQG3URJUDPPH,PSOHPHQWDWLRQ1DWLRQDO6DPSOH6XUYH\2IILFH (PSOR\PHQWDQGXQHPSOR\PHQWVLWXDWLRQLQ,QGLD-XO\–-XQH1665HSRUW $YDLODEOHIURP KWWS PRVSLQLFLQ0RVSLB1HZXSORDGQVVBUHSRUWBBMDQSGI -RKQ50 3ULFHeODVWLFLW\eVWLPDWHVIRUWREDFFRSURGXFWVLQ,QGLD +HDOWK3ROLF\3ODQ *XLQGRQ*(1DQGL$&KDORXSND)--KD36RFLRHFRQRPLFdLIIHUHQFHVLQWKHiPSDFWRIsPRNLQJWREDFFRDQG aOFRKROSULFHVRQsPRNLQJLQ,QGLD1%(5ZRUNLQJSDSHUQR&DPEULGJH0$ 1DWLRQDO%XUHDXRI (FRQRPLF5HVHDUFK >FLWHG-XQH@$YDLODEOHIURP KWWS ZZZQEHURUJSDSHUVZ *RYHUQPHQWRI,QGLD5HSRUWRIWKHWK)LQDQFH&RPPLVVLRQ >FLWHG1RY@ $YDLODEOHIURP KWWS ILQFRPLQGLDQLFLQ6KRZ&RQWHQW2QHDVS["LG 6HFWLRQ -DLQ5. &HQWUDOe[FLVHWDULIIRI,QGLD1HZ'HOKL &HQWD[3XEOLFDWLRQ YDULRXV\HDUV *RYHUQPHQWRI,QGLD0LQLVWU\RI)LQDQFH 'LUHFWRUDWHRI'DWD0DQDJHPHQW 'HOKL &XVWRPVDQG&HQWUDO ([FLVH *RYHUQPHQWRI,QGLD0LQLVWU\RI)LQDQFH&RQWUROOHU*HQHUDORI$FFRXQWV$FFRXQWVaWDJODQFH YDULRXV \HDUV >FLWHG 1RY@ $YDilaEOH IURP KWWS ZZZFJDQLFLQ *RYHUQPHQWRI,QGLD 0LQLVWU\RI&RPPHUFH 'LUHFWRUDWH*HQHUDORI&RPPHUFLDO,QWHOOLJHQFHDQG6WDWLVWLFV 1HZ'HOKL YDULRXVyHDUV >FLWHG )HE@$YDilaEOH IURP KWWS FRPPHUFHQLFLQHLGEHFRPTDVS 44 Chapter 3 Smokeless Tobacco Use Among Youth 'KLUHQGUD16LQKD1HKD0DWKXU2*DXUDQJ31D]DU3 9*DMDODNVKPL9HQGKDQ4.ULVKQD03DOLSXGL56DPLUD$VPD5 0RQLND$URUD0DUN3DUDVFDQGROD-DJGLVK.DXU :RUOG+HDOWK2UJDQL]DWLRQ5HJLRQDO2I¿FHIRU6RXWK(DVW$VLD1HZ'HOKL 23XEOLF+HDOWK)RXQGDWLRQRI,QGLD1HZ'HOKL 3+HDOWK5HODWHG,QIRUPDWLRQ'LVVHPLQDWLRQ$PRQJVW Smokeless Tobacco and Public Health in India INTRODUCTION 7KHSUHYDOHQFHRIFXUUHQWVPRNHOHVVWREDFFR 6/7 XVHDPRQJ\RXWKLVDQLPSRUWDQWSUHGLFWRURI WKHIXWXUHEXUGHQRIWREDFFRUHODWHGGLVHDVHV7KHLQFUHDVHGSUHYDOHQFHRIFHUWDLQIRUPVRI6/7 SURGXFWVDPRQJ,QGLDQ\RXWKKDVGLUHFWO\FRQWULEXWHGWRDQDODUPLQJLQFUHDVHLQWKHLQFLGHQFHRI RUDOFDQFHUVDPRQJ\RXQJHUDJHJURXSV3UHYHQWLQJ\RXQJSHRSOHIURPEHJLQQLQJWRXVH6/7 UHTXLUHV LQWHUYHQWLRQ LQ HDUO\ DGROHVFHQFH EHIRUH WKH\ H[SHULPHQW ZLWK LW 7KXV WKH \RXWK SRSXODWLRQLVDFULWLFDOWDUJHWIRUWREDFFRFRQWUROHIIRUWV7KLVFKDSWHUFRQVROLGDWHVWKHHYLGHQFH RQSUHYDOHQFHRI6/7XVHand XVHRIVSHFLILF6/7SURGXFWVFRPSDUHVSUHYDOHQFHRIVPRNLQJ DQG 6/7 XVH DQG WUDFNV WUHQGV LQ 6/7 XVH DQG IDFWRUV DVVRFLDWHG ZLWK LWV DFTXLVLWLRQ DPRQJ \RXWKLQ,QGLD SOURCE OF DATA: THE GLOBAL YOUTH TOBACCO SURVEY, INDIA (2003, 2006, 2009) 7KLVFKDSWHUSUHVHQWVGDWDRQSUHYDOHQFHRI6/7XVHDPRQJ\RXWKDJHV–\HDUVZKLFKZDV FROOHFWHGXVLQJWKH*OREDO 47 Chapter 3. Smokeless Tobacco Use Among Youth 7KH *<76,QGLDDOVRHPSOR\HGWKHVDPHVDPSOLQJSURFHGXUHWKDWZDVXVHGDVLQWKHWZR HDUOLHUVXUYH\V0LQRUPRGLILFDWLRQVZHUHPDGHLQWKHGLVWULEXWLRQRIVWDWHVE\UHJLRQWRPLUURU WKHUHJLRQDOFRPSRVLWLRQRIVWDWHVLQWKH*OREDO$GXOW7REDFFR6XUYH\ *$76 ZKLFKZDVDOVR FRQGXFWHG LQ ,QGLD LQ 8WWDU 3UDGHVK DQG 5DMDVWKDQ ZHUH LQFOXGHG LQ WKH &HQWUDO 5HJLRQLQVWHDGRIWKH1RUWKUHJLRQLQ *<76LQ,QGLD7KHVL[UHJLRQVLQWKH *<76 UHSUHVHQW RI ,QGLD’s total VFKRROJRLQJ VWXGHQW SRSXODWLRQ ,Q WRWDO VWXGHQWV SDUWLFLSDWHGLQWKHVL[UHJLRQDOVXUYH\V PREVALANCE OF SLT USE To put India’s prevalence data in a global context, it is notable that ,QGLD UDQNV KLJKHVW LQ SUHYDOHQFHRI6/7XVHDPRQJERWKER\V DQGJLUOV LQWKHIRXUPRVWSRSXORXVFRXQWULHVIRUZKLFK FRPSDUDEOHHVWLPDWHVDUHDYDLODEOH )LJXUH 3UHYDOHQFHRI6/7XVHIURP*<76– DUHDVIROORZV LQ,QGLDDPRQJER\VDQGDPRQJJLUOV LQ%DQJODGHVK ER\V DQGJLUOV LQWKH 8QLWHG6WDWHV ER\VJLUOV LQ,QGRQHVLD ER\VDQGJLUOV Figure 3.1: SLT use in four of the world’s most populous countries Source: 1DWLRQDO&DQFHU,QVWLWXWHDQG&HQWHUVIRU'LVHDVH &RQWURODQG3UHYHQWLRQ 6RPH FRXQWULHV ZLWK VPDOOHU SRSXODWLRQV UHSRUWHG KLJKHU SUHYDOHQFH RI 6/7 XVH DPRQJ ER\V WKDQ,QGLD3UHYDOHQFHVLQFRXQWULHVVXFKDV&RQJR 1DPLELD 'MLERXWL /HVRWKR DQG%KXWDQ ZHUH higher than India’s rate of 11.1%. Similarly, among JLUOV SUHYDOHQFH ZDV KLJKHU LQ VRPH FRXQWULHV ZLWK VPDOOHU SRSXODWLRQV VXFK DV 1DPLELD &RQJR /HVRWKR %RWVZDQD 8JDQGD 'MLERXWL -DPDLFD 48 Smokeless Tobacco and Public Health in India *<76WKHSUHYDOHQFHRIFXUUHQW6/7XVHLQWKHFRXQWU\ZDV IRUER\VDQG 4 IRU JLUOV ZKHUHDV LQ *<76 WKH SUHYDOHQFH RI 6/7 XVH LQ WKH FRXQWU\ ZDV ER\V 4 JLUOV PREVALENCE OF SLT USE, BY SPECIFIC PRODUCT $VGHVFULEHGLQFKDSWHUDQGWKHDFFRPSDQ\LQJIDFWVKHHWVP\ULDGYDULHWLHVRI6/7SURGXFWVare DYDLODEOHDQGXVHGLQYDULRXVZD\VLQ,QGLD7KHIROORZLQJVXEVHFWLRQVSUHVHQWGDWDRQVSHFLILF 6/7SURGXFWXVHE\\RXWK SLT Products Used as Dentifrices 6HYHUDOYDULHWLHVRI6/7SURGXFWVDUHFRQVXPHGLQ,QGLDDVDGHQWLIULFHRUIRUWKHWUHDWPHQWRI RUDODQGGHQWDOSUREOHPV)LJXUHLVDJUDSKLFGHSLFWLRQRI*<76GDWDRQWKHXVHRIWKUHH6/7 SURGXFWV DV DGHQWLIULFH E\ \RXWK—WREDFFRWRRWKSDVWHV HJ ,SFR'HQWREDF RWKHUSDVWHOLNH PDWHULDO HJ JXGDNKX DQG WRRWK SRZGHU HJ lDO GDQW PDQMDQ JXO PLVKUL —LQ ,QGLDQ VWDWHV 0DKDUDVKWUD*RD6LNNLP8WWDU3UDGHVK2ULVVD%LKDU$VVDP0L]RUDP8WWDUDQFKDO 0HJKDOD\D$UXQDFKDO3UDGHVK7ULSXUD0DQLSXUDQG1DJDODQG Figure 3.2: Prevalence of using various SLT products as a dentifrice among 13- to 15-year-old students in selected Indian states (GYTS 2000–2002) Source: 6LQKDHWDO 49 Chapter 3. Smokeless Tobacco Use Among Youth 7KHSUHYDOHQFHRIXVHRIWRRWKSDVWHFRQWDLQLQJWREDFFRUDQJHGIURPDORZRILQ0DKDUDVKWUD DQG *RD WR D KLJK RI LQ 1DJDODQG 7KH SUHYDOHQFH RI WRRWK SRZGHU FRQWDLQLQJ WREDFFR UDQJHGIURPLQ6LNNLP0DQLSXU0DKDUDVKWUDDQG*RDWR LQ%LKDU and ZDVKLJKHUWKDQ LQIRXURWKHUVWDWHV 8VHRIJXOZDVORZHVWLQ2GLVKDDQG0HJKDOD\D DQGKLJKHVWLQ %LKDU RIWKHHLJKWVWDWHVVWXGLHG Prevalence of Gutka Use *XWNDLVDFKHDSPDVVSURGXFHGZLGHO\DYDLODEOH6/7SURGXFW,WFDQEHHDVLO\SXUFKDVHGE\ FKLOGUHQIURPVKRSVDQGNLRVNV*<76–UHYHDOHGWKDWWKHSUHYDOHQFHRIFXUUHQWJXWND XVHUDQJHGIURPDORZRI LQ7DPLO1DGX WRDKLJKRILQ%LKDUDQGZDVKLJKHUWKDQ LQPRVWRIWKHVWDWHVVWXGLHG )LJXUH Figure 3.3: Prevalence of gutka use among students aged 13–15 years in selected states of India (GYTS 2000–2002) 5 Sources: *DMDODNVKPLHWDO 6LQKDHWDO 6LQKDHWDO Tobacco Smoking Versus SLT 7KHSUHYDOHQFHRIFXUUHQWXVHRI6/7SURGXFWVZDVKLJKHUWKDQFXUUHQWWREDFFRVPRNLQJDPRQJ ER\VDQGJLUOVLQWKHDQGVXUYH\VEXWSUHYDOHQFHVRI6/7DQGVPRNLQJDPRQJER\V 2 4 were aOPRVWLGHQWLFDOLQ )LJXUH 50 Smokeless Tobacco and Public Health in India Figure 3.4: Prevalence of using smoked and smokeless forms of tobacco products among 13- to 15-year-old boys and girls (GYTS 2003, 2006, and 2009) 2 3 4 Sources: 6LQKDHWDO *OREDO NATIONAL TRENDS IN SLT USE AMONG YOUTH &XUUHQWXVHRI6/7in India VLJQLILFDQWO\GHFUHDVHGEHWZHHQ DQG EXW WKHQUHPDLQHGXQFKDQJHGXQWLO )LJXUH $GHFUHDVHLQ6/7XVHRFFXUUHG IRU ER\V LQ WR LQ DQG LQ EXW QRW IRU JLUOV ,Q ER\V 2 4 KDG VLJQLILFDQWO\ KLJKHU XVH RI 6/7 WKDQ JLUOV 7UHQG GDWD RQ WKH XVH RI VSHFLILF6/7SURGXFWVOLNHJXWNDDUHQRWNQRZQDWWKHQDWLRQDOOHYHO 51 Chapter 3. Smokeless Tobacco Use Among Youth Figure 3.5: Prevalence of using SLT products, by gender (GYTS 2003, 2006 and 2009) 2 3 Sources: 6LQKDHWDO *OREDO FACTORS ASSOCIATED WITH YOUTH ACQUISITION OF SLT USE 3HRSOH XVXDOO\ EHJLQ XVLQJ 6/7 SURGXFWV GXULQJ DGROHVFHQFH ,Q DGGLWLRQ WR WKH LQIOXHQFH RI IDPLO\PHPEHUVDQGSHHUV LPSRUWDQWIDFWRUVDVVRFLDWHGZLWKDFTXLVLWLRQRI6/7XVHDPRQJ 23 \RXWKLQFOXGHWKHVFKRROHQYLURQPHQWH[SRVXUHWRWREDFFRDGYHUWLVHPHQWV DQGH[SRVXUHWR 24 GHSLFWLRQVRI WREDFFRXVHLQ PRYLHV /RZSULFH HDV\DYDLODELOLW\RI WREDFFRSURGXFWV DQG ODFNRINQRZOHGJHDQGSRVLWLYHDWWLWXGHVDERXWWREDFFRXVHDOVRFRQWULEXWHWRDGRSWLRQRIWREDFFR XVHE\\RXWK School Environment 8VH RI 6/7 SURGXFWV ZDV PRUH SUHYDOHQW DPRQJ VWXGHQWV LQ VFKRROV PDQDJHG E\ WKH VWDWH JRYHUQPHQW WKDQ DPRQJ VWXGHQWV LQ VFKRROV PDQDJHG E\ WKH FHQWUDO JRYHUQPHQW &HQWUDO JRYHUQPHQW VFKRROV KDG D SROLF\ RI EDQQLQJ XVH RI WREDFFR SURGXFWV E\ VWXGHQWV VFKRRO SHUVRQQHODQGRWKHUVRQVFKRROSUHPLVHV Exposure to Advertisements $VZLWKFLJDUHWWeVD VWURQJDVVRFLDWLRQKDVEHHQIRXQGEHWZHHQH[SRVXUHWR6/7DGYHUWLVHPHQWV ERWKGLUHFWDQGLQGLUHFW HJRQWHOHYLVLRQLQPDJD]LQHVRQEXVHVDQGELOOERDUGVDQGDWSRLQWRI VDOH DQGJXWNDXVHDPRQJ\RXWK3RLQWRIVDOHDGYHUWLVHPHQWVLQFUHDVHd QDWLRQZLGH DIWHU WKHLPSOHPHQWDWLRQRIWKH7REDFFR&RQWUROUXOHVRI*<76UHVXOWVVKRZWKDWDERXWRXW 2 4 RIVWXGHQWVVDZDGYHUWLVHPHQWVIRU6/7SURGXFWVRQELOOERDUGVLQDQG 52 Smokeless Tobacco and Public Health in India 5HVXOWV RIDFURVVVHFWLRQDOVWXG\RIVFKRROJRLQJDGROHVFHQWV WKDQGWKJUDGHUV LQ VFKRROV LQ 'HOKL DQG &KHQQDL VXJJHVWHG WKDW VWXGHQWV ZLWK KLJKHU H[SRVXUH WR WREDFFR DGYHUWLVLQJ WKDWLVWKH\VDZDGYHUWLVHPHQWVLQPRUHWKDQORFDWLRQV ZHUHDWKLJKHUULVN RIEHLQJ HYHU WREDFFRXVHUV RUFXUUHQW WREDFFRXVHUV FRPSDUHG WR WKRVH ZLWK ORZHU H[SRVXUH >WKRVH ZKR VDZ DGYHUWLVHPHQWV LQ QR SODFHV RU– SODFHV @ )LJXUH )RUWKJUDGHUVDGRVH–UHVSRQVHUHODWLRQVKLSH[LVWHG$ORQJLWXGLQDOIROORZXSRI 2VWXGHQWVRYHU\HDUVVXJJHVWHGWKDWER\VZKRwere UHFHSWLYHWRWREDFFRDGYHUWLVLQJZHUH DWWLPHVJUHDWHUULVNRIEHFRPLQJWREDFFRXVHUV7KHVHUHVXOWVXQGHUVFRUHWKHILQGLQJWKDW H[SRVXUHWRWREDFFRDGYHUWLVLQJLVDVVRFLDWHGZLWKKLJKHUWREDFFRXVH Figure 3.6: Differences in tobacco use by exposure to advertising among students Source: $URUDHWDO $Q DQDO\VLV RI D VXEVHW RI *<76 ,QGLD LQ VWDWHV IRXQG WKH IROORZLQJ GDWD RQ H[SRVXUH WR WREDFFRDGYHUWLVLQJ )LJXUH x 2Q DYHUDJH RYHU RI WKH VWXGHQWV UHSRUWHG KDYLQJ VHHQ DFWRUV FKHZLQJ 6/7 RQ television ‘a lot’ in 6 out of the 12 states studied (ranging from 65.9% in Manipur to LQ%LKDU x 2QDYHUDJHRYHURIWKHVWXGHQWVLQRXWRIVWDWHVVWXGLHGUHSRUWHGKDYLQJVHHQ ‘a lot’ of gutka advertisements (ranging from 94.6% in Mizoram to 14.6% in Orissa 53 Chapter 3. Smokeless Tobacco Use Among Youth Figure 3.7: Students’ exposure to smokeless tobacco advertisements on television (GYTS, 2000–2002) 2 Source: $GDSWHGIURP6LQKD *<76–SURYLGHVHYLGHQFHDERXWWKHUROHRIWREDFFRDGYHUWLVHPHQWVLQQHZVSDSHUVDQG PDJD]LQHV DQG GLVWULEXWLRQ RI IUHH WREDFFR VDPSOHV DW VSRUWV DQG VRFLDO HYHQWV LQ OHDGLQJ WR LQLWLDWLRQDQGXVHRIWREDFFRSURGXFWVE\VWXGHQWV )LJXUH *<76ILQGLQJVVKRZHGWKDW x More than 30% of the students in most of the states under study had seen ‘a lot’ of gutka DGYHUWLVHPHQWVLQQHZVSDSHUVPDJD]LQHVLQWKHSDVWPRQWK UDQJLQJIURP LQ%LKDU WR LQ0L]RUDP x 0RUHWKDQ RIWKHVWXGHQWV LQPRVWRIWKHVWDWHV saw ‘a lot’ of gutka advertisements at VSRUWVDQGRWKHUVRFLDOHYHQWV IURP LQ0L]RUDPWR LQ%LKDU x 0RUHWKDQ RIWKHVWXGHQWVKDGEHHQRIIHUHGIUHHJXWNDLQ RIWKHVWDWHV IURP LQ0L]RUDPWR LQ%LKDU 54 Smokeless Tobacco and Public Health in India Figure 3.8: Students’ exposure to tobacco advertisements and distribution of free tobacco samples at events Source: 6LQKD Tobacco Use in Movies 6WXGLHV DPRQJ VFKRROJRLQJ DGROHVFHQWV LQ 'HOKL VKRZHG WKDW GHSLFWLRQ RI WREDFFR XVH LQ %ROO\ZRRGPRYLHV ZDV DVVRFLDWHGZLWK PRUHWKDQWZLFHWKHULVNRI WREDFFR XVH LQ WKHKLJKO\ H[SRVHGJURXSDVFRPSDUHGWRWKRVHOHDVWH[SRVHG,QDGGLWLRQDGROHVFHQWVZKRZHUHUHFHSWLYH WR WREDFFR SURPRWLRQV ZHUH WZR WLPHV PRUH OLNHO\ WR KDYH WULHG WREDFFR )LQGLQJV IURP WKH *<76 – VXJJHVW WKDW 6/7 SURGXFWV VXFK DV JXWND DUH KLJKO\ SURPRWHG WKURXJK HOHFWURQLFPHGLD,QUHVSRQVH WR*<76–VXUYH\TXHVWLRQVVWXGHQWVUHSRUWHGWKDWWKH\ ZHUHH[SRVHG to gutka advertisements ‘a lot’, ‘sometimes’, RU ‘never’ )LJXUH Price 7KHORZ FRVWRI6/7SURGXFWVLVDPDMRUFRQWULEXWRUWRWKHSUREOHPRI\RXWKWREDFFRXVH*<76 –ILQGLQJVVKRZHGDVWURQJSRVLWLYHDVVRFLDWLRQEHWZHHQDYDLODELOLW\RISRFNHWPRQH\ DQG6/7XVHLQGLIIHUHQWVWDWHVRI,QGLD7KLVDVVRFLDWLRQZDVKLJKHVWLQ8WWDUDQFKDO>RGGVUDWLR 25 FRQILGHQFH LQWHUYDO &, @ LQGLFDWLQJ WKDW \RXWK ZLWK PRUH 24 GLVSRVDEOHLQFRPHDUHDWKLJKHUULVNIRU6/7XVH Access and Availability $QRWKHULPSRUWDQWULVNIDFWRUIRUWREDFFRXVHLVHDV\DYDLODELOLW\RIWREDFFRSURGXFWVZKLFKDUH ZLGHO\ DYDLODEOH IRU VDOH DQG HVSHFLDOO\ DURXQG HGXFDWLRQDO LQVWLWXWLRQV 7R FRQWURO DFFHVV WR WREDFFRSURGXFWVE\ \RXWKWKHVDOHRIWREDFFRSURGXFWVLQVLGHWKHSUHPLVHVDQGZLWKLQWKHUDGLXV RI \DUGV IURP VFKRROHGXFDWLRQDO LQVWLWXWLRQV waV SURKLELWHG E\ ODZ KRZHYHU HIIHFWLYH HQIRUFHPHQW RI WKHVH SURYLVLRQV LV D ELJ FKDOOHQJH &273$ EDQQHG WKH VDOH RI WREDFFR 25 SURGXFWV WR DQG E\ PLQRUV EXW IXOO HIIHFWLYH LPSOHPHQWDWLRQ RI WKLV SURYLVLRQ UHTXLUHV 55 Chapter 3. Smokeless Tobacco Use Among Youth RYHUFRPLQJPDQ\ REVWDFOHV *<76 GDWDVKRZWKDWQHDUO\KDOIRIVWXGHQWVZKRFXUUHQWO\ VPRNHERXJKW WREDFFRSURGXFWVLQVWRUHVDQGRIWKHVH ZHUHQRWUHIXVHGEHFDXVHRIWKHLU 3 DJH Knowledge and Attitudes Toward Smokeless Tobacco Use 6WXGLHVFRQGXFWHGLQ,QGLDZLWKVFKRROJRLQJDGROHVFHQWVKDYHVKRZQWKDWSV\FKRVRFLDOIDFWRUV VXFKDVLQWHQWLRQVWRXVHWREDFFRDQGVXVFHSWLELOLW\WRLWVXVHSRVLWLYHUHDVRQVWRXVHWREDFFRDQG QRUPDWLYHH[SHFWDWLRQVDUHDOODVVRFLDWHGZLWKJUHDWHUWREDFFRXVH LQFOXGLQJ6/7XVH ZLWKWKH \RXQJHUVWXGHQWVKDYLQJDKLJKHUSV\FKRVRFLDOULVNSURILOHIRUWREDFFRXVH FRPSDUHGZLWKROGHU VWXGHQWV7KHWREDFFR LQGXVWU\KDVWUDGLWLRQDOO\DWWHPSWHGWRWDUJHWWKLVJURXSE\LQIOXHQFLQJ WKHVHULVNIDFWRU—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mokeless Tobacco and Public Health in India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hapter 3. Smokeless Tobacco Use Among Youth user SLT SLT user Never- user SLT SLT user Never- 32 32 user SLT SLT user Never- user 15) toward15) tobacco use SLT SLT – 33 33 user st Indian states) (percent) Never- user SLT SLT Meghalaya Mizoram Nagaland Sikkim Tripura user Never- tudes of adolescents (ages 13 user SLT SLT 2002 conducted in 8 North-Ea2002 – Manipur 24 24 user Never- (GYTS 2000(GYTS user SLT SLT Table 3.1: Knowledge and atti Pradesh Arunachal user Never- user SLT SLT 5 Assam 22 22 user Never- 6LQKDHWDO )LJXUHLQSDUHQWKHVLVGHQRWHV &, LQJPRWLRQ %R\VZKR VPRNHRU FKHZORRN PRUH DWWUDFWLYH %R\VZKR VPRNHRU FKHZKDYH PRUHIULHQGV *LUOVZKR VPRNHRU FKHZORRN PRUH DWWUDFWLYH *LUOVZKR VPRNHRU FKHZKDYH PRUHIULHQGV 7REDFFR KHOSVLQ UHOLHYLQJ WRRWKDFKHPR rn 7REDFFR KHOSVWRIHHO PRUH FRPIRUWDEOH DWSDUWLHV 6PRNHOHVV WREDFFRLV KDUPIXO Note: Source: 58 Smokeless Tobacco and Public Health in India 7KH EDVHOLQH GDWD IURP WKH QRQVFKRROEDVHG SURMHFW $&7,9,7< 7DEOH FRPSDULQJ WKH LQWHUYHQWLRQDQGFRQWUROFRPPXQLWLHVVKRZHGQRVLJQLILFDQWGLIIHUHQFHLQLQWHQWLRQVWRXVH any W\SH RI WREDFFR DPRQJ HYHUXVHUV S 6XVFHSWLELOLW\ RI HYHUXVHUV ZDV DOVR QRW VLJQLILFDQWO\ GLIIHUHQW EHWZHHQ WKH WZR FRPPXQLWLHV RI \RXWK LQ LQWHUYHQWLRQ FRPPXQLWLHV DQG RI \RXWK LQ FRQWURO FRPPXQLWLHV ZHUH VXVFHSWLEOH WR XVLQJ WREDFFR S Table 3.2: Intention and susceptibility at 2009 baseline survey, Project ACTIVITY, by trial condition (mixed-effects regression models) (n=6,023) Intervention community Control community Product use P value Prevalence 95% CI Prevalence 95% CI Intention $Q\WREDFFR – – 6PRNLQJWREDFFR – 2 – &KHZLQJ WREDFFR – – 2WKHUWREDFFR – – Susceptibility $Q\WREDFFR – – 6PRNLQJWREDFFR – – &KHZLQJ WREDFFR – – 2WKHUWREDFFR – – Source: $URUD HWDO DATA LIMITATIONS AND RESEARCH NEEDS CONCLUSIONS ,Q,QGLDDFFRUGLQJWR*<76GDWDDOPRVWRQHLQWHQVWXGHQWVDJHG–\HDUVXVHVVRPHIRUP RI6/7SURGXFW3UHYDOHQFHRI6/7XVHDPRQJVWXGHQW\RXWKYDULHVZLGHO\DFURVVVWDWHVUDQJLQJ IURPLQ+LPDFKDO3UDGHVKWRLQ%LKDU$FFRUGLQJWR*<76GDWDWKHSUHYDOHQFHRI6/7 XVH DPRQJ VWXGHQWV DJHG – \HDUV GLG QRW FKDQJH EHWZHHQ DQG $PRQJ JLUOV SUHYDOHQFHRI6/7XVHLVKLJKHUWKDQSUHYDOHQFHRIVPRNLQJ7KHSUHYDOHQFHRI6/7XVHDPRQJ VWXGHQWVDJHG–\HDUVGLGQRWFKDQJHEHWZHHQDQG 3UHYDOHQFH RI 6/7 XVH DPRQJ VWXGHQW \RXWK YDULHV ZLGHO\ DFURVV VWDWHV UDQJLQJ IURP LQ Himachal Pradesh to 56% in Bihar. SLT use among India’s youth is influenced by a number of 59 Chapter 3. Smokeless Tobacco Use Among Youth HQYLURQPHQWDO DQG LQGLYLGXDOOHYHO IDFWRUV LQFOXGLQJ SULFH DYDLODELOLW\ DQG VRFLDO QRUPV 7REDFFRLQGXVWU\DGYHUWLVHPHQWVDQGSURPRWLRQVDQGDUHDOVRLPSRUWDQWIDFWRUVLQIOXHQFLQJ6/7 XVH DPRQJ \RXWK 7KH HYLGHQFH IURP VFKRROEDVHG LQWHUYHQWLRQV VXFK DV 3URMHFW 0<575, VXJJHVWVWKDWPXOWLFRPSRQHQWLQWHUYHQWLRQVDUHHIIHFWLYHLQSUHYHQWLQJDGROHVFHQWVIURPVWDUWLQJ WREDFFR XVH LQ VFKRRO VHWWLQJV DQG LQ FKDQJLQJ FRPPXQLW\ QRUPV DURXQG WREDFFR XVH DQG GHQRUPDOLsLQJ6/7XVHDPRQJDOOFRPPXQLW\PHPEHUV 60 Smokeless Tobacco and Public Health in India REFERENCES *XSWD3&6LQRU31%KRQVOH5%3DZDU960HKWD+& 2UDOVXEPXFRXVILEURVLVLQ,QGLD DQHZ HSLGHPLF" 1DWO0HG-,QGLD 6LQKD'1*XSWD3&5HGG\.6HWDO/LQNLQJJOREDOyRXWKWREDFFRsXUYH\DQGdDWDWRWREDFFR FRQWUROSROLF\LQ,QGLD-6FK+HDOWK *RYHUQPHQWRI,QGLD 0LQLVWU\RI+HDOWKDQG)DPLO\:elfare 7REDFFRXse aPRQJsWXGHQWVDQGWHDFKHUV fLQGLQJVIURP*OREDO 61 Chapter 3. Smokeless Tobacco Use Among Youth 0D]XPGDU3'1DUHQGUD6-RKQ67REDFFRaGYHUWLVLQJSURPRWLRQDQGsSRQVRUVKLSaFURVV6RXWKDQG6RXWK (DVW$VLD FKDOOHQJHVDQGRSSRUWXQLWLHV,QGLD &HQWUHIRU0HGLD6WXGLHV +HDOWK%ULGJH 6XVKPD&6KDUDQJ&3DQPDVDODDGYHUWLVHPHQWVDUHVXUURJDWHIRUWREDFFRSURGXFWV,QGLDQ-&DQFHU 2VZDO.&)DFWRUVaVVRFLDWHGwLWKWREDFFRXse aPRQJaGROHVFHQWVLQ,QGLD rHVXOWVfURPWKH*OREDO 62 Chapter 4 Smokeless Tobacco Use Among Adults in India .ULVKQD03DOLSXGL3UDNDVK&*XSWD26DPLUD$VPD 'KLUHQGUD16LQKD33UDEKDW-KD4 &HQWHUVIRU'LVHDVH&RQWURODQG3UHYHQWLRQ$WODQWD*$86$ 2+HDOLV6HNKVDULD,QVWLWXWHIRU3XEOLF+HDOWK1DYL0XPEDL 3:RUOG+HDOWK2UJDQL]DWLRQ5HJLRQDO2I¿FHIRU6RXWK(DVW$VLD1HZ'HOKL 4&HQWUHIRU*OREDO+HDOWK5HVHDUFK1HZ'HOKL Smokeless Tobacco and Public Health in India INTRODUCTION India is home to over 70% of the world’s adult smokeless tobacco users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and DQG WKH ,QWHJUDWHG 'LVHDVH 6XUYHLOODQFH3URMHFW ,'63 GXULQJ Global Adult Tobacco Survey (GATS) (2009-2010) 2 *$76 ,QGLD XVHG JOREDO VWDQGDUGV IRU V\VWHPDWLFDOO\ PRQLWRULQJ WREDFFR XVH VPRNLQJDQGVPRNHOHVVIRUPV DQGWUDFNLQJNH\LQGLFDWRUVRIWREDFFRFRQWURO7KLVQDWLRQDOOy representative survey elicits information on the respondent’s background characteristics, tobacco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ational Family Health Survey (NFHS) (1998-1999, 2005-2006) 3 5 7KH 1DWLRQDO )DPLO\ +HDOWK 6XUYH\ ZDV D QDWLRQDOO\ UHSUHVHQWDWLYH KRXVHKROG VXUYH\ WKDW HPSOR\HGDPXOWLVWDJHVWUDWLILHGVDPSOLQJGHVLJQ7KHWZRZDYHVRI1)+6WKDWZHUHFRQGXFWHG LQ,QGLDGXULQJ DQGLQFOXGHGTXHVWLRQVRQ6/7XVH JXWNDRWKHUFKHZLQJ WREDFFRDQGVQXII Integrated Disease Surveillance Project (IDSP) 2007-2008 7KH ,QWHJUDWHG'LVHDVH 6XUYHLOODQFH3URMHFW ,'63 ZDV DVWDWHEDVHGVXUYH\ZKLFKZDV ILUVW FRQGXFWHG LQ ,QGLD LQ ZLWK WKH DVVLVWDQFH RI WKH :RUOG %DQN ZLWK SHULRGLF VXUYHLOODQFHRIQRQFRPPXQLFDEOHGLVHDVHULVNIDFWRUVSODQQHGIRUVXEVHTXHQW\HDUV 7KLV VXUYH\ FRYHULQJ WKHSRSXODWLRQEHWZHHQWKHDJHVRIDQG SURYLGHs GDWDRQULVNIDFWRUVUHODWHGWR 1&'V LQFOXGLQJ WREDFFR XVH 7KH VXUYH\ DOVR DLPHG WR HVWDEOLVK WKH EDVHOLQH GDWDEDVHRI1&'ULVNIDFWRUVQHHGHGWRPRQLWRUWUHQGVLQSRSXODWLRQKHDOWKEHKDYLRXUDQGULVN IDFWRUV IRU FKURQLF GLVHDVHV RYHU WLPH LQ VHYHQ VWDWHV—$QGKUD 3UDGHVK .HUDOD 0DGK\D 3UDGHVK0DKDUDVKWUD0L]RUDP7DPLO1DGXDQG 8WWDUDNKDQG 65 Chapter 4. Smokeless Tobacco Use Among Adults in India PREVALENCE OF SLT USE %\ZD\RIJOREDOFRQWH[W 6/7XVHSUHYDOHQFH DPRQJPDOHVDJHV–ZDVKLJKHVWin India LQFRPSDULVRQZLWK WKHFRXQWULHVWKDWSDUWLFLSDWHGLQWKH'HPRJUDSKLFDQG+HDOWK 6XUYH\V '+6 +RZHYHU WKH 67(36 VXUYH\V VKRZ WKDW DPRQJ PDOHV ,QGLD UDQNV VHFRQG LQSUHYDOHQFHRI6/7XVHDIWHU 0\DQPDU DPRQJIHPDOHV,QGLDKDVWKHWKLUG KLJKHVWSUHYDOHQFHRI6/7XVH DIWHU%DQJODGHVK DQG0DGDJDVFDU Prevalence of SLT Use, by Demographic Characteristics 2 4 ,QIRUPDWLRQRQSUHYDOHQFHRI6/7XVH DWWKHQDWLRQDOOHYHOLVDYDLODEOHIURPQDWLRQDOVXUYH\V DOWKRXJKWKHLUPHWKRGRORJLHVDQGWRROVYDU\DQGLVUHSUHVHQWHGLQ)LJXUH 2 $FFRUGLQJWRWKH*$76,QGLD DTXDUWHU RIDOODGXOWVDJHG\HDUVDQGROGHU LQ,QGLDXVH6/77KH\FKHZLWRUDSSO\LWWRWKHWHHWKDQGJXPVRUVQLIILWWKURXJKWKHQRVH 7KHIROORZLQJDVVRFLDWLRQVEHWZHHQ6/7XVHDQGGHPRJUDSKLFFKDUDFWHULVWLFVZHUHIRXQG 2 4 x Gender: 3UHYDOHQFH RI 6/7 XVH ZDV KLJKHU DPRQJ PDOHV WKDQ IHPDOHV )LJXUH +LJKHUSUHYDOHQFHRI6/7XVHDPRQJPDOHVKDV EHHQUHSRUWHGLQPRVWRIWKHVWDWHVLQ ,QGLD H[FHSW 0L]RUDP 0HJKDOD\D 7ULSXUD 7DPLO 1DGX DQG 3RQGLFKHUU\ ZKHUH SUHYDOHQFH RI 6/7 XVH DPRQJ IHPDOHV was hiJKHU WKDQ DPRQJ PDOHV $FFRUGLQJ WR *$76QHDUO\RQHWKLUG RIPHQDQGRQHLQILYH ZRPHQXVH6/7LQ,QGLD Figure 4.1: Prevalence of SLT use among adults (ages 15 years and older) in India 3 4 Sources: 1DWLRQDO)DPLO\+HDOWK6XUYH\ 1)+6 1DWLRQDO)DPLO\+HDOWK6XUYH\ 1)+6 *OREDO$GXOW7REDFFR 2 6XUYH\ *$76 66 Smokeless Tobacco and Public Health in India x Residence: 6/7XVHLVKLJKHUDPRQJWKHUXUDOSRSXODWLRQ WKDQDPRQJWKHXUEDQ 2 SRSXODWLRQ 6LPLODU ILQGLQJs ZHUH REVHUYHG LQ RWKHU QDWLRQDO DQG VXEQDWLRQDO VXUYH\V 7KH ,'63 VXUYH\ ILQGLQJV VKRZ WKH SUHYDOHQFH RI 6/7 XVH LQ VHYHQ VWDWHV RI ,QGLD ZLWK WKH KLJKHVW SUHYDOHQFH LQ 0L]RUDP XUEDQ UXUDO DQGWKHORZHVWLQ.HUDOD XUEDQ UXUDO )LJXUH Figure 4.2: Prevalence of SLT use among adults (age 15 years and above), by residence in 7 states Source: ,QWHJUDWHG'LVHDVH6XUYHLOODQFH3URMHFW ,'63 x Age: ,Q 1)+6 WKH SUHYDOHQFH RI FKHZLQJ WREDFFR LQFUHDVHG ZLWK DJH 5 XQWLO DJH DQG WKHQ UHPDLQHG FRQVWDQW RU GHFOLQHG ,Q *$76 ,QGLD DOVR 6/7XVHLQFUHDVHGZLWKDJH DPRQJPHQWKHUHZDVDVKDUSULVHEHWZHHQDJHVDQG DQG EHWZHHQ DQG \HDUV and WKHQ D GHFOLQH +RZHYHU DPRQJ IHPDOHV 6/7 XVH LQFUHDVHG ZLWKDJHXQWLOROGDJHZKHQWKHGLIIHUHQFHLQXVHEHWZHHQPDOHVDQGIHPDOHV GLVDSSHDUHG )LJXUH ,'63 ZKLFK H[DPLQHG XVH LQ VHYHQ VWDWHV $QGKUD 3UDGHVK .HUDOD 0DGK\D 3UDGHVK 0DKDUDVKWUD 0L]RUDP 7DPLOQDGX DQG 8WWDUDNKDQG DOVR IRXQGWKDW6/7 XVHLQFUHDVHGZLWKDJH x Education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hapter 4. Smokeless Tobacco Use Among Adults in India DPRQJSHRSOHZLWKQRIRUPDOVFKRROLQJZDVZKLOHDPRQJSHRSOHZLWKDVHFRQGDU\ 2 HGXFDWLRQRUKLJKHUSUHYDOHQFHRIXVHZDV Figure 4.3: Prevalence of SLT use among adults (aged 15 years and older), by age 2 Source: *$76,QGLD x Castes and Religion: 3UHYDOHQFHRI6/7XVHZDVKLJKHVWDPRQJWKHVFKHGXOHGWULEH 67 SRSXODWLRQFRPSDUHGWRJHQHUDOFDWHJRU\$PRQJWKH6LNKFRPPXQLW\WKHSUHYDOHQFHRI 5 FKHZLQJWREDFFRLVDOPRVWQHJOLJLEOH x Geographical region and state/Union Territory (UT): 7KH *$76 GDWD VKRZ ZLGH 2 YDULDWLRQLQWKHSUHYDOHQFHRI6/7XVHDPRQJDGXOWVDJHG\HDUVDQGROGHUE\UHJLRQV DQG VWDWHV VHH )LJXUH 2WKHU QDWLRQDO VXUYH\V UHSRUW PXFK JUHDWHU YDULDWLRQ LQ 3 SUHYDOHQFHRIXVHE\IHPDOHV 68 Smokeless Tobacco and Public Health in India Figure 4.4: Prevalence of using smokeless tobacco in general and using specific SLT products, by region/states, Union Territories, and gender in India 2 Source: *$76,QGLD Total SLT Users by Demographic Group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x PLOOLRQ PLOOLRQPDOHVDQGPLOOLRQIHPDOHV FKHZHGNKDLQL x PLOOLRQ PLOOLRQPDOHVDQGPLOOLRQIHPDOHV FRQVXPHGJXWND x PLOOLRQ PLOOLRQ PDOHV DQG PLOOLRQ IHPDOHV FKHZHG EHWHO TXLG ZLWK WREDFFR x PLOOLRQ PLOOLRQ PDOHV DQG PLOOLRQ IHPDOHV XVHG WREDFFR IRU RUDO DSSOLFDWLRQ x PLOOLRQ PLOOLRQPDOHVDQGPLOOLRQIHPDOHV XVHGRWKHU6/7SURGXFWV Males’ prevalences were higher than females’ for each kind of SLT product except products for RUDODSSOLFDWLRQ VXFKDVVQXIIPLVKULJXOJXGDNKX DQGRWKHUSURGXFWV SDQPDVDODEHWHOTXLG ZLWKRXWWREDFFRDQGQDVDOXVHRIVQXII ZKLFKIHPDOHVXVHGDWKLJKHUUDWHV7KHQXPEHURIUXUDO XVHUVRIDOO6/7SURGXFWVFRPELQHG PLOOLRQ ZDVKLJKHUWKDQWKHQXPEHURIXUEDQXVHUV 2 PLOOLRQ 69 Chapter 4. Smokeless Tobacco Use Among Adults in India PREVALENCE OF SLT USE, BY SPECIFIC PRODUCT 2 $FFRUGLQJWR*$76 GDWD NKDLQL ZDVWKHPRVWFRPPRQO\XVHG6/7SURGXFW IROORZHG E\ JXWND (8.2%) and betel quid with tobacco (6.2%). Products in the ‘oral tobacco’ category (such as snuff, mishri, gul, and gudakhu) were less prevalent (4.7%). In the ‘other 2 VPokeless tobacco’ category, products such as nasal snuff had a prevalence of 4.4% 3UHYDOHQFHRINKDLQLJXWND DQGEHWHOTXLGZLWKWREDFFRZDVIRXQGWREHKLJKHUDPRQJPDOHV FRPSDUHGWRIHPDOHVZKLOHSUHYDOHQFHRIRWKHUWREDFFRDQGRIRUDOWREDFFRXVHGDVGHQWLIULFH ZDVKLJKHUDPRQJIHPDOHVWKDQDPRQJPDOHV )LJXUH $PRQJ PDOHV NKDLQL ZDV WKH PRVW FRPPRQO\ XVHG 6/7 SURGXFW KRZHYHU DPRQJ FHUWDLQ JURXSVRIPDOHVVXFKDVDGROHVFHQWV DJHV– XUEDQPDOHVPDOHVZLWKVHFRQGDU\RUKLJKHU HGXFDWLRQDQGPDOHVWXGHQWVJXWND LVWKHPRVWFRPPRQO\XVHG6/7SURGXFW$PRQJIHPDOHVLQ JHQHUDO 6/7LV XVHGPDLQO\E\RUDO DSSOLFDWLRQ IROORZHGE\ RWKHUVPRNHOHVVWREDFFR EHWHOTXLGZLWKWREDFFR NKDLQL DQGJXWND $PRQJPHQSUHYDOHQFHRIXVLQJNKDLQLDQGXVLQJEHWHOTXLGZLWKWREDFFRLQFUHDVHVZLWKDJH .KDLQL XVH LQFUHDVHV IURP DPRQJ PHQ LQ WKH – DJH JURXS WR DPRQJ WKRVH DJHV 25– XVHRIEHWHOTXLGZLWKWREDFFRLQFUHDVHVIURPLQWKH–DJHJURXSWRDPRQJ PHQ DJHV – 0HQ’V XVH RI ERWK SURGXFWV UHPDLQV DOPRVW XQFKDQJHG LQ VXEVHTXHQW DJH JURXSV3UHYDOHQFHRIJXWND XVH LQFUHDVHVIURP DPRQJPDOHV DJHs –WRDPRQJ WKRVHDJH–EXWWKHQGHFUHDVHVWRDPRQJPHQDJHVDQGROGHU0HQ’VXVHRINKDLQL 2 DQGRUDOWREDFFRSURGXFWVGHFUHDVHVZLWKULVLQJHGXFDWLRQ Figure 4.5: Prevalence of specific SLT product use among adults (15 years and older), by gender 2 Source: *$76,QGLD 70 Smokeless Tobacco and Public Health in India 0DOHV XVH NKDLQL PRUH WKDQ IHPDOHV LQ DOO UHJLRQV )LJXUH 8VH RI EHWHO TXLG LV PRUH SUHYDOHQWDPRQJPDOHVWKDQIHPDOHVLQDOOUHJLRQVH[FHSWWKH6RXWKZKHUHEHWHOTXLGSUHYDOHQFH LVKLJKHUDPRQJIHPDOHV )LJXUH Figure 4.6: Prevalence of khaini use, by gender and region 2 Source: *$76,QGLD Figure 4.7: Prevalence of use of betel quid with tobacco, by gender and region 2 Source: *$76,QGLD 71 3UHYDOHQFHRIRUDOWREDFFR HJVQXIIPLVKULJXODQGJXGDKNX XVHLVKLJKHUDPRQJIHPDOHV WKDQPDOHVLQWKH:HVW&HQWUDO(DVWDQG1RUWK(DVWUHJLRQV,QWKH6RXWKSUHYDOHQFHVRIXVH DPRQJ ERWK JHQGHUV DUH PRUH VLPLODU ZKLOH SUHYDOHQFH RI RUDO WREDFFR XVH LV KLJKHU DPRQJ PDOHVWKDQIHPDOHVLQWKH1RUWKUHJLRQ )LJXUH Figure 4.8: Prevalence of oral tobacco use, by gender and region 2 Source: *$76,QGLD +LJKHVWSUHYDOHQFHVRIXVLQJRWKHUVPRNHOHVVWREDFFR HJQDVDOVQXII DUHIRXQGLQWKH1RUWK 2 (DVW DQG (DVW UHJLRQV )LJXUH 3UHYDOHQFH RI RWKHU WREDFFR XVH LV UHSRUWHG PRUH DPRQJ IHPDOHVLQWKH(DVWDQG 6RXWKUHJLRQV LQDOORWKHUUHJLRQV SUHYDOHQFHZDVVLPLODUDPRQJERWK JHQGHUV 72 Smokeless Tobacco and Public Health in India Figure 4.9: Prevalence of other smokeless tobacco use, by gender and region 2 Source: *$76,QGLD DAILY, OCCASIONAL, AND PAST USE OF SMOKELESS TOBACCO $FFRUGLQJWR *$76 GDWDRIWKHRIDGXOWV LQ ,QGLDZKRXVH6/7XVHLW GDLO\DQGWKHUHPDLQLQJ XVHLW RQO\RFFDVLRQDOO\$PRQJWKHRIPDOHVZKRXVH6/7 XVHLWHYHU\GD\DQGWKHUHPDLQLQJ XVHLW RFFDVLRQDOO\6LPLODUO\RIIHPDOHVXVHD VPRNHOHVVSURGXFWHYHU\GD\DQGRQO\XVHRFFDVLRQDOO\3URSRUWLRQDOO\PRUHDGXOWVLQUXUDO DUHDVXVH6/7ERWKGDLO\DQGRFFDVLRQDOO\WKDQDGXOWVLQXUEDQDUHDV7KHSURSRUWLRQRIGDLO\ XVHUVRI6/7DPRQJPDOHVLQFUHDVHVZLWKDJHIURPLQWKH–DJHJURXSWRLQWKH 25–DJHJURXSEXWWKHQGHFUHDVHVWRDERXWDPRQJPDOHVDJH–DQG DQGROGHU 7KHSUHYDOHQFHRIGDLO\6/7XVHUVDPRQJIHPDOHVLQFUHDVHVIURPLQWKH –DJHJURXSWR DPRQJIHPDOHVDJHDQGDERYH$PRQJDGROHVFHQWVDJHV–RIPDOHVDQGRI 2 IHPDOHVXVH6/7HYHU\GD\DQGRIPDOHVDQGRIIHPDOHVXVHLWRFFDVLRQDOO\ *$76 ,QGLD VKRZV WKDW IRUPHU GDLO\ XVH RI VPRNHOHVV WREDFFR ZDV DPRQJPDOHV LQIHPDOHV DQGIRUPHURFFDVLRQDOXVH LQPDOHV LQIHPDOHV 7KXV SDVW XVH GLG QRW GLIIHU PXFK E\ JHQGHU EXW WKHUH was JUHDWHU YDULDWLRQ LQ IRUPHU RFFDVLRQDOXVHDFURVVVWDWHVZLWKDUDQJHRIWR2YHUDOOLWLVFOHDUWKDWSUHYDOHQFHRI SDVW XVH ZDV TXLWH VPDOO—less WKDQ HYHU\ZKHUH H[FHSW LQ -KDUNKDQG ZKHUH IRUPHU 2 RFFDVLRQDOXVHZDV 7DEOH 73 Chapter 4. Smokeless Tobacco Use Among Adults in India Table 4.1: Prevalence of past use of smokeless tobacco among adults (GATS India 2009-2010) Overall (%) Male (%) Female (%) Frequency of SLT use )RUPHUGDLO\XVHU )RUPHURFFDVLRQDOXVHU Range in different states a e f i )RUPHUGDLO\XVHU – E – – M d h l )RUPHURFFDVLRQDOXVHU F – J – N – Notes: a &KDQGLJDUKE 1DJDODQGF 3XQMDEd -KDUNKDQGe 'HOKLf *XMDUDWJ 'HOKL*RD7DPLO1DGXh 0DGK\D3UDGHVKi 0L]RUDPM %LKDUN 3XQMDE+DU\DQD0L]RUDPl -KDUNKDQG 2 Source: *$76,QGLD NATIONAL TRENDS IN SLT USE AMONG ADULTS $OWKRXJK UHSHDWHG QDWLRQDO VXUYH\V XVLQJ WKH VDPH PHWKRGRORJ\ KDYH QRW EHHQ FRQGXFWHG LQ ,QGLDFRPSDULQJWKHDYDLODEOHQDWLRQDOVXUYH\GDWDRYHUWKHODVWGHFDGHVKRZVDQLQFUHDVHLQWKH 2 4 SUHYDOHQFH RI 6/7 XVH )LJXUH $PRQJ IHPDOHV WKH GLIIHUHQFH EHWZHHQ SUHYDOHQFH RI VPRNLQJ DQG 6/7 XVH ZDV JUHDWHU Ln *$76 FRPSDUHG WR 1)+6 ZLWK 6/7 XVH LQFUHDVLQJ )LJXUH Males’ rDWHVRIVPRNLQJDQG6/7XVHZHUHVLPLODULQWKHHDUOLHUWZRVXUYH\VEXW GLYHUJHG LQ *$76 ,QGLD ZKLFK VKRZHG DQ LQFUHDVH LQ 6/7 XVH DQG D GHFUHDVH LQ VPRNLQJ )LJXUH IQ,QGLDDVDZKROHWKHSUHYDOHQFHRI6/7LVJUHDWHUWKDQWKDWRIVPRNLQJ 2 ERWKDPRQJPHQDQGZRPHQ Figure 4.10: Prevalence of smoking and smokeless tobacco use among females 3 4 Sources: 1DWLRQDO)DPLO\+HDOWK6XUYH\ 1)+6 1DWLRQDO)DPLO\+HDOWK6XUYH\ 1)+6 *$76,QGLD 2 74 Smokeless Tobacco and Public Health in India Figure 4.11: Prevalence of smoking and smokeless tobacco use among males 2 Sources: 1)+62 1)+6 *$76,QGLD DATA LIMITATIONS AND GAPS 7KH GLIIHUHQW PHWKRGRORJLHV DJH UDQJHV GHILQLWLRQV VXUYH\ TXHVWLRQV DQG VDPSOH UHSUHVHQWDWLYHQHVV RI WKH VXUYH\V FLWHG LQ WKLV FKDSWHU *$76 1)+6 ,'63 HWF OLPLW WKH FRPSDUDELOLW\RIWKHLUGDWD$FRPPRQIHDWXUHRIDOOWKHVHGDWDVRXUFHVZDVWKHFURVVVHFWLRQDO QDWXUH RI GDWD ZKLFK OLPLWV WKH VFRSH IRU FDXVDO LQIHUHQFH $QRWKHU FKDUDFWHULVWLF RI WKHVH VXUYH\VLVWKDWWKHLUGDWDZHUHFROOHFWHGIURPWKHVHOIUHSRUWVRIDUDQGRPO\VHOHFWHGUHVSRQGHQW IURP HDFK VHOHFWHG KRXVHKROG ZLWKRXW DQ\ REMHFWLYH YDOLGDWLRQ 7KH VWXG\ GHVLJQ RI WKHVH VXUYH\VDOORZHGIRUWKHLQYHVWLJDWLRQRIRQO\DOLPLWHGQXPEHURIVRFLRGHPRJUDSKLFYDULDEOHV 7KHVH VXUYH\V DOVR IRFXVHG RQ GLIIHUHQW VXEMHFWV *$76 ,QGLD KDG TXHVWLRQV RQ WREDFFR FHVVDWLRQ ZKHUHDV 1)+6 DQG ,'63 GLG QRW 7REDFFR XVH ZDV D VPDOO FRPSRQHQW Rf ERWK 1)+6DQG1)+63 UDWKHUWKDQWKHFHQWUDOIRFXVand RQO\IHZTXHVWLRQVZHUHXVHGWR GHWHUPLQHWKHSUHYDOHQFHRIWREDFFRXVH1)+6LVSULPDULO\DUHSURGXFWLYHKHDOWKVXUYH\ZKLFK VDPSOHGZRPHQDJHV– 0HQZHUHVDPSOHGLQWKHKRXVHKROGVRIWKHIHPDOHVDPSOH7KLV VDPSOLQJLQWURdXFHVWKHSRWHQWLDOIRUGRZQZDUGELDV6LQFHWKHVDPSOHRIPHQLVFRQGLWLRQDORQ WKHKRXVHKROGVIURPZKLFKZRPHQZHUHVDPSOHGDQGVLQFHZRPHQDUHPXFKOHVVOLNHO\WREH WREDFFRXVHUVWKDQPHQWKHSRRORIPHQVDPSOHGPD\QRWEHUHSUHVHQWDWLYHRIPDOHXVHUV7KHVH VXUYH\VGRQRWSURYLGHGHWDLOHGGDWDRQ WKHW\SHRUYROXPHRIWREDFFRXVHRUIRUWKH IUHTXHQF\RI XVHRI6/7SURGXFWV 75 7KH 1)+6 VXUYH\ ZDV DGPLQLVWHUHG WKURXJK SUR[\ UHVSRQGHQWV LQ ZKLFK RQH KRXVHKROG PHPEHU DQVZHUHG TXHVWLRQV IRU RWKHU PHPEHUV 7KLV LV D VHULRXV OLPLWDWLRQ EHFDXVH WKH LQIRUPDWLRQSURYLGHGE\RQHPHPEHUIRURWKHUVPD\QRWEHDFFXUDWH$OVR1)+6ODFNHGLQ GHSWKFODVVLILFDWLRQRIWREDFFRSURGXFWV IRUH[DPSOH6/7XVHZDVUHSUHVHQWHGRQO\E\FKHZLQJ DQGFKHZLQJRIRWKHUSURGXFWVVXFKDVEHWHOTXLGZLWKWREDFFRJXWNDNKDLQLJXODQGPLVKUL ZDVQRWFRQVLGHUHG 7KH,'63VXUYH\LQFOXGHGRWKHUIRFXVDUHDVVXFKDVDOFRKROGLHWDQGSK\VLFDODFWLYLW\DQGLV QRWSULPDULO\FRQFHUQHGZLWKWREDFFR ,WLQFOXGHGOLPLWHGLQGLFDWRUVUHODWHGWRWREDFFRFRQWURO DQGSURYLGHGGDWDRQDOLPLWHGQXPEHURIVWDWHVLQ,QGLD CONCLUSIONS 'DWDIURPYDULRXVVRXUFHV VKRZWKDW ,QGLDLV KRPHWR RYHURI JOREDO VPRNHOHVVWREDFFR XVHUV3UHYDOHQFHRI6/7XVH in IndiDLVRQHRIWKHKLJKHVWDPRQJWKHPRVWSRSXORXVFRXQWULHVRI WKHZRUOG6/7XVHLVPRUHSUHYDOHQW DPRQJPDOHVWKDQIHPDOHV LQPRVWRIWKHFRXQWU\ in a few areas SUHYDOHQFH LV KLJKHU DPRQJ IHPDOHV WKDQ PDOHV 3UHYDOHQFH RI 6/7 XVH LV DOVR KLJKHU DPRQJ WKH SRRU DQG XQHGXFDWHG 3UHYDOHQFH RI XVLQJ GLIIHUHQW 6/7 SURGXFWV YDULHV ZLGHO\ among India’s regions and states. 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Dual Tobacco Use in India Men Women % of % of All Dual All tobacco Dual tobacco State. rural district, Number tobacco users tobacco users who users users who and reference surveyed users (%) users (%) are dual (%) are dual (%) users users *XMDUDW %KDYQDJDU 3 – 0HKWDHWDO .HUDOD (UQDNXODP 3 0HKWDHWDO 0DKDUDVKWUD 3XQH 4 – 0HKWDHWDO 8WWDU3UDGHVK 0DLQSXUL 34 5 :DKLHWDO 5 Note: 7KHDJHJURXSZDV\HDUVIRUDOOVXUYH\VH[FHSWWKHVXUYH\LQ8WWDU3UDGHVK ZKHUHWKHDJHJURXSZDV\HDUV ,Q D VXUYH\ FRQGXFWHG LQ – DPRQJ DGXOWV DJHG \HDUV DQG DERYH LQ 0XPEDL SUHYDOHQFHRIGXDOXVHZDV DPRQJPHQDPRQJZRPHQDQGDPRQJWKHWRWDO SRSXODWLRQ ,Q WKH 1DWLRQDO )DPLO\ +HDOWK 6XUYH\ VHFRQG URXQG 1)+6 FRQGXFWHG LQ WKH SUHYDOHQFHRIGXDOWREDFFRXVHZDVDPRQJDGXOWV DJHG\earVDQGROGHU 7KH *OREDO $GXOW 7REDFFR 6XUYH\ *$76 FRQGXFWHG in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umbers and Proportions 7KHQXPEHURI DGXOWGXDO XVHUV \HDUV LQ ,QGLDZDVHVWLPDWHGDWPLOOLRQ7KLVZDV RUDERXWRQHVL[WKRIWKHWRWDORIPLOOLRQWREDFFRXVHUVLQ,QGLD0RUHWKDQRQHWKLUG RIWREDFFRVPRNHUVDQGRQHILIWK RI6/7XVHUVZHUHGXDOXVHUV Sociodemographic Profile 'XDO XVHUV ZHUH SUHGRPLQDQWO\ PHQ ZLWK a SUHYDOHQFH RI :RPHQ KDG D GXDO XVH SUHYDOHQFH RI 7KH PDOH IHPDOH UDWLR ZDV 7KH – DJH JURXS KDG WKH KLJKHVW SUHYDOHQFH RYHUDOO $QDO\VLQJ IRU HGXFDWLRQDO OHYHO WKH KLJKHVW SUHYDOHQFH RI GXDO WREDFFR XVH ZDV DPRQJ DGXOWV ZLWK VRPH SULPDU\ HGXFDWLRQ $PRQJ DOO RFFXSDWLRQDO JURXSV WKH SUHYDOHQFH ZDV ORZHVW DPRQJ VWXGHQWV DQG ZDV KLJKHVW DPRQJ ZRUNLQJ 82 Smokeless Tobacco and Public Health in India SHRSOHZLWKHDFKDPRQJJRYHUQPHQWQRQJRYHUQPHQWHPSOR\HHVDQGWKHVHOIHPSOR\HG 7KH SUHYDOHQFH ZDV VXEVWDQWLDOO\ KLJKHU LQ UXUDO DUHDV WKDQ XUEDQ DUHDV 7DEOH %\ UHJLRQ WKH KLJKHVW SUHYDOHQFH ZDV IRXQG LQ WKH 1RUWK(DVW DQG WKH ORZHVW LQ WKH 1RUWK 7KH &HQWUDO DQG WKH (DVW 5HJLRQV KDG KLJKHUWKDQDYHUDJH SUHYDOHQFH 7KH &HQWUDO5HJLRQLVWKHPRVWKLJKO\SRSXODWHGUHJLRQRIWKHFRXQWU\KHQFHLWKDVDODUJHQXPEHURI GXDOXVHUV )LJXUH Table 5.2: Prevalence and sociodemographic profile of dual tobacco users and all tobacco users, and proportion of dual users among all tobacco users, among adults, by age Men Women Overall % of % of % of tobacco tobacco tobacco All users All users All users Dual tobacco who are Dual tobacco who are Dual tobacco who are Background users users dual users users dual users users dual Characteristics (%)* (%)* users (%) (%)* users (%)* (%) users All India By Age –24 25–44 45– Residence 8UEDQ 5XUDO Education 1RIRUPDO 3ULPDU\ 3ULPDU\EXW VHFRQGDU\ 6HFRQGDU\ and aERYH Occupation *RYHUQPHQW QRQ JRYHUQPHQW HPSOR\HH 6HOIHPSOR\HG 6WXGHQWV +RPHPDNHUV 5HWLUHG XQHPSOR\HG Sources: 'DWDREWDLQHGRUFDOFXODWHGIURP WKH *$76,QGLD GDWDVHWLQFOXGLQJIURPFRXQWU\UHSRUWs DQG*XSWDHWDO 83 Chapter 5. Dual Tobacco Use in India Figure 5.1: Prevalence of dual use among adults age 15 years and older in India, by region Source: *$76,QGLD 7KHVWDWHZLVHSUHYDOHQFHRIGXDOWREDFFRXVHUDQJHGIURPLQ*RD LQWKH:HVWHUQ5HJLRQ WRLQ1DJDODQG LQWKH1RUWK(DVW5HJLRQ 7DEOH 7KHGXDOXVHSUHYDOHQFHLQDOOWKH VWDWHVRIWKH&HQWUDO(DVWDQG1RUWK(DVWUHJLRQVH[FHHGHGWKHQDWLRQDODYHUDJHRI 84 Smokeless Tobacco and Public Health in India Table 5.3: Prevalence of dual tobacco use and all tobacco use, and proportion of dual users among all tobacco users, among adults age 15 years and older, by region and state Men Women Overall % of % of % of All tobacco tobacco tobacco Dual tobacco users who Dual All users who Dual All users who Region and users users are dual users tobacco are dual users tobacco are dual state (%)* (%) users † (%)* users (%) users † (%)* users (%) users † All India North -DPPX .DVKPLU +LPDFKDO 3UDGHVK 3XQMDE &KDQGLJDUK 8WWDUNKDQG +DU\DQD 'HOKL Central 5DMDVWKDQ 8WWDU 3UDGHVK &KKDWWLV JDUK 0DGK\D 3UDGHVK East :HVW%HQJDO -KDUNDQG 2GLVKD %LKDU North-East 6LNNLP $UXQDFKDO 3UDGHVK 1DJDODQG 0DQLSXU 0L]RUDP 7ULSXUD 0HJKDOD\D $VVDP West *XMDUDW 0DKDUDVKWUD 85 Chapter 5. Dual Tobacco Use in India Men Women Overall % of % of % of All tobacco tobacco tobacco Dual tobacco users who Dual All users who Dual All users who Region and users users are dual users tobacco are dual users tobacco are dual state (%)* (%) users † (%)* users (%) users † (%)* users (%) users † *RD South $QGKUD 2 3UDGHVK .DUQDWDND .HUDOD 7DPLO1DGX 3XGXFKHUU\ Sources: 'DWDREWDLQHGRUFDOFXODWHGIURP WKe *$76,QGLD GDWDVHWLQFOXGLQJIURPFRXQWU\UHSRUWs DQG*XSWDHWDO FURTHER ANALYSIS OF GATS DATA $VSHFLDODQDO\VLVRIWKH*$76,QGLDGDWD UHYHDOVDGGLWLRQDOFKDUDFWHULVWLFVRIGXDOXVHUVDV GLVFXVVHGLQWKLVVHFWLRQ Association Between Smoking and Smokeless Forms of Tobacco Use 2GGVUDWLRV 25 IRUFXUUHQW6/7XVHUVDOVREHLQJVPRNHUVFRPSDUHGWRQRQ6/7XVHUVEHLQJ VPRNHUV DV FDOFXODWHG E\ ORJLVWLF UHJUHVVLRQ ZHUH VLJQLILFDQWO\ HOHYDWHG HVSHFLDOO\ LQ XUEDQ DUHDV HYHQ DIWHU DGMXVWLQJ IRU VWDWH JHQGHU DJH UHVLGHQFH HGXFDWLRQ DQG RFFXSDWLRQ$W \RXQJHUDJHV –\HDUV WKHUHZDVDSRVLWLYHDVVRFLDWLRQEHWZHHQ6/7XVHDQGVPRNLQJEXW DW ROGHU DJHV \HDUV DQG DERYH WKH DVVRFLDWLRQ ZDV QHJDWLYH 7KH DVVRFLDWLRQ ZDV KLJKHVW DPRQJ WRyearROGV 25 &, – )RULQGLYLGXDOVZLWKVHFRQGDU\HGXFDWLRQ DQGDERYHWKHDVVRFLDWLRQEHWZHHQ6/7XVHDQGVPRNLQJZDVSRVLWLYHEXWDPRQJWKRVHKDYLQJ QR HGXFDWLRQ LW ZDV QHJDWLYH $PRQJ RFFXSDWLRQDO JURXSV VWXGHQWV ZKR XVHG 6/7 KDG WKH KLJKHVW RGGV RI FRQFXUUHQW VPRNLQJ 25 &, HYHQ WKRXJK WKH\ KDG WKH ORZHVWSUHYDOHQFHRIGXDOWREDFFRXVH ,Q VWDWHV DQG XQLRQ WHUULWRU\ 87 &KDQGLJDUK RXW RI VWDWHV DQG 87V WKHUH ZDV D VLJQLILFDQWO\ KLJK RGGV UDWLR IRU 6/7 XVHUV EHLQJ VPRNHUV FRPSDUHG WR QRQXVHUV 7KH DVVRFLDWLRQZDVVLJQLILFDQWLQVL[RIHLJKWVWDWHVLQWKH1RUWK(DVWZKHUHSUHYDOHQFHZDVKLJK Product Combinations 7KH PRVW SUHYDOHQW SURGXFW FRPELQDWLRQXVHGE\ DERXW RQHWKLUGRI GXDO XVHUVZDVELGLDQG NKDLQL )LJXUH2 7KHQH[WPRVWSUHYDOHQWFRPELQDWLRQVZHUHELGLVDQGJXWND FLJDUHWWHVDQGNKDLQL DQGFLJDUHWWHVDQGJXWND 7KHSRSXODULW\RIDSDUWLFXODU FRPELQDWLRQUHIOHFWHGWKHSRSXODULW\RI WKHSURGXFWVXVHGVLQJO\ $VWKHGDWDIURP*$76 India VKRZHGELGLV DQGFLJDUHWWHVZHUHWKHPRVWSRSXODUVPRNLQJSURGXFWV NKDLQLJXWND DQG EHWHO TXLG ZHUH WKH PRVW SRSXODU VPRNHOHVV SURGXFWV 3URGXFWV FRQWDLQLQJ DUHFD QXW SUHGRPLQDWHG JXWND EHWHOTXLG DQGSDQPDVDOD RYHURWKHUWREDFFRVPRNHOHVVSURGXFWV )LJXUH 0DQ\ GXDO XVHUV UHSRUWHG XVLQJ WZR RU PRUH SURGXFWV ZLWKLQ WKH VPRNLQJ RU VPRNHOHVV FDWHJRU\—LQRWKHUZRUGVWKH\UHSRUWHGXVHRIPRUHWKDQRQHFRPELQDWLRQ 86 Smokeless Tobacco and Public Health in India Figure 5.2: Product combination profile (%) of dual users in India Source: *XSWDHWDO Daily Dual Use 2YHUKDOI RIGXDOXVHUVXVHGERWKW\SHVRISURGXFWVGDLO\$PRQJDOOGXDOXVHUVQHDUO\ IRXUILIWKV XVHG6/7GDLO\ZKLOHWZRWKLUGVVPRNHGGDLO\$PRQJ WKRVHGXDO XVHUV ZKR XVHG RQO\RQHW\SHRISURGXFWRQDGDLO\EDVLV6/7ZDVWKHIDYRXUHGW\SH2QO\RIGXDOXVHUV XVHGERWKW\SHs RISURGXFWRQDQRQGDLO\EDVLV Frequency of Daily Dual Use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nitiation Pattern $PRQJHYHUGDLO\WREDFFRXVHUVWKHPHDQDJHRILQLWLDWLRQWRGDLO\XVHZDV\HDUV7KHDJH RILQLWLDWLRQWRVPRNLQJGLGQRWGLIIHUIURPWKDWIRULQLWLDWLRQWR6/7 87 Chapter 5. Dual Tobacco Use in India $Q DQDO\VLV RI WKH GLIIHUHQFH LQ DJH RI LQLWLDWLRQ WR WKH WZR W\SHV RI SURGXFWV UHYHDOHG WKDW DOWKRXJKVWDUWLQJXVHRIDVHFRQGSURGXFWFRXOGRFFXUDQ\WLPHDIWHUWKHVWDUWRIWKHILUVW XSWR \HDUV PRUHWKDQKDOIRIGXDOXVHUV VWDUWHGXVLQJWKHVHFRQGSURGXFWZLWKLQRQOy 2 years RIWKHVWDUWLQJXVHRIWKHILUVWRQHDQGDOPRVWRQHWKLUG VWDUWHGXVLQJERWKSURGXFWVLQ WKHVDPH\HDU7KLVVHHPVWRLQGLFDWHWKDWPRVWGDLO\GXDOXVHUVVWDUWHGXVLQJERWKSURGXFWVDWD \RXQJDJH6RPHRIGXDOXVHUVVWDUWHGVPRNLQJDWOHDVW\HDUEHIRUHVWDUWLQJ6/7XVH DQGVWDUWHGXVLQJ6/7DWOHDVW\HDUEHIRUHVWDUWLQJVPRNLQJ)RUWKRVHZKRVWDUWHGXVLQJ ERWKLQWKHVDPH\HDULWZDVQRWSRVVLEOHWRILQGRXWZKLFKSURGXFWZDVXVHGILUVW Cessation Profile 2YHURQHWKLUGRIGXDOWREDFFRXVHUV ZHUHLQWHUHVWHGLQTXLWWLQJERWKIRUPVRIWREDFFR XVHVRPHWLPHLQ WKHIXWXUH ZKLFKLQFOXGHGLQ WKHQH[W PRQWKWKHQH[WPRQWKV DQGVRPH GD\ 7KH SHUFHQWDJH RI GXDO XVHUV ZKR ZHUH LQWHUHVWHG LQ TXLWWLQJ ERWK IRUPV RI XVe far H[FHHGHG WKHSURSRUWLRQRIGXDOXVHUVLQWHUHVWHGLQTXLWWLQJRQO\VPRNLQJ RURQO\6/7 XVH )LJXUH 1HDUO\RQHIRXUWKRIGDLO\GXDOXVHUVKDGDWWHPSWHGWRTXLWERWKIRUPV RIWREDFFRXVHLQWKHPRQWKVEHIRUHWKHVXUYH\PXFKPRUH WKDQWKHSHUFHQWDJHZKRKDGWULHG TXLWWLQJVLQJOHXVH+RZHYHURISHRSOHZKRKDGHYHUEHHQGXDOXVHUVRQO\KDGDFWXDOO\ PDQDJHGWRTXLWERWKIRUPVRIWREDFFRLQWKHSDVW\HDU Figure 5.3: Cessation profile of dual users in India Source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mokeless Tobacco and Public Health in India DOWKRXJKPDQ\GXDOWREDFFRXVHUVKDYHDVWURQJGHVLUHWRTXLWXVLQJERWKTXLWWLQJGXDOWREDFFR XVHLVPRUHGLIILFXOWWKDQTXLWWLQJXVHRIDVLQJOHSURGXFW Figure 5.4: Prevalence of former tobacco users (abstained for the past 12 months), by form of tobacco used Source: *XSWDHWDO HEALTH RISKS OF DUAL TOBACCO USE $UHYLHZRISXEOLVKHGLQIRUPDWLRQRQWKHKHDOWKULVNVRIGXDOXVHLQGLFDWHVWKDWDVDJURXSGXDO XVHUVKDYHKLJKHUKHDOWKULVNVWKDQVLQJOHXVHUV,Q,QGLDLQFUHDVHGULVNVRIRUDOOHXNRSODNLDDQG FHUWDLQ FDQFHUV RUDO SKDU\QJHDO DQG RHVRSKDJHDO KDYH EHHQ GRFXPHQWHG LQ FURVVVHFWLRQDO VWXGLHV DVKLJKHUSUHYDOHQFH DQGFDVHFRQWUROVWXGLHV DVRGGVUDWLRV ,QDGGLWLRQKLJKHU RGGV UDWLRV IRUKHDUWGLVHDVHKDYHEHHQGRFXPHQWHGLQ GXDO XVHUV FRPSDUHGWR VLQJOHXVHUVLQ ,QGLDDQGRWKHUFRXQWULHV Higher Prevalence of Oral Leukoplakia 7KHSUHYDOHQFHRIRUDOOHXNRSODNLDDPRQJDGXOW \HDUV GXDOXVHUVIURPILYHUXUDODUHDVRI ,QGLDZDVDFFRUGLQJWRD VKRXVHWRKRXVHVXUYH\VRI DGXOWVZKLFKLQFOXGHG WREDFFRXVHUV3UHYDOHQFHRIOHXNRSODNLDDPRQJH[FOXVLYHELGLVPRNHUVZDV 3 DQGDPRQJH[FOXVLYH6/7XVHUVZDV 7DEOH Excess Risk of Oral Cancer ,QWKHVDPHVWXG\RI DGXOWUHVLGHQWVIURPUXUDODUHDVRIILYHGLVWULFWVLQIRXUVWDWHVGXDO XVHUVKDGDOPRVWWZLFHWKHSUHYDOHQFHRIRUDOFDQFHU FRPSDUHGWRH[FOXVLYH6/7XVers DQG DERXW WHQ WLPHV KLJKHU SUHYDOHQFH RI RUDO FDQFHU WKDQ H[FOXVLYH ELGL VPRNHUV 3 7DEOH 89 Chapter 5. Dual Tobacco Use in India Table 5.4: Prevalence of oral leukoplakia and cancer among dual tobacco users and single tobacco users in large rural populations surveyed in India Prevalence Prevalence in in dual Exclusive exclusive Study Population tobacco SLT users tobacco Disease years surveyed users (%) (%) smokers (%) Reference /HXNRSODNLD – 0HKWDHWDO 3 PHQ FKHZHUV ELGLV § ZRPHQ 2UDOFDQFHU – 0HKWDHWDO 3 PHQ FKHZHUV ELGLV § ZRPHQ 2UDOFDQFHU – :DKLHWDO 5 PHQ 0DLQSXUL WREDFFR 2UDOFDQFHU – :DKLHWDO 5 ZRPHQ 0DLQSXUL WREDFFR 2UDOFDQFHU – :DKLHWDO 5 PHQ RWKHU WREDFFR 2UDOFDQFHU – :DKLHWDO 5 ZRPHQ RWKHU WREDFFR 3HULRGSUHYDOHQFH2IZKLFKXVHGWREDFFRLQDQ\IRUP ,Q D VWXG\ LQ 8WWDU 3UDGHVK FRQGXFWHG GXULQJ WR DPRQJ PHQ DQG ZRPHQWKHSHULRGSUHYDOHQFHRIRUDODQGRURSKDU\QJHDOFDQFHUVDPRQJPDOHGXDOWREDFFRXVHUV ZKRERWKVPRNHGDQGXVHG0DLQSXULWREDFFR ZDVWLPHVJUHDWHUWKDQWKDWRIH[FOXVLYH VPRNHUV DQGQHDUO\GRXEOHWKDWRIH[FOXVLYHXVHUVRI6/7 0HQZKRZHUHGXDO users who both smoked and used ‘other tobacco’ (mainly plain tobacco with lime) had a SUHYDOHQFH RI RUDO FDQFHU ZKLFK ZDV QHDUO\ WKUHH WLPHV KLJKHU WKDQ WKDW RI H[FOXVLYH VPRNHUV DQGGRXEOHWKHSUHYDOHQFHIRXQGDPRQJH[FOXVLYH6/7XVHUV :RPHQ GXDOXVHUVKDGKLJKHUSUHYDOHQFHRIRUDODQGRURSKDU\QJHDOFDQFHUFRPSDUHGWRVLQJOHXVHUV Whey 5 DOVRKDGWZLFHWKHRUDOFDQFHUSUHYDOHQFHFRPSDUHGWRPHQGXDOWREDFFRXVHUV 7DEOH )RXU FDVH FRQWURO VWXGLHV LQ ,QGLD IXUWKHU LOOXVWUDWH WKH KLJKHU ULVNV RI RUDO SKDU\QJHDO DQG RHVRSKDJHDOFDQFHULQGXDOWREDFFRXVHUVFRPSDUHGWRVLQJOHXVHUVDQGQHYHUXVHUVZKHUHRGGV UDWLRV RI GLVHDVH IRU GXDO XVHUV DUH VLJQLILFDQWO\ HOHYDWHG FRPSDUHG WR QHYHUXVHUV DQG HYHQ KLJKHUWKDQIRUVLQJOHWREDFFRXVHUV 7DEOH 90 Smokeless Tobacco and Public Health in India Table 5.5: Dual tobacco users and single users compared to never tobacco users: case control studies with odds ratios (OR) of diseases and 95% confidence intervals (CI) Dual tobacco Exclusive SLT Exclusive tobacco Study Disease Study samples users users smokers Reference (Country) years OR (95% CI) OR (95% CI) OR (95% CI) %XFFDODQG – (YHUXVHUVYV – – 6DQNDUDQDUD\DQDQHW DO ODELDOFDQFHU QHYHUXVHUV PHQRQO\ SDQZLWKWREDFFR ,QGLD FDVHV FRQWUROV *LQJLYDO – (YHUXVHUVYV – – – 6DQNDUDQDUD\DQDQHW al FDQFHU QHYHUXVHUV PHQRQO\ SDQZLWKWREDFFR VWUDWLILHG ,QGLD H[FOXGHV DOFRKRO GULQNLQJ FDVHV 5 FRQWUROV 2UDOFDQFHU – (YHUXVHUVYV – – – =QDRUHWDO QHYHUXVHUV PHQRQO\ SDQZLWKWREDFFR ,QGLD VWUDWLILHG H[FOXGHV DOFRKRO GULQNLQJ FDVHV FRQWUROV 3KDU\QJHDO – (YHUXVHUVYV – – – =QDRUHWDO FDQFHU QHYHUXVHUV PHQRQO\ SDQZLWKWREDFFR ,QGLD VWUDWLILHG H[FOXGHV DOFRKRO GULQNLQJ FDVHV FRQWUROV 2HVRSKDJHDO – (YHUXVHUVYV – – – =QDRUHWDO FDQFHU QHYHUXVHUV PHQRQO\ SDQZLWKWREDFFR ,QGLD VWUDWLILHG H[FOXGHV DOFRKRO GULQNLQJ FDVHV FRQWUROV 2HVRSKDJHDO – (YHUXVHUVYV – – – 3KXNDQHWDO FDQFHU QHYHUXVHUV PHQRQO\ SDQZLWKWREDFFR ,QGLD VWUDWLILHG H[FOXGHV DOFRKRO GULQNLQJ FDVHV FRQWUROV 91 Chapter 5. Dual Tobacco Use in India Dual tobacco Exclusive SLT Exclusive tobacco Study Disease Study samples users users smokers Reference (Country) years OR (95% CI) OR (95% CI) OR (95% CI) 1RQIDWal – &XUUHQWXVHUV – – – 7HRHWDO P\RFDUGLDO YVQHYHUXVHUV LQIDUFWLRQ FKHZLQJDQ\IRUP FLJDUHWWHV FRXQWULHVLQFOXGLQJ FDVHV RIWREDFFR – IndiD FRQWUROV ELGLV ,QFLGHQW – (YHUXVHUVYV – – – 5DKPDQDQG=DPDQ FRURQDU\ QHYHUXVHUV KHDUWGLVHDVH DGMXVWHGIRU JHQGHUDJH %DQJODGHVK K\SHUWHQVLRQ FDVHV FRQWUROV Notes: 3YDOXHVQRWDYDLODEOHH[FHSWIRU3KXNDQHWDO 3DUWLFXODUVPRNHOHVV DQGVPRNLQJSURGXFWVXVHGDUHLQGLFDWHGZKHUHUHOHYDQW ,QDVWXG\LQ7ULYDQGUXPRIFDVHVRIEXFFDO FKHHN DQGODELDO OLS FDQFHUDQG FRQWUROV GXDOXVHUVKDGDQRGGVUDWLRRIIRUKDYLQJWKHVHFDQFHUVFRPSDUHG WRQHYHUWREDFFRXVHUV 7KLV ZDV KLJKHU WKDQ WKH RGGV UDWLR IRU H[FOXVLYH 6/7 XVHUV 25 DQG ILYH WLPHV KLJKHUWKDQWKDWIRUH[FOXVLYHELGLVPRNHUV 25 ,QDQRWKHUVWXG\LQ7ULYDQGUXPRIFDVHVRIFDQFHURIWKHJLQJLYD JXPV DQG FRQWUROV 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Determinants of Smokeless Tobacco Use in India Figure 6.2: Knowledge of the harms of SLT use, by education 100 90 80 70 No Formal Schooling 60 Less than Primary 50 40 Primary but less than 30 Secondary Awareness Levels (%) Awareness Levels 20 Secondary and above 10 0 Overall Current Non User User Source: *$76,QGLD Myths Associated with Smokeless Tobacco Use in India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knowledge levels, whereby women’s lack of awareness of SLT’s harms makes them more YXOQHUDEOHWR6/7XVH6LPLODUO\UXUDOSRSXODWLRQVKDYHEHHQUHSRUWHGWRKDYHORZHUDZDUHQHVV OHYHOV WKDQ XUEDQ SRSXODWLRQV 7KHVH ILQGLQJV VXJJHVW WKDW IXWXUH LQWHUYHQWLRQV WR LQFUHDVH awareness of SLT’s should be tailored to address these social inequalities. 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These determinants have direct impact on health and SUHGLFW WKH VWDWXV YDULDQFH 7KH\ DOVR LQWHUDFW ZLWK HDFK RWKHU DQG VWUXFWXUH WKH KHDOWKUHODWHG EHKDYLRXUV ZLWKLQ D VRFLHW\ 7KHVH GHWHUPLQDQWV RI 6/7 XVH DUH IXUWKHU GLVFXVVHG XQGHU WKH 104 Smokeless Tobacco and Public Health in India IROORZLQJ KHDGLQJV 6RFLRGHPRJUDSKLF 'HWHUPLQDQWV 6RFLRHFRQRPLF 'HWHUPLQDQWV DQG 6RFLRFXOWXUDO 'HWHUPLQDQWV Sociodemographic Determinants (Age, Gender, and Area of Residence) Sociodemographic Determinants of Prevalence of SLT Use 6WXGLHVKDYHGHVFULEHGWKHYDULDWLRQVLQSUHYDOHQFHRI6/7XVHDFFRUGLQJWRVRFLRGHPRJUDSKLF GHWHUPLQDQWV VXFK DV DJH JHQGHU DQG DUHD RI UHVLGHQFH 5DQL DQG FROOHDJXHV DQDO\VHG WKH GDWD IURP 1DWLRQDO )DPLO\ +HDOWK 6XUYH\ 1)+6 WR LGHQWLI\ SUHGLFWRUV RI WREDFFR XVH LQ ,QGLD WKH\ IRXQG KLJKHU RGGV RI 6/7 XVH ZLWK LQFUHDVLQJ DJH DPRQJ ERWK JHQGHUV 0DOH UHVSRQGHQWV \HDUV RI DJH DQG ROGHU ZHUH WLPHV PRUH OLNHO\ WR EH 6/7 XVHUV WKDQ WKRVH ZLWKLQ WKH DJH JURXS RI – DIWHU DGMXVWLQJ IRU SRWHQWLDO FRQIRXQGHUV S ZKLOHIHPDOHVDJHVDQGROGHUZHUHWLPHVPRUHOLNHO\WRXVH6/7WKDQIHPDOHV DJHV– S $VLJQLILFDQW JUDGLHQWDFFRUGLQJWRDJHDIWHUDGMXVWLQJIRUDOOSRWHQWLDO FRQIRXQGHUVZDVDOVRREVHUYHG S 0DOHVIURPUXUDODUHDVZHUHWLPHVPRUHOLNHO\WREH6/7XVHUVFRPSDUHGWRWKRVHIURPWKH XUEDQDUHDV S $VLPLODUDVVRFLDWLRQZDVUHSRUWHGDPRQJIHPDOHV 25 S KRZHYHUDIWHUDGMXVWLQJIRUSRWHQWLDOFRQIRXQGHUVWKHUHVXOWVFKDQJHG 25 S $FFRUGLQJ WR WKH *$76 ,QGLD UHSRUW WKH SUHYDOHQFH RI DQ\ 6/7 XVH ZDV KLJKHU DPRQJPDOHV WKDQDPRQJIHPDOHV ,QWHUPVRIDUHDRIUHVLGHQFHWKHSUHYDOHQFH RI6/7XVHLQUXUDODUHDVwas KLJKHU WKDQLQXUEDQDUHDV Sociodemographic Determinants of Initiation of SLT Use Chewing tobacco products have been reported as ‘starter tobacco products’ for adolescents EHFDXVHWKH\DUHFKHDSDQGHDVLO\DFFHVVLEOHZKLFKDWDODWHUDJHLQLWLDWHVGXDOXVHRIWREDFFR SURGXFWV 7KXV LQLWLDWLRQ RI 6/7 LV D JDWHZD\ IRU SURORQJHG XVH RI WREDFFR 6WXGLHV KDYH H[SORUHGWKHGHWHUPLQDQWV RILQLWLDWLRQRI6/7XVHLQ \RXWK $VWXG\E\5LOH\DQGFROOHDJXHV UHSRUWHGWKDWDJHRI6/7LQLWLDWLRQLVVLJQLILFDQWO\DQGQHJDWLYHO\FRUUHODWHGZLWKQLFRWLQH LQWDNHDPRQJDGROHVFHQWV—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ociodemographic Determinants of SLT Quitting Behaviour (IIHFW RI VRFLRGHPRJUDSKLF IDFWRUV QLFRWLQH GHSHQGHQFH OHYHOV DQG VHOIHIILFDF\ KDYH EHHQ LGHQWLILHGDVVWURQJSUHGLFWRUVRITXLWWLQJWREDFFRXVHLQWKH:HVW7RQVWDGDQGFROOHDJXHVLQ WKHLUVWXG\RQ&DPERGLDQDGXOWVUHSRUWHGWKDW6/7XVHUVZHUHWLPHV 25 OHVVOLNHO\WR 42 TXLW FRPSDUHG WR VPRNHUV 7KH *$76 ,QGLD UHSRUW IRXQG WKDW RYHUDOO RI 105 Chapter 6. Determinants of Smokeless Tobacco Use in India FXUUHQWXVHUVRI6/7ZHUHQRWLQWHUHVWHGLQTXLWWLQJ$PRQJWKHVHPRUHIHPDOHV ZHUH QRW LQWHUHVWHG LQ TXLWWLQJ WKDQ PDOHV DQG LW ZDV DOVR UHSRUWHG WKDW LQWHUHVW LQ TXLWWLQJ6/7XVHGHFUHDVHGDVDJHLQFUHDVHG Socioeconomic Determinants 7KLVVHFWLRQGLVFXVVHVVRFLRHFRQRPLFGHWHUPLQDQWVRI6/7XVHWKDWKDYHEHHQH[SORUHGLQWKH OLWHUDWXUHVXFKDVLQFRPH ZHDOWK HGXFDWLRQDODWWDLQPHQWHPSOR\PHQWDQGRFFXSDWLRQ Socioeconomic Determinants of Prevalence of SLT Use Income (Wealth) 7KHUHLVVWURQJHYLGHQFHWKDWLQFRPHRUZHDOWKLVDVVRFLDWHGZLWKWKHKHDOWKRIDQLQGLYLGXDODQG LWKDVEHHQREVHUYHGWKDWKHDOWKFRPSURPLVLQJEHKDYLRXUVWHQGWRRFFXUDQGFOXVWHUPRUHDPRQJ the poor rather than the wealthy. Rani and colleagues’ 2001 study of the association between 6/7XVHDQGLQFRPHLQ,QGLDVKRZHGDFOHDUVRFLDOJUDGLHQWDFFRUGLQJWRKRXVHKROG ZHDOWKIRU ERWKJHQGHUVLQGLFDWLQJWKDWVXVFHSWLELOLW\WRXVH6/7ULVHVZLWKGHFUHDVLQJKRXVHKROGLQFRPH WKHJUDGLHQWZDVVLJQLILFDQWHYHQDIWHUDGMXVWLQJIRUSRWHQWLDOFRQIRXQGHUV S 6LPLODU JUDGLHQWVZHUHUHSRUWHGLQDQRWKHUVWXG\WKDWDQDO\VHGERWK1)+6DQG1)+6DQGUHSRUWHG SRROHGHVWLPDWHVIRU6/7XVH 7KHSRRUHVWLQGLYLGXDOVZHUHWZLFHDVOLNHO\ 25 &, – WRXVH6/7DVWKHULFKHVWRQHV :KHQSUHYDOHQFHRI6/7XVHZDVFURVVWDEXODWHGZLWKLQFRPHTXLQWLOHVXVLQJ*$76India GDWDWKHKLJKHVWXVHRI6/7ZDVIRXQGDPRQJWKRVHLQWKHORZHVWTXLQWLOHRILQFRPH$Q LQYHUVHJUDGLHQWZDVREVHUYHGLQWKHDVVRFLDWLRQRILQFRPHDQGXVHRIJXWND WKHPRVWSUHYDOHQW 6/7 SURGXFW +LJKHU XVH ZDV FRUUHODWHG ZLWK ORZHU LQFRPH DPRQJ PDOH XVHUV RI DOO 6/7 SURGXFWV 6LPLODUO\SRVLWLYHJUDGLHQWVZHUHREVHUYHGLQPDOHVIRUDOOSURGXFWVH[FHSWQDVDOVQXII ZKLOHWKHVDPHZDVREVHUYHGIRUDOOSURGXFWVH[FHSWEHWHOTXLGZLWKWREDFFRDQGSDQPDVDODDQG EHWHOTXLGZLWKRXWWREDFFRDPRQJIHPDOHV 7DEOH Table 6.2: Prevalence of smokeless tobacco use according to wealth quintiles Gutka or Pan masala Khaini or Oral tobacco Betel quid tobacco/lime/ and betel quid tobacco–lime (snuff, mishri, Nasal snuff Any others with tobacco areca nut without mixture gul, gudakhu) mixture tobacco % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) :HDOWK 4XLQ 0)0)0)0)0)0)0) WLOHV VW 2nd 3rd WK 106 Smokeless Tobacco and Public Health in India Gutka or Pan masala Khaini or Oral tobacco Betel quid tobacco/lime/ and betel quid tobacco–lime (snuff, mishri, Nasal snuff Any others with tobacco areca nut without mixture gul, gudakhu) mixture tobacco % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) :HDOWK 4XLQ 0)0)0)0)0)0)0) WLOHV WK Source: *$76,QGLD Educational Attainment (GXFDWLRQDODWWDLQPHQWKDVEHHQZLGHO\XVHGDVDSUR[\IRUVRFLRHFRQRPLFVWDWXVDQGHYLGHQFH VXJJHVWVWKDWHGXFDWLRQLVDVWURQJSUHGLFWRURIKHDOWKDQGKHDOWKUHODWHGEHKDYLRXUV6WXGLHVWKDW KDYHDVVHVVHGWKHVRFLRHFRQRPLFFRUUHODWHVRI6/7XVHKDYHUHSRUWHGYDULDWLRQLQSUHYDOHQFHRI 6/7XVHDFFRUGLQJWRHGXFDWLRQDODWWDLQPHQW7KLVVHFWLRQZLOOGLVFXVVYDULDWLRQVLQSUHYDOHQFH RI6/7XVHDFFRUGLQJWRHGXFDWLRQDODWWDLQPHQWDQGLWVDVVRFLDWLRQZLWKLQLWLDWLRQDQGFHVVDWLRQ RI6/7 XVH $VVRFLDWLRQVEHWZHHQHGXFDWLRQDQGSUHYDOHQFHRI6/7XVHZHUHVLPLODUWRWKRVHIRXQGEHWZHHQ 6/7XVHDQGLQFRPH5DQLDQGFROOHDJXHVUHSRUWHGFOHDUDQGVLJQLILFDQWHGXFDWLRQDO JUDGLHQWV DPRQJPDOHV S EXWQRWDVFOHDUO\DPRQJIHPDOHV*UHDWHUVXVFHSWLELOLW\WR6/7XVHZDV IRXQG DPRQJ OHVVHGXFDWHG IHPDOHV 25 S IRU WR \HDUV VFKRROLQJ 25 S IRUQRHGXFDWLRQ FRPSDUHGWRZRPHQZLWK\HDUVRIVFKRROLQJ $QRWKHUVWXG\ UHSRUWHGFOHDUDQGVLJQLILFDQWHGXFDWLRQDOJUDGLHQWVZLWKQRQHGXFDWHGLQGLYLGXDOVEHLQJWKUHH WLPHVPRUHOLNHO\ 25 &, – WREH6/7XVHUVFRPSDUHGWRSRVWJUDGXDWHV $QDVVHVVPHQWRIVRFLDOGLVSDULWLHVLQWREDFFRXVHLQ0XPEDLUHSRUWHGWKDWLOOLWHUDWHZRPHQZHUH DERXWWLPHVPRUHOLNHO\ 25 &,–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mployment or Occupation $ VWXG\E\6RUHQVRQDQGFROOHDJXHVUHSRUWHGKLJKHUVXVFHSWLELOLW\WR6/7XVHDPRQJERWK XQHPSOR\HGPDOHV 25 &,– DQGXQHPSOR\HGIHPDOHV 25 &, – LQ 0XPEDL FRPSDUHG WR SURIHVVLRQDO ZRUNHUV LQ WKDW FLW\ 6WURQJHU DVVRFLDWLRQV EHWZHHQRFFXSDWLRQDQG6/7XVHZHUHREVHUYHGDPRQJPDOHVWKDQDPRQJIHPDOHV 107 Chapter 6. Determinants of Smokeless Tobacco Use in India Socioeconomic Determinants of Initiation of SLT Use (GXFDWLRQDODWWDLQPHQWZDVDOVRREVHUYHGDVa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ocioeconomic Determinants of SLT Quitting Behaviour $FFRUGLQJWR *$76GDWDLQGLYLGXDOVZLWKKLJKHUHGXFDWLRQDODWWDLQPHQWZHUHPRUH LQWHUHVWHGLQTXLWWLQJ6/7WKDQWKRVHZLWKOHVV HGXFDWLRQ$PRQJDOORFFXSDWLRQVWKHKLJKHVW UDWHRIZLOOLQJQHVVWRTXLW6/7XVHZLWKLQWKHQH[WPRQWKZDVIRXQGDPRQJVWXGHQWV IROORZHGE\WKHUHWLUHGRUXQHPSOR\HG VHOIHPSOR\HGSHRSOH JRYHUQPHQWDQG QRQJRYHUQPHQWHPSOR\HHV DQGKRPHPDNHUV Sociocultural Determinants 7KHVRFLDODQGFXOWXUDOSDWWHUQVZLWKLQWKHKXPDQFRPPXQLW\WKDWDIIHFWKHDOWKLQFOXGLQJVXFK IDFWRUV DV VKDUHG EHOLHI V\VWHPV IDPLO\ VWUXFWXUHV DQG VRFLDO FRQWUDFWV DUH NQRZQ DV WKH VRFLRFXOWXUDOGHWHUPLQDQWVRIKHDOWK(YLGHQFHVXJJHVWVWKDWEHWHOTXLGXVHKDVEHHQHPEHGGHGLQ WKHFXOWXUDOV\VWHPRI,QGLDIRUDYHU\ORQJWLPH )LJXUH3 $IWHUWREDFFRZDVLQWURGXFHGLQ WKLVUHJLRQLWEHFDPHDQLQJUHGLHQWLQEHWHOTXLGZKLFKEHFDPHRQH RIWKHPRVWFRPPRQO\XVHG 43 6/7SURGXFWV Figure 6.3: Smokeless tobacco (tambul) in a traditional utensil for serving guests in Assam Source: )LHOGYLVLWGXULQJ17&3(YDOXDWLRQ $QNXU6LQJK 108 Smokeless Tobacco and Public Health in India 6RFLRFXOWXUDOIDFWRUVDUHFUXFLDOGHWHUPLQDQWVRI6/7XVHLQ,QGLD6PRNLQJLQIURQWRIIDPLO\ HOGHUVLQ,QGLDLVVWLOOFRQVLGHUHGWDERRDQG6/7SURGXFWVZKLFKKDYHIHZHURGRXUVDQGDUHOHVV QRWLFHDEOHUHSUHVHQWDQDFFHSWDEOHDOWHUQDWLYH7REDFFRXVHLV FRQVLGHUHGDFFHSWDEOHRUGHVLUDEOH PDOHEHKDYLRXULQ,QGLDQFXOWXUHZKLFKKDVOHGWR6/7XVHLQLWLDWLRQDPRQJZRPHQDQG\RXWK ZKR ZLVK WR DWWDLQ WKH VDPH VRFLDO VWDWXV DV WKH GRPLQDQW PDOHV 5HVHDUFK KDV VKRZQ DQ 43 DVVRFLDWLRQEHWZHHQWREDFFRXVHLQLWLDWLRn and power dynamics in India’s sociocultural system Summary of Social Determinants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’s Framework Convention on Tobacco Control (FCTC) identified PHGLD DV D NH\ IDFWRU LQ WREDFFR XVH DQG KDV WUDQVODWHG WKH HYLGHQFH RQ WKH UROH RI PHGLD LQ WREDFFRXVHWRDSUHVFULSWLRQIRUDFWLRQE\UHTXLULQJUDWLI\LQJFRXQWULHVWRDGRSWDWRWDOEDQRQ WREDFFRDGYHUWLVLQJSURPRWLRQDQGVSRQVRUVKLS 7$36 EDUULQJDQ\FRQVWLWXWLRQDOOLPLWDWLRQV LQWKRVHFRXQWULHV (YLGHQFHVKRZVWKDWPDVVPHGLDFDPSDLJQVWKURXJKWHOHYLVLRQDQGUDGLRZHUHPRUHHIIHFWLYHLQ UHDFKLQJ PRUH PDUJLQDOLsHG SRSXODWLRQV VXFK DV UXUDO UHVLGHQWV DQG WKRVH RI ORZHU 45 VRFLRHFRQRPLF VWDWXV DQG IDFLOLWDWLQJ EHKDYLRXU FKDQJH $PRQJ 6/7 XVHUV D VLJQLILFDQW UHODWLRQVKLS EHWZHHQ FDPSDLJQ DZDUHQHVV DQG campaign-relevant NQRZOHGJH DQG DWWLWXGHV WRZDUG 6/7 KDV EHHQ REVHUYHG ZKLFK VXJJHVWV WKDW PHGLD FDQ EH XVHIXO LQ SURPRWLQJ 6/7 FRQWUROPHVVDJHVDPRQJSRSXODWLRQVDWKLJKULVN$OVRWKHFKRLFHRIPHGLXPLQSURPRWLQJWKHVH 45 PHVVDJHVLVRINH\LPSRUWDQFH $FFRUGLQJ WR WKH *$76 UHSRUW LQHTXDOLWLHV LQ UHFHSWLRQ RI KHDOWKUHODWHG LQIRUPDWLRQ FDQ EH REVHUYHGDFURVVWKHSRSXODWLRQ2YHUDOORIWKHUHVSRQGHQWVQRWLFHGDQ\DGYHUWLVHPHQWRU SURPRWLRQRI6/7SURGXFWV0RUHFXUUHQWXVHUVRI6/7 WKDQQRQXVHUV QRWLFHG DQ\DGYHUWLVHPHQWRUSURPRWLRQ0RUHSHRSOHQRWLFHd 6/7DGYHUWLVHPHQWVRQWHOHYLVLRQWKDQRQ RWKHU PHGLD DQG ERWK IHPDOHV DQG UXUDO UHVLGHQWV VKRZHG JUHDWHU OLNHOLKRRG RI QRWLFLQJ DGYHUWLVHPHQWVRQWKHPRVWSRSXODUPHGLXP WHOHYLVLRQ DQGRILGHQWLI\LQJ6/7DGYHUWLVHPHQWV DQ\ZKHUH7DEOHVKRZVWKHKLJKHUYXOQHUDELOLW\RIUXUDOUHVLGHQWVDQGIHPDOHVWRVPRNHOHVV WREDFFRXVHDVPHDVXUHGE\WKHUDWHDWZKLFKWKH\QRWLFH6/7DGYHUWLVLQJWKURXJKWHOHYLVLRQ 109 Chapter 6. Determinants of Smokeless Tobacco Use in India Table 6.3: Percentage of adults (age 15 years and older) who noticed smokeless tobacco advertising, by gender and residence News- papers Some- In Bill- Cine- Public Public Any- TV Radio Posters or Internet where Stores boards mas transport walls where maga- else zines % % % % % (95% % (95% % (95% % (95% % (95% % (95% % (95% % (95% (95% (95% (95% (95% CI) CI) CI) CI) CI) CI) CI) CI) CI) CI) CI) CI) 1DWLRQDO 0DOH )HPDOH 8UEDQ 5XUDO Source: *$76,QGLD *$76 ,QGLD DOVR HYDOXDWHG PHVVDJHV DJDLQVW 6/7 XVH DQG UHSRUWHG WKDW PDOHV QRWLFHGDQWL6/7PHVVDJHVLQQHZVSDSHUVDQGPDJD]LQHVDQGRQELOOERDUGVDOPRVWWZLFHDVRIWHQ DVIHPDOHV$QWL6/7PHVVDJHVRQWHOHYLVLRQZHUHQRWLFHGE\RIPDOHV &, – DQG RI IHPDOHV &, – 7KH GLIIHUHQFH LQ SURSRUWLRQV RI PHQ DQG ZRPHQQRWLFLQJDQWL6/7LQIRUPDWLRQRQWHOHYLVLRQZDVOHVVIRUWHOHYLVLRQWKDQIRURWKHUPHGLD ,QXUEDQDQGUXUDODUHDVWHOHYLVLRQZDVUHSRUWHGDVWKHPRVWSRSXODUPHGLXPIRUUHFHLYLQJDQWL 6/7LQIRUPDWLRQ 7DEOH $QWL6/7LQIRUPDWLRQLVQRWUHDFKLQJWRPDMRULW\RIZRPHQDQG UXUDOUHVLGHQWVDQGFRXQWHUVWUDWHJLHVDQGPDVVPHGLDFDPSDLJQVQHHGWREHWDLORUHGWRSURYLGH KHDOWKPHVVDJLQJIRUWKHVHSRSXODWLRQJURXSV 110 Smokeless Tobacco and Public Health in India Table 6.4: Percentage of adults (age 15 years and older) who noticed anti-smokeless tobacco information in various media, by gender and residence Newspapers or Somewhere magazines TV Radio Billboards else Anywhere % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) 1DWLRQDO 0DOH )HPDOH 8UEDQ 5XUDO Source: *$76,QGLD 7KHFROOHFWLYHHYLGHQFHRQPHGLDDVDGHWHUPLQDQWRI6/7XVHVWURQJO\VXJJHVWVWKDWWKHUHDUH VRFLDOLQHTXDOLWLHVLQUHFHSWLRQRIERWK6/7DGYHUWLVHPHQWVDQGDQWL6/7PHVVDJHV:KLOHIHZHU ZRPHQ DQG UXUDO UHVLGHQWV QRWLFH DQWL6/7 PHVVDJHV ERWK IHPDOHV DQG UXUDO UHVLGHQWV KDYH QRWLFHG PRUH 6/7 DGYHUWLVHPHQWV LQ WKH PRVW SRSXODU FRPPXQLFDWLRQ PHGLD WKDQ PDOHV DQG XUEDQ UHVLGHQWV 7KLV ILQGLQJ KLJKOLJKWV WKH YXOQHUDELOLW\ RI ZRPHQ DQG UXUDO UHVLGHQWV WR LQLWLDWLQJ DQG FRQWLQXLQJ 6/7 XVH DV D UHVXOW RI DGYHUWLVHPHQWV DQG SURPRWLRQV XVHG E\ WKH LQGXVWU\ GAPS IN RESEARCH 0RVWVWXGLHVRINQRZOHGJHaWWLWXGHV EHKDYLRXUDQGSUDFWLFHVKDYHIRFXVHGRQRYHUDOOWREDFFR XVH EXW RQO\ D IHZ VWXGLHV VSHFLILFDOO\ DGGUHVV 6/7 XVH :KLOH HYLGHQFH LV DYDLODEOH RQ NQRZOHGJH OHYHOV UHJDUGLQJ WKH KDUPIXO HIIHFWV RI VPRNLQJ—ZKLFK LQFOXGH GLVHDVHV VXFK DV FDQFHUK\SHUWHQVLRQGLDEHWHV—ORFDODQGQDWLRQDOVXUYH\VKDYHQRWDVVHVVHGNQRZOHGJHOHYHOV VSHFLILFDOO\UHJDUGLQJWKHKDUPVRI6/7XVH0RVW VWXGLHVRISURIHVVLRQDOJURXSVKDYHIRFXVHG RQDZDUHQHVVOHYHOVRIKHDOWKSURIHVVLRQDOVUHJDUGLQJ6/7XVH LWLVVXJJHVWHGWKDWIXWXUHVWXGLHV VKRXOGDOVRDVVHVVWKHDZDUHQHVVOHYHOVRIRWKHUSURIHVVLRQDOVVXFKDVWHDFKHUV and ODZ\HUV 6WXGLHVKDYHPRVWO\DVVHVVHGWKHDVVRFLDWLRQRIGHWHUPLQDQWVDQG6/7XVHLQYDULRXVSDUWVRIWKH FRXQWU\ 7KH DYDLODEOH HYLGHQFH ZDV FKDUDFWHULsHG E\ JHRJUDSKLFDO YDULDWLRQ DQG was QRW JHRJUDSKLFDOO\ UHSUHVHQWDWLYH RI ,QGLD XQWLO *$76 ZDV FRQGXFWHG LQ ,QGLD 7KH DVVRFLDWLRQ EHWZHHQYDULRXVGHWHUPLQDQWVDQG6/7XVHVKRXOGEHIXUWKHUVWXGLHGE\DSSO\LQJPXOWLYDULDWH and PXOWLOHYHODQDO\WLFDOWHFKQLTXHVWRWKH*$76GDWD)XUWKHUDOWKRXJKVWXGLHVKDYHDVVHVVHG WKHUROHRIGHWHUPLQDQWVIRULQLWLDWLRQRIRYHUDOOWREDFFRXVHIHZKDYHIRFXVHGVSHFLILFDOO\RQWKH GHWHUPLQDQWV RI VPRNHOHVV WREDFFR LQLWLDWLRQ ZKLFK LV D JDS WKDW QHHGV WR EH DGGUHVVHG 6LPLODUO\IXWXUHVWXGLHVVKRXOGDOVRDVVHVVWKHGHWHUPLQDQWVRIFHVVDWLRQRI6/7 XVH /LWWOHUHVHDUFKKDVH[SORUHGXSVWUHDPVRFLDOGHWHUPLQDQWVDQGWKHLUDVVRFLDWLRQZLWK6/7XVHLQ ,QGLD6WXGLHVLQWKH:HVWKDYHH[SORUHGWKHDVVRFLDWLRQRIVPRNLQJZLWKNH\VRFLDOGHWHUPLQDQWV 111 Chapter 6. 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The SLT industry’s PDUNHWLQJ VWUDWHJLHV DUH VLPLODU WR WKRVH RI RWKHU WREDFFR LQGXVWULHV LQ WKDW WKH\ LJQRUH WKH HYLGHQFH RQ WKH KDUPIXOQHVV RI WKHLU SURGXFWV 7KLV FKDSWHU DLPV WR GHVFULEH WKH PDUNHWLQJ VWUDWHJLHV RI WKH VPRNHOHVV WREDFFR LQGXVWU\ LQ ,QGLD DQG LOOXVWUDWH KRZ WKH\ KDYH FKDQJHG DV QHZWREDFFRFRQWUROSROLFLHVKDYHEHHQDGRSWHGRYHUWKH\HDUV POLICY ENVIRONMENT AND SLT MARKETING TIMELINE 2YHU WLPH 6/7 PDUNHWLQJ LQ ,QGLD KDV EHHQ VKDSHG E\ WREDFFR FRQWURO SROLFLHV VXFK DV WKH :RUOG+HDOWK2UJDQL]DWLRQ’s Framework &RQYHQWLRQRQ7REDFFR&RQWURODGRSWHGE\WKH:RUOG +HDOWK $VVHPEO\ LQ WKH &LJDUHWWHV DQG 2WKHU 7REDFFR 3URGXFWV 3URKLELWLRQ RI $GYHUWLVHPHQWDQG5HJXODWLRQRI7UDGHDQG&RPPHUFH3URGXFWLRQ6XSSO\DQG'LVWULEXWLRQ $FW &273$ DQDPHQGPHQW LQ WRWKH3UHYHQWLRQRI)RRG$GXOWHUDWLRQ$FW DQG WKH )RRG DQG 6DIHW\ 6WDQGDUGV $FW $PHQGPHQW DPRQJ RWKHU SROLFLHV &KDSWHU ‘$GYRFDF\ DQG3ROLF\ 0HDVXUHV’ SURYLGHV GHWDLOV RIWKHVH SROLFLHVDQGGHVFULEHV KRZWKH\KDYHDIIHFWHG6/7PDUNHWLQJ 7DEOHGLVSOD\VWKHWLPHOLQHRIWKHPDMRUHYHQWVWKDWKDYHVKDSHG6/7PDUNHWLQJLQ,QGLDLQ WKHODVWILYHGHFDGHVZKLFKDUHGLYLGHGLQWRWKUHHSHULRGV WKURXJK EHWZHHQ DQG DQGIURPXQWLOWKHSUHVHQW 7KHVHGLYLVLRQVUHIOHFWWZRVSHFLILFHYHQWV WKH ODXQFKRIVLQJOHSRUWLRQSRXFKHVRISDQPDVDOD ZLWKDQGZLWKRXWWREDFFR LQ DQGWKHHQWU\ LQWRIRUFHRIWKHPDMRUFRPSUHKHQVLYHWREDFFRFRQWUROODZLQ 117 Chapter 7. Advertising and Marketing of Smokeless Products Table 7.1: Timeline of smokeless tobacco control and marketing Year Milestones in Smokeless Tobacco Control and Marketing in India Through 1984 7KH,QGLDQJRYHUQPHQWVHWXSWKH'LUHFWRUDWHRI$UHFD1XWDQG6SLFHV'HYHORSPHQWXQGHUWKH 4 0LQLVWU\RI$JULFXOWXUHWRSURPRWHWKHSURGXFWLRQDQGPDUNHWLQJRIDUHFDQXW -XO\ $UHFDQXWIDUPHUVIRUPDPXOWLVWDWHFRRSHUDWLYHWKH&HQWUDO$UHFDQXWDQG&RFRD0DUNHWLQJDQG 5 3URFHVVLQJ&RRSHUDWLYH/WG &$03&2 DW0DQJDORUH $XJXVW 3DQ3DUDJSDQPDVDODLQODUJHWLQVLVODXQFKHGDQGDGYHUWLVHPHQWVIRULWDSSHDURQWHOHYLVLRQ 1985–2003 /DXQFKRI3DQ3DUDJSDQPDVDODLQVLQJOHSRUWLRQSRXFKHV ,QWHUQDWLRQDO$JHQF\IRU5HVHDUFKRQ&DQFHU ,$5& UHOHDVHVLWVreSRUW Tobacco Habits Other Than Smoking; Betel-Quid and Areca-Nut Chewing; and Some Related Nitrosamines YROXPHLQLWV VHULHV0RQRJUDSKVRQWKH(YDOXDWLRQRIWKH&DUFLQRJHQLF5LVNRI&KHPLFDOVWR+XPDQV ZKLFK ILQGVVXIILFLHQWHYLGHQFHWKDWFKHZLQJEHWHOTXLGFRQWDLQLQJWREDFFRLVFDUFLQRJHQLFWRKXPDQV and WKDWRUDOXVHRIWREDFFRPL[HGZLWKOLPH NKDLQL LVFDUFLQRJHQLFWRKXPDQV 5HOHDVHRIU.S. Surgeon General’s Report, The Health Consequences of Using Smokeless Tobacco, ZKLFK FRQFOXGHVWKDW6/7FDQFDXVHFDQFHU DGGLFWLRQ DQGGHSHQGHQFH 1ew rule added to the Prevention of Food Adulteration Rules, 1986 (under PFA, 1955): ‘Every package of chewing tobacco shall bear the following label, namely: “Chewing of tobacco is injurious to health”’ LQ HIIHFWIURP 'HFHPEHU 1HZUXOHDGGHGWRWhe Prevention of Food Adulteration Rules 1990 (under PFA, 1955): ‘Every SDFNDJHRISDQPDVDODDQGDGYHUWLVHPHQWUHODWLQJWKHUHWRVKDOOFDUU\WKHIROORZLQJZDUQLQJQDPHO\ “Chewing of Pan Masala may be injurious to health”’ in HIIHFWIURP $XJXVW ,Q DQDPHQGPHQWWR WKH'UXJVDQG&RVPHWLFV$FW EDUUHGPDQXIDFWXUHUVIURPXVLQJ WREDFFRDVRQHRIWKHLQJUHGLHQWVLQWRRWKSDVWHDQGWRRWKSRZGHU V 'XULQJWKH VPDQ\QHZFRPSDQLHVHQWHUWKHSDQPDVDODJXWND EXVLQHVV6HYHUDORIWKHVH FRPSDQLHVEHFRPHYHU\ODUJe 7KH7UDGH0DUNs $FW DOORZVDVLQJOHEUDQGWREHUHJLVWHUHGIRUPRUHWKDQRQHSURGXFW DOORZLQJWKH6/7LQGXVWU\WRDGYHUWLVHIRUQRQWREDFFRSURGXFWVZLWKWKHVDPHEUDQGQDPHDV WREDFFRSURGXFWV 7KH&DEOH7HOHYLVLRQ1HWZRUNV5XOHV ZDVDPHQGHGRQ25 )HEUXDU\ SURKLELWLQJ GLUHFWDQGLQGLUHFW DGYHUWLVHPHQWRI WREDFFRSURGXFWV LQFDEOHDQGWHOHYLVLRQQHWZRUNVEXWWKLV DPHQGPHQWZDVGLOXWHGLQDQRWKHUQRWLILFDWLRQRQ)HEUXDU\ *XWNDLVEDQQHGLQVHYHUDOVWDWHVXQWLOWKLVEDQ ZDVUHYHUVHGE\WKH6XSUHPH&RXUW )UDPHZRUN&RQYHQWLRQRQ7REDFFR&RQWUROLVUDWLILHGE\ India 3 7KH&LJDUHWWHVDQG2WKHU7REDFFR3URGXFWV 3URKLELWLRQRI$GYHUWLVHPHQWDQG5HJXODWLRQRI7UDGH DQG&RPPHUFH3URGXFWLRQ6XSSO\DQG'LVWULEXWLRQ $FW &273$ $GYHUWLVLQJ5XOHV SURKLELWGLUHFWDQGLQGLUHFWDGYHUWLVLQJRIall WREDFFR SURGXFWVLQFOXGLQJVPRNHOHVVWREDFFR in HIIHFWIURP 0D\ 2004–2013 6XUURJDWHDGIRU&KDLQL.KDLQLLVEURDGFDVWIURPDFULFNHWPDWFKLQ $XVWUDOLDDQGLVYLHZHGLQ India 7KH6XSUHPH&RXUWKDGUXOHGLQGXULQJWKHKHDULQJRIDFDVHWKDWSDQPDVDODJXWNDDQG VXSDULDUHDOOIRRGZLWKLQWKHPHDQLQJRI6HFWLRQ Y RIWKH3)$$FW DQGODWHUXQGHUWKH )RRG6DIHW\DQG6WDQGDUGV$FW 2QO\2 ERDUGVRIFP[ FPZHUHSHUPLWWHGDWSRLQWRIVDOH 118 Smokeless Tobacco and Public Health in India Year Milestones in Smokeless Tobacco Control and Marketing in India $PHQGPHQW5XOHVWR6HFWLRQRI&273$JRLQWRIRUFHSURKLELWLQJDOODGYHUWLVLQJH[FHSWSRLQWRI VDOH ZLWKHIIHFWIURP$XJXVW 6L]HRIERDUGVZDVDPHQGHGWRFP[FP 0LQLVWU\RI+HDOWKDQG)DPLO\:HOIDUH:RUOG/XQJ)RXQGDWLRQDQG9RLFHRI7REDFFR9LFWLPV ODXQFKDQWLWREDFFRFDPSDLJQV 7KH6XSUHPH&RXUWGLUHFWVWKH0LQLVWU\WRLVVXHDQRUGHUEDQQLQJSDFNDJLQJRIVPRNHOHVVWREDFFR LQSODVWLFSRXFKHV )RRG6DIHW\DQG6WDQGDUGV 3URKLELWLRQDQG5HVWULFWLRQVRQ6DOHV 5HJXODWLRQV 5XOH ‘Product not to contain any substance which may be injurious to health: Tobacco and nicotine shall not be used as ingredients in any food products’ (LQHIIHFW IURP $XJXVW – 6WDWHVEHJLQWRDQQRXQFHEDQVRQVDOHRIJXWNDDQGSDQPDVDODIODYRXUHGVPRNHOHVVWREDFFRXQGHU )66$5HJXODWLRQV5XOH MARKETING STRATEGIES IN RESPONSE TO POLICY Period I: Through 1984 Products %HFDXVH 6/7 XVH KDV EHHQ WUDGLWLRQDO LQ ,QGLD IRU RYHU IRXU FHQWXULHV D YDVW UDQJH RI 6/7 SURGXFWV VXFK DV JXWND NKDLQL ]DUGD 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Advertising and Marketing of Smokeless Products Figure 7.1: Pre-COTPA SLT ads for gutka and zarda 2QHEUDQGRI Zarda 2QHEUDQGRI*XWND 2QHEUDQGRI*XWND 2QHEUDQGRI*XWND 2 6RXUFH 0LOOHU 'XULQJ WKUHH GHFDGHV IURP WKH PLG V WKH SDQ PDVDOD DQG JXWND LQGXVWU\ UHJLVWHUHG SKHQRPHQDOJURZWK–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tates Begin Banning Gutka ,QWKHUHZDVDODUPLQJHYLGHQFHWKDWRUDOFDQFHUZDVLQFUHDVLQJLQ\RXQJPHQZRPHQZHUH VKRZLQJ D SUHIHUHQFH IRU 6/7 DQG D YXOQHUDELOLW\ WR VWDUWLQJ JXWND XVH FKLOGUHQ ZHUH LQFUHDVLQJO\EHFRPLQJDGGLFWHGDQGPDJQHVLXPFDUERQDWHZDVEHLQJDGGHGWRSDQPDVDODDQG JXWND LQH[FHVVRIDPRXQWVSHUPLWWHGLQIRRG7KLVHYLGHQFHZDVSUHVHQWHGWRVWDWHJRYHUQPHQWV DQGDVDUHVXOWVHYHUDOVWDWHVEHJDQEDQQLQJWKHPDQXIDFWXUHVDOHDQGVWRUDJHRIJXWNDZLWKLQ 2 WKHLUERUGHUV 122 Smokeless Tobacco and Public Health in India Period III: 2004 Through 2011 'XULQJWKLVSHULRGWKHVPRNHOHVVWREDFFRLQGXVWU\H[SHULHQFHGLQWHQVHJURZWK %HWZHHQ DQG UHWDLOYROXPHVDOHVRI6/7LQFUHDVHGE\,Q WKHWRSVL[VPRNHOHVVWREDFFR PDQXIDFWXUHUVLQ,QGLDDFFRXQWHGIRURIVDOHV 7KHUHVWRIWKHVDOHVZHUHFRQWUROOHGE\ UHJLRQDO DQG ORFDO SOD\HUV %\ WKHUH ZHUH – PDQXIDFWXUHUV RI FKHZLQJ WREDFFR SURGXFWVLQ,QGLD 0XFKRIWKLVLQGXVWU\JURZWKZDVIXHOHGE\WKHPDUNHWLQJVWUDWHJLHVDGRSWHG A New Regulatory Environment ,Q D FRPSUHKHQVLYHWREDFFRFRQWURO ODZ ZDV HQDFWHGLQ ,QGLDWKH&LJDUHWWHV DQG2WKHU 7REDFFR 3URGXFWV 3URKLELWLRQ RI $GYHUWLVHPHQW DQG 5HJXODWLRQ RI 7UDGH DQG &RPPHUFH 3URGXFWLRQ6XSSO\DQG'LVWULEXWLRQ $FWRU&273$8QGHUWKHILUVW5XOHVWRWKH$FWQRWLILHG RQ )HEUXary WREDFFR DGYHUWLVLQJ LQ PDVV PHGLD DQG RXWGRRU PHGLD ZDV SURKLELWHG H[FHSW DW ZDUHKRXVHV DQG SRLQWV RI VDOH RQ ERDUGV QR ODUJHU WKDQ FP [ FP ZKHUH WKH warning, ‘Tobacco Causes Cancer’ or ‘Tobacco Kills’ was required. ,QDGYHUWLVLQJUXOHVXQGHU&273$ZHUHDPHQGHGVHYHUHO\UHVWULFWLQJSRLQWRIVDOH 326 DGYHUWLVLQJVRWKDWQREUDQGQDPHVSDFNVKRWVRUORJRVZHUHWREHYLVLEOHRQ326DGYHUWLVLQJ ERDUGV 7KLV QHZ UHVWULFWLRQ KRZHYHU ZDV QRW REVHUYHG DQG WKLV ODZ ZDV VWD\HG LQ D &RXUW DURXQG LQ UHVSRQVH WR D ZULW SHWLWLRQ IURP WKH WREDFFR LQGXVWU\ 7KXV WKH SUHYLRXV DGYHUWLVLQJSUDFWLFHVSUHYDLOHGXQWLOWKHVWD\ZDVOLIWHGLQ-DQXDU\ Price 7KHJXWND LQGXVWU\LQJHQHUDOLVKLJKO\IUDJPHQWHGZLWKUHJDUGWRSULFLQJ7KHPDUNHWLVOHGE\ WKH 50' %DED 6KLNKDU 7XOVL DQG .DPOD 3DVDQG EUDQGV ZKLFK DUH DOO PDUNHWHG DV SDQ PDVDOD7KHQDWLRQDOPDUNHWKDVRQO\DIHZELJQDPHVVXFKDV50'DQG3DQ3DUDJZKLFKDUH VWURQJLQWKH5V–SHUVDFKHWVHJPHQW'R]HQVRIUHJLRQDOSOD\HUVGRPLQDWHWKH5V–SHU 3 VDFKHWVHJPHQW *XWNDZDVSULFHGRQO\VOLJKWO\KLJKHUWKDQSDQPDVDODZLWKRXWWREDFFR Product and ‘Customer Benefit’ 0LVOHDGLQJGHVFULSWLRQV RIJXWNDOike ‘taazgi dene wala’ VRPHWKLQJWKDWJLYHVIUHVKQHVV DQG ‘kesaryukt’ VDIIURQEOHQGHG KDYHEHHQXVHGWRFUHDWHLOOXVLRQDU\LPSUHVVLRQVLQWKHPLQGRIWKH FRQVXPHUVDERXWSRWHQWLDOEHQHILWVRUKDUPOHVVQHVVRIWKHSURGXFWV%UDQGVOLNH9LPDO FODLPWKDW each grain of their gutka contains the aroma of saffron (‘dane dane mein haike sarkadum’ ZKLFK LVWKHPRVWH[SHQVLYHVSLFHLQWKHZRUOGWUDGLWLRQDOO\XVHGWRHQKDQFHIODYRXUDQGFRORXULQIRRG SUHSDUDWLRQV5DMQLJDQGKDSDQPDVDOD QDPHGDIWHU WKHWXEHURVHIORZHUDOVRWKHQDPHRID ILOP is advertised as having ‘bemisal IODYRXUlajawab swaad’ XQSDUDOOHOHGIODYRXUXQHTXDOOHGWDVWH 7KLVW\SHRIPHVVDJHGLVWUDFWVWKHFRQVXPHUIURPIRFXVLQJRQWKHKD]DUGRXVFDUFLQRJHQVLQ6/7 DQGLQVWHDGJLYHVWKHLOOXVLRQWKDWLWLVDKLJKTXDOLW\SURGXFWWKDWJLYHVSOHDVXUHDQGZKLFKPD\ be ‘good for the body’. 7KHHIIHFWRIWKLVW\SHRIDGYHUWLVLQJZDVLOOXVWUDWHGLQDQLQWHUYHQWLRQVWXG\DPRQJ UXUDO VFKRROFKLOGUHQ –\HDUV LQ0DGK\D3UDGHVKZKHUHPRVWFKLOGUHQFRQVLGHUHGJXWNDDPRXWK IUHVKHQHU DQG D VWDWXV V\PERO 1RQH RI WKH FKLOGUHQ ZHUH DZDUH WKDW JXWND ZDV KDUPIXO RU FRQWDLQHGWREDFFR DOWKRXJKWKHYDVW PDMRULW\ ZHUH DZDUHWKDWNKDLQL DQG ]DUGD ZHUH KDUPIXO 32 WREDFFRSURGXFWV 123 Chapter 7. Advertising and Marketing of Smokeless Products Promotion Indirect Advertising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adYHUWLVHPHQWIRU0DQLNFKDQG3DQ0DVDOD*XWND 7KHSUDFWLFHRIEUDQGVWUHWFKLQJDQGWUDGHPDUNH[WHQVLRQLVVXSSRUWHGE\WKH7UDGH0DUNV$FWRI ZKLFKDOORZVDWUDGHPDUNWREHUHJLVWHUHGXQGHUGLIIHUHQWFDWHJRULHV0DQ\WREDFFREUDQGV DQG WUDGHPDUNV UHJLVWHUHG XQGHU &ODVV RI WKH $FW DUH DOVR UHJLVWHUHG XQGHU QRQWREDFFR FDWHJRULHV VXFK DV IRRG DQG FORWKLQJ 0RVW 6/7 FRPSDQLHV SURGXFH D VLQJOH EUDQG EXW XVH GLIIHUHQW IODYRXU YDULDQWV DQG SDFNHW VL]HV WR SRSXODULsH WKH EUDQG LQ D PDUNHW IORRGHG ZLWK sFRUHVRIORFDOSOD\HUV7KH7UDGH0DUNV$FWDOVRDOORZVWKHFRPSDQ\WRFLUFXPYHQWWKHODZDQG DGYHUWLVH WKH VDPH EUDQG QDPH ZKHQ LW LV XVHGIRU D QRQWREDFFR SURGXFW SDQ PDVDOD 0DQ\ VPRNHOHVVSURGXFWEUDQGVOLNH.DPOD3DVDQG*RD6RQLDQG&KDLQL KDYHWKHVDPHEUDQGQDPH IRUWREDFFRDVZHOODVQRQWREDFFRSURGXFWV,QDGGLWLRQEUDQGVWUHWFKLQJLVFORVHO\OLQNHGZLWK SDFNDJLQJ DV SDFNDJH GHVLJQ DQG FRORXU FDQ EH LGHQWLFDO IRU ERWK WREDFFR DQG QRQWREDFFR SURGXFWV 6HYHUDO EUDQGV OLNH 6KLNKDU &KDLQL 6RQL 5DM 'XUEDU 50' 7XOVL and .DPOD 3DVDQG DOVRKDYHLGHQWLFDOJXWNDDQGSDQPDVDODSDFNHWGHVLJQV )LJXUH Figure 7.2: Two examples of brand stretching: Soni Gutka and Soni Pan Masala; Chaini Khaini and Chaini Chaini 3KRWRJUDSKVFRXUWHV\RI 9+$,3KRWREDQN 124 Smokeless Tobacco and Public Health in India &RUSRUDWHVRFLDOUHVSRQVLELOLW\FDPSDLJQVFXOWXUDOHYHQWVDQGVSRQVRUVKLSDFWLYLWLHVDOVRSOD\D SDUWLQ EUDQGVWUHWFKLQJ—IRUH[DPSOHWKH.DPOD3DVDQG0$;6WDUGXVW $ZDUG and WKH 0DQLNFKDQG )LOPIDUH $ZDUGV XQWLO 7KH 6WDUGXVW $ZDUGV LQ DQG ZHUH VSRQVRUHGE\.DPOD3DVDQGZKLFKLV WKHEUDQGQDPHIRUERWKJXWNDDQGSDQPDVDOD SURGXFWV +HDOWK DGYRFDWHV DQG DFWLYLVWV LQ ,QGLD LQ ZHUH DOVR VKRFNHG WR VHH SDQ PDVDOD DGYHUWLVHPHQWERDUGVIRU&KDLQL&KDLQLZKLFKZHUHVHHQDVVXUURJDWHDGs IRUWKH &KDLQL.KDLQL EUDQG RI VPRNHOHVV WREDFFR LPPHGLDWHO\ EHKLQG WKH SLWFK DW D WHOHYLVHG FULFNHW PDWFK EHLQJ SOD\HGDW6\GQH\$XVWUDOLD7KHRIIHQGLQJDGVZHUHUHPRYHGIROORZLQJSURWHVWVIURP$FWLRQRQ 6PRNLQJ RQ +HDOWK $6+ DQG RWKHUV WR WKH $XVWUDOLDQ 'HSDUWPHQW RI +HDOWK DQG WR &ULFNHW $XVWUDOLD $ VWXG\ E\ 6DODDP %RPED\ )RXQGDWLRQ LQ IRXQG WKDW ERWK FKLOGUHQ DQG DGXOWV PDGH D PHQWDODVVRFLDWLRQEHWZHHQDGYHUWLVHGSDQPDVDODEUDQGVDQGJXWND$WRWDORIFhildren DJHV – DQG DQ HTXDO QXPEHU RI DGXOWV DJHs – IURP YDULRXV DUHDV LQ 0XPEDL ZHUH VKRZQIODVKFDUGVRIWKUHHDGYHUWLVHGSDQPDVDODEUDQGVDQGDVNHGWRLGHQWLI\ZKDWWKH\ZHUH The respondents’ association of the two products was demonstrated by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anesh Chaturthi LQ0XPEDLWKHFLW\LV IORRGHGZLWKVXUURJDWHDGYHUWLVHPHQWVDWEXVVWRSVDQGRQEXVHVDQGSDQGDOV ODUJHWHPSRUDU\ VWUXFWXUHVHUHFWHGIRUUHOLJLRXVREVHUYDQFHV 7KH6DODDP%RPED\)RXQGDWLRQFRQGXFWHGDSLORW VWXG\ RQ WKH LVVXH GXULQJ Ganesh Chaturthi LQ DQG IRXQG WKDW 6/7 EUDQGV XVH QDPHV VLPLODUWR QDPHVRIWREDFFRSURGXFWV ZKHQWKH\ DGYHUWLVHRQSDQGDOV DQGDW EXV VWRSVZKLFK LQGLFDWHV WKDW WREDFFR FRPSDQLHV DUH SURPRWLQJ JXWND WKURXJK VWUDWHJLF VXUURJDWH 3 DGYHUWLVHPHQWV 3 7KHUHVXOWVRIa VWXG\FRQGXFWHGE\WKH9ROXQWDU\+HDOWK$VVRFLDWLRQRI,QGLD 9+$, DQGLWVVWDWHSDUWQHUVUHYHDOHGWKDWIRUEUDQGVVXFKDV6KLNKDU.DPOD3DVDQG50'DQG*RD RQO\JXWND ZDVDYDLODEOHDWRXWOHWVVXUYH\HG7KHUHWDLOHUVWKHPVHOYHVDGPLWWHGGXULQJIDFHWR IDFH LQWHUYLHZV WKDW RQO\ JXWND LV DYDLODEOH XQGHU WKH EUDQG QDPH 7KH FRPSDQLHV SHUKDSV PDQXIDFWXUHQHJOLJLEOHTXDQWLWLHVRIPRXWKIUHVKeQHUVSDQPDVDODLQRUGHUWRFRQWLQXHLQGLUHFW PDUNHWLQJ Violation of Advertising Rules at Points of Sale 7KH ODWHVW &273$ 5XOHV RQ 6HFWLRQ OLPLW SRLQWRIVDOH DGYHUWLVLQJ WR MXVW D OLVWLQJ RI WKH SURGXFWVIRUVDOHE\WKHLUJHQHULFQDPHVDORQJZLWKKHDOWKZDUQLQJVRQWZRSUHVFULEHGERDUGV SHUVKRS+RZHYHUWKHLQGXVWU\PDQLSXODWHVWKHDOORZDQFHVRURYHUWO\IORXWVUHVWULFWLRQV0DQ\ WREDFFRFRPSDQ\EUDQGVVSRQVRUWKHERDUGVDWWKHVHVPDOOVKRSV,Q'HOKLDQXPEHURINLRVNV RXWVLGHSURPLQHQWFLQHPDKDOOVDQGVKRSSLQJPDOOVKDYHEULJKWO\OLWFRORXUHGERDUGVDGYHUWLVLQJ WKH6/7SURGXFWEHDULQJVLPLODUFRORXUVDQGGHVLJQVDVRQWKHSDFNDJLQJRI6/7SURGXFWVZLWKD small underplayed warning at the bottom saying ‘Sale of tobacco products to minors is a 125 Chapter 7. Advertising and Marketing of Smokeless Products punishable offence’ or ‘Tobacco is injurious to health’. Figure 7.3 shows a marketplace in Jaipur ZKHUHDVHULHVRISDQDQGELGLVKRSVGLVSOD\ed FRPSDQ\VSRQVRUHGERDUGVWKDWYLRODWHDOO326 UHJXODWLRQV 7KHERDUGVZHUHELJJHUWKDQWKHPDQGDWHGFP[45 FPVL]HWKH\GLVSOD\HGQR ZDUQLQJV DQG QHDUO\ RI WKH ERDUG VSDFH ZDV WDNHQ XS E\ WKH EUDQG QDPH DQG SDFNDJH GHVLJQ7KHUHDUHRWKHUVLPLODUH[DPSOHVRI6/7VSRQVRUVKLSRIVKRSERDUGV Figure 7.3: POS board in Jaipur, Rajasthan 3KRWRJUDSK FRXUWHV\9+$,3KRWREDQN ,Q DGGLWLRQ WR VLJQERDUGV WKH VWULSV RI SURGXFW SRXFKHV WKHPVHOYHV VHUYH WR DGYHUWLVH WKH SURGXFWVDWSRLQWRIVDOH)LJXUHVKRZVWKHDUUD\RIFRORXUIXOVLQJOHSRUWLRQSRXFKHVKDQJLQJ DWDVKRSLQ'HOKLWRDWWUDFWFXVWRPHUV Figure 7.4: Display of SLT products outside a shop in South Delhi 3KRWRJUDSK FRXUWHV\RI 9+$,3KRWREDQN )XUWKHU DOO NLQGV RI GDQJOHUV GLVSOD\ UDFNVER[HV DQG VWLFNHUV DUH RIWHQ YLVLEOH DW SRLQWV RI SXUFKDVHZKLFKLVQRWDOORZHGXQGHUWKHODZ &273$$GYHUWLVLQJ5XOHV 7KHVH 126 Smokeless Tobacco and Public Health in India GLVSOD\VDWWUDFWFKLOGUHQDQG\RXWKZKRFRPHWRWKHVKRSVWREX\FDQGLHVVQDFNLWHPVDQGVRIW GULQNV Use of Outdoor Media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are H[DPSOHV RI EUDQGV WKDW DUH DGYHUWLVHG RQ WKHVH SURSHUWLHV )LJXUH )LJXUH VKRZV DQ H[DPSOHRIDGYHUWLVLQJLQSDUNLQJORWV 6/7DGVDUHRIWHQVHHQRQSXEOLFWUDQVSRUWOLNHEXVHVDQGDXWRULFNVKDZV,Q LQ0XPEDL SDQ PDVDOD DGYHUWLVHPHQWV ZHUH VHHQ RQ EXVHV—D FOHDU FDVH RI VXUURJDWH DGYHUWLVLQJ +RZHYHUFRQWLQXHGDGYRFDF\DQGDQWLWREDFFRFDPSDLJQVE\FLYLOVRFLHW\RUJDQLsDWLRQVUHVXOWHG 3 LQWKHUHPRYDORIWKHVHDGV Figure 7.5: Hoarding at a railway property overbridge, near Pragati Maidan, New Delhi 3KRWRJUDSK FRXUWHV\RI 9+$,3KRWREDQN 127 Chapter 7. Advertising and Marketing of Smokeless Products Figure 7.6: Billboard at a shopping mall parking lot in Rajouri Garden, New Delhi 3KRWRJUDSK FRXUWHV\RI 9+$,3KRWREDQN Marketing in Rural Areas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eople: Marketing to Children and Youth Much SLT marketing is directed at youth. ‘Muh main Rajnigandha, kadmo main duniya’ 5DMQLJDQGKD LQWKHPRXWKWKHZRUOGDW\RXUIHHW LVDWDJOLQHXVHGE\'6*URXSWRPDUNHWWKHLU pan masala to ‘quality conscious young consumers in India and overseas’, creating a false LPSUHVVLRQWKDWHDWLQJ5DMQLJDQGKDZRXOGJLYHWKHPFRQILGHQFHVWDWXVDQGDOOWKH\DVSLUHWR. 6LPLODUO\ 3DQ 3DUDJ XVHV WKH WDJOLQH ‘Choice of young India’ on their sachets and tins )LJXUH 128 Smokeless Tobacco and Public Health in India Figure 7.7: Targeting youth with pan masala ads: an ad hoarding on the main road in Laxmi Nagar, New Delhi; and the tagline on a sachet, ‘Choice of Young India’ 3KRWRJUDSKVFRXUWHV\RI 9+$,3KRWREDQN 6/7 FRPSDQLHV DOVR FRQWLQXDOO\ WDUJHW FKLOGUHQ 6/7 SURGXFWV DUH GLVSOD\HG IRU VDOH EHVLGH FDQGLHV FROG GULQNV FKLSV DQG RWKHU SURGXFWV WDUJHWHG SDUWLFXODUO\ DW NLGV H[SRVLQJ WKHP WR SURWREDFFR VWDWHPHQWV DQG LPDJHU\ ,Q ,QGLD IUHH GLVWULEXWLRQ RI JXWND GXULQJ PDUULDJH celebrations and social functions encourages a perception that it is a ‘family product’. 0DUNHWLQJRQVRFLDOQHWZRUNLQJVLWHVLVLQWHQGHGWROXUH\RXWK 7RGD\VRFLDOPHGLDZHEVLWHVOLNH )DFHERRN Public Awareness of Promotions $FFRUGLQJ WR *$76 ,QGLD – QHDUO\ WZRWKLUGV RI DOO DGXOWV LQ ,QGLD QRWLFHG WKH SURPRWLRQRIDQ\WREDFFRSURGXFW PDOHVDQG IHPDOHV 6RPHRIDGXOWVRYHUDOO RI PDOHV DQG RI IHPDOHV KDG QRWLFHG DQ\ DGYHUWLVHPHQW RU SURPRWLRQ RI 6/7 SURGXFWV ZLWKLQ GD\V SULRU WR WKH *$76 ,QGLD VXUYH\ 0RUH DGXOWV QRWLFHG SURPRWLRQVRI6/7SURGXFWVWKDQRWKHUWREDFFRSURGXFWV—QRWLFHd ELGLDGYHUWLVHPHQWVDQG QRWLFHGFLJDUHWWHDGV—DQGPRUH6/7XVHUVWKDQQRQXVHUVQRWLFHGDGVIRU6/7SURGXFWV 3 FRPSDUHGWRUHVSHFWLYHO\ 3XEOLFDZDUHQHVVRISURPRWLRQVYDULHGLQWHUPVRIWKHORFDWLRQRIWKHVHSURPRWLRQVRUWKHPHDQV E\ ZKLFK WKH\ ZHUH GHOLYHUHG 'DWD IURP *$76 ,QGLD UHYHDO WKDW DGYHUWLVHPHQWV GHOLYHUHG E\ HOHFWURQLF PHGLD VXFK DV WHOHYLVLRQ RU WKH ,QWHUQHW ZHUH QRWLFHG E\ WKH KLJKHVW SHUFHQWDJHRIVXUYH\UHVSRQGHQWV EXWWKLVSURSRUWLRQZDVRQO\VOLJKWO\KLJKHUWKDQWKH 129 Chapter 7. Advertising and Marketing of Smokeless Products SHUFHQWDJH RI SHRSOH ZKR QRWLFHG 6/7 DGYHUWLVHPHQWV RXWGRRUV RQ ELOOERDUGV KRDUGLQJV SRVWHUV SXEOLF WUDQVSRUWDWLRQ VWDWLRQV RU SXEOLF ZDOOV 6RPH KDG QRWLFHG 6/7 DGYHUWLVHPHQWV LQ WKH SULQW PHGLD ZKLOH KDG QRWLFHG DGV DW SRLQW RI VDOH 0RUH SHRSOH QRWLFHGSURPRWLRQVRI6/7SURGXFWVYLDIUHHVDPSOHVGLVFRXQWVDQGJLIWV WKDQQRWLFHG VLPLODU SURPRWLRQV RI VPRNHG SURGXFWV FLJDUHWWH SURPRWLRQV ELGL SURPRWLRQV 0RUH\RXWKDQG\RXQJDGXOWVWKDQROGHUDGXOWVQRWLFHGDQ\6/7DGYHUWLVHPHQWVRUSURPRWLRQV 3 DFFRUGLQJWR*$76 India \RXWK\RXQJ DGXOWV DGXOWVRYHU 7RVXPPDULVH,QGLDQDGXOWVZHUHPRVWOLNHO\WRQRWLFHSURPRWLRQVRUDGYHUWLVHPHQWVIRU6/7 SURGXFWVWKDWZHUHGHOLYHUHGYLDHOHFWURQLFPHGLDRXWGRRUDGYHUWLVLQJDQGDWSRLQWRIVDOH0en ZHUH PRUH OLNHO\ WKDQ ZRPHQ WR QRWLFH 6/7 SURPRWLRQV DQG \RXQJ SHRSOH DJHV –24 were PRUHOLNHO\WRQRWLFH6/7SURPRWLRQVWKDQROGHUDGXOWV 7KHVHJURXSVGLIIHUHGRQO\VOLJKWO\LQ 3 WKHUDWHVDWZKLFKWKH\QRWLFLQJ6/7SURPRWLRQVGHOLYHUHGYLDHOHFWURQLFPHGLD Packaging 0DQXIDFWXUHUVFRQVLGHULWYLWDOIRU6/7SURGXFWVWRUHWDLQWKHLUIODYRXUDQGIUDJUDQFHDVWKHVH DGGWDVWHWRWKHNH\LQJUHGLHQWV3DFNDJLQJWKHUHIRUHEHFRPHVDQLPSRUWDQWIDFWRU6DFKHWVDUH SUHIHUUHGIRUIUHVKQHVVEHFDXVHWLQQHGSURGXFWVORVHIODYRXUDQGDURPD DIWHUVRPHWLPHDVWKH\ DUHUHRSHQHGDJDLQDQGDJDLQ6RPHPDQXIDFWXUHUVVXFKDV*DQHVK=DUGDFODLP WKDWWKH\XVH an exclusive packaging technique known as the ‘snus packaging’ which helps preserve colour, IODYRXUDQGIUDJUDQFH 6/7LVDOVRVROGLQWKHIRUPRIVLQJOHXVHSDFNHWVVRWKDWWKHFRQVXPHUUHWXUQVDJDLQDQGDJDLQWR EX\PRUH6LQJOHXVHSDFNHWVDUHDOVRHDV\WRGLVSRVHRIDIWHUXVHDQGRQHGRHVQRWKDYHWRFDUU\ RUVWRUHWKHP7KHVHSDFNHWVDUHEULJKWO\FRORXUHGDQGDWWUDFWLYHDQGPDQ\KDYH HLWKHUSLFWXUHV RI JRGV JRGGHVVHV RU ZRPHQ %HFDXVH RI WKH DG EDQ FRPSDQLHV WU\ WR DGYHUWLVH RQ WKH packaging itself, using words like ‘fresh’, ‘sabki pasand’ HYHU\ERG\ OLNHV LW DQG RWKHU H[SUHVVLRQV)XUWKHUPRVW6/7SURGXFWSDFNHWVGRQRWOLVWLQJUHGLHQWVRUGHWDLOVRIQXWULWLRQDO value, which violates packaging laws for food products and restricts the consumer’s right to LQIRUPDWLRQ 6LQFH &273$ SHUPLWV LQSDFN DQG RQSDFN DGYHUWLVLQJ ZLWK UHVWULFWLRQV WREDFFR FRPSDQLHV KDYHIRFXVHGRQFUHDWLQJ SUHPLXPlooking packaging to communicate the brands’ message to FRQVXPHUV7KHPDMRU6/7FRPSDQLHVKDYHGHYHORSHGGLIIHUHQWSDFNDQGWLQGHVLJQVDVDPHDQV RIEUDQGEXLOGLQJ 7KHPDQGDWRU\SLFWRULDOKHDOWKZDUQLQJVZKLFKZHUHILUVWLPSOHPHQWHGLQ0D\ DUHEDUHO\ OHJLEOHLQWKHPLGVWRIWKHpackages’ EULJKWVKLQ\GHVLJQDQGFRORXU 2Q 'HFHPEHU WKH 6XSUHPH &RXUW GLUHFWHG WKH 0LQLVWU\ RI (QYLURQPHQW WR UHVWUDLQ PDQXIDFWXUHUVIURPXVLQJSODVWLFPDWHULDOLQWKHVDFKHWVRIJXWNDWREDFFR DQGSDQPDVDODXQGHU WKH(QYLURQPHQWDO3URWHFWLRQ$FW DVWKHXVHGSODVWLFVDFKHWV FDXVHGDSUREOHPRIQRQ 4 ELRGHJUDGDEOHOLWWHU7KLV GLUHFWLRQFDPHLQWRIRUFHRQ 0DUFK $IWHU WKDW GDWH 9+$, FRQGXFWHG D VWXG\ LQ HLJKW VWDWHV—$VVDP $QGKUD 3UDGHVK %LKDU 0DGK\D 3UDGHVK 2ULVVD 5DMDVWKDQ7DPLO1DGXDQG8WWDU3UDGHVK—WRFROOHFWHYLGHQFHRQLPSOHPHQWDWLRQRIWKHQHZ UXOHV RQ SODVWLF XQGHU WKH 3ODVWLF :DVWH DQG 0DQDJHPHQW $FW RI 6WDWHZLVH UHVXOWV UHYHDOHG ZLGHVSUHDG YLRODWLRQV RI WKH QHZ UXOHV 0DQXIDFWXUHUV ZHUH XVLQJ PXOWLOD\HUHG SDFNDJLQJ ZLWK RQH OD\HU RI SODVWLF LQ FRPELQDWLRQ ZLWK RWKHU PDWHULDOV VXFK DV SDSHU 130 Smokeless Tobacco and Public Health in India DOXPLQLXP IRLO RU PHWDOOLF ERDUG 7KLV QHZ SDFNLQJ PDWHULDO UHGXFHG WKH VKHOI OLIH RI WKH SURGXFWDFFRUGLQJWRnews iWHPVDQGUHSRUWVIURPDUDQGRPVXUYH\RI6/7VHOOHUVLQ'HOKLDOVR 42 FRQGXFWHGE\9+$, %\DQGODUJHPDQXIDFWXUHUVdid QRWDGKHUe WRWKHQHZODZEXWFRQWLQXHG 43 WRXVHSODVWLF Positioning 7KH LQGXVWU\ WDUJHWV WUDGLWLRQDO VHQWLPHQWV WR JLYH FUHGLELOLW\ WR LWV EUDQGV ,QGXVWU\ GRHV QRW KHVLWDWHWRSRVLWLRQLWVSURGXFWVZLWKLQWKHVRFLRFXOWXUDOPLOLHXDQGRIWHQSOD\VZLWKUHOLJLRXVDQG FXOWXUDOVHQWLPHQWVWRVHOODQGSURPRWHLWVSURGXFW'XULQJIHVWLYDOVVSHFLDOSDFNVZLWKDWWUDFWLYH GHVLJQV DUH SURGXFHG DQG SURGXFWV DQG EUDQG QDPHV DUH DJJUHVVLYHO\ PDUNHWHG WKURXJK SULQW DGV$FDVHLQSRLQWLVWKHLVVXHRIDainik Bhaskar GDWHG2FWREHULQZKLFKTXDUWHUSDJH DGV IRU -DIUL EUDQG SDQ PDVDOD ZLVKHG UHDGHUV D +DSS\ 'LZDOL DQG SURPLQHQWO\ GLVSOD\HG SLFWXUHV RI WKH SDFNDJH ,Q Rajasthan Patrika GDWHG 2FWREHU DQ DG IRU WKH EUDQG 'LOEDJKZLVKHGUHDGHUVShubh Deepawali (+DSS\ 'LZDOL ,QDDainik Bhaskar LVVXHGDWHGWKH same day, an ad for Vimal pan masala wished its readers ‘Damdaar Shubh Kamnayen’ +HDUWLHVW %HVW:LVKHV ,QGXVWU\XVHVFHOHEULW\HQGRUVHPHQWVLQDQDWWHPSWWRJLYH6/7SURGXFWVDPRUHXSVFDOHLPDJH Traditionally, SLT has been considered a poor man’s tobacco, a product for the masses not the FODVVHV ZKLFK SUHIHUUHG FLJDUHWWHV ,Q WKH V WKH WREDFFR FRPSDQLHV EHJDQ D PDUNHWLQJ EOLW]NULHJXVLQJFHOHEULW\HQGRUVHPHQWV6HQLRUFKDUDFWHUDFWRUVOLNH-DODO$JKD$VKRN.XPDU DQG 6KDPPL .DSRRU PHPRUDEO\ HQGRUVHG 3DQ 3DUDJ SDQ PDVDOD RQ 79 ZLWK WKH VORJDQ ‘baraatiyon ka swagat, Pan Parag se kijiye’ (welcome the groom’s procession with Pan Parag). 7KHUHDIWHUSRSXODUSHUVRQDOLWLHVHQGRUVHGJXWNDDQGSDQPDVDODEUDQGV&XUUHQWO\ ILOP VWDUV 0DQRM %DMSDL 6DQMD\ 'XWW 0DODLND $URUD DQG )DUGHHQ .KDQ HQGRUVH 3DQ 9LODV *RD &KDLQL&KDLQLDQG%DEDEUDQGV7KHLUDGYHUWLVHPHQWVDUHRIWHQDFFRPSDQLHGE\FDWFK\VORJDQV like ‘shauq badi cheez hai’ SDVVLRQPDWWHUV DQG ‘chain se maza lo’ UHOD[DQGHQMR\ FUHDWLQJ DQLPSUHVVLRQWKDWXVLQJWKHVHSURGXFWVLVVW\OLVKJODPRURXVDQGDVVRFLDWHGZLWKDQXSPDUNHW OLIHVW\OH([DPSOHVRIWKHVHDGYHUWLVHPHQWVFDQEHIRXQGDWWKHIROORZLQJORFDWLRQV KWWS ZZZ\RXWXEHFRPZDWFK"Y UX6-X/X= – OLQN RI &KDLQL &KDLQL DG IHDWXULQJ 0DODLND $URUD.KDQ KWWS ZZZ\RXWXEHFRPZDWFK"Y (BI8VTZB/$ IHDWXUH UHODWHG – SDQ SDUDJ DG IHDWXULQJ6KDPPL.DSRRU ,Q ,QGLDQ FLJDUHWWH PDQXIDFWXUHU *RGIUH\ 3KLOOLSV D MRLQW YHQWXUH RI WKH PXOWLQDWLRQDO 3KLOLS0RUULVHQWHUHGWKHSDQPDVDODVHJPHQWE\ODXQFKLQJ 3DQ9LODV7KHFRPSDQ\GHVFULEHV WKLVSURGXFWDVWDUJHWHGDWWKHGLVFHUQLQJSUHPLXPSDQPDVDODFRQVXPHUDQGFODLPVWKDWLWZDV India’VILUVWSDQPDVDODWRIXOO\FRPSO\ZLWK3UHYHQWLRQRI)RRG$GXOWHUDWLRQ 3)$ 5XOHV Place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hapter 7. Advertising and Marketing of Smokeless Products $FFRUGLQJWR*$76 ,QGLD RIXVHUVRI6/7SXUFKDVHGLWIURPDVWRUHIURP NLRVNV DQG IURP D VWUHHW YHQGRU 6WRUHV DUH WKH PRVW SRSXODU SODFH WR SXUFKDVH 6/7 SURGXFWVIRUDGXOWVLQVWDWHV87VZLWKWKHKLJKHVWUDWHRIVWRUHSXUFKDVHLQ0L]RUDP .LRVNVDUHWKHPRVWSUHIHUUHGVRXUFHLQHLJKW VWDWHVOHGE\'HOKL$UXQDFKDO3UDGHVK KDV 3 WKHKLJKHVWSURSRUWLRQRIXVHUVEX\LQJ6/7IURPVWUHHWYHQGRUV Period IV: 2012 Through 2014 7KLVVHFWLRQGHVFULEHVWKHPDUNHWLQJVWUDWHJLHVREVHUYHGDIWHUJXWNDZDVEDQQHGXQGHUWKH)RRG 6DIHW\DQG6WDQGDUGV$FW DQG5HJXODWLRQVWKHUHXQGHU ZKLFKFDPHLQWRIRUFHLQ$XJXVW Product and Packaging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mokeless Tobacco and Public Health in India Figure 7.8: Post-ban SLT distribution and marketing channels in Madhya Pradesh: a rapid impact assessment 8VHUVKDYHEHHQVZLWFKLQJIURPJXWNDWRWUDGLWLRQDOSDQ EHWHOTXLG VD\LQJWKDWWKHWUDGLWLRQDO EHWHOOHDI–wrapped product has no ‘chemicals’ or ‘hazardous material’ and is, most importantly, ‘legal’. A switchover to pan masala also exists, but is minimal. Some brands have now started labeling the product as ‘not a tobacco product under COTPA’. Instead of the earlier ‘ready to consume mixes’, some companies have introduced products SDFNHGLQVHSDUDWHVDFKHWVZKHUHFKHZLQJ WREDFFRDQGSDQPDVDODDUHVROGORRVHRULQVHSDUDWH VDFKHWVDQGDGYHUWLVHPHQWVUHIOHFWWKLV)RUH[DPSOHRQ 5HG)0 DVRf -XQH DQ DGYHUWLVHPHQWIRU6KXGKSDQPDVDODPHQWLRQV‘Shudh pan masala, ab chhotu kesaath’ (‘Pure pan PDVDOD QRZ ZLth a small companion packet’). ‘Chhottu’ UHIHUV WR D VPDOOHU SRXFK RI ORRVH WREDFFRVROGVHSDUDWHO\ZLWKWKHSDQPDVDOD )LJXUH 133 Chapter 7. Advertising and Marketing of Smokeless Products Figure 7.9: Shudh and Rounaq pan masala twin packs 3KRWRJUDSKFRXUWHV\RI 9+$,3KRWREDQN $FFRUGLQJ WR Outlook Business India, ‘Local vendors point out that the DS Group sells 5DMQLJDQGKD SDQ PDVDOD SDLUHG ZLWK VDFKHWV RI 7XOVL WREDFFR—SRS ERWK LQWR WKH PRXWK DQG voila, there’s “legal” gutka’ 2I FRXUVH '6 *URXS LV QRW WKH RQO\ FRPSDQ\ RIIHULQJ WKLV FRPSOHWHO\ OHJDO ZD\ RI FLUFXPYHQWLQJ WKH EDQ—PDQ\ RWKHU IRUPHU JXWND EUDQGV DUH QRZ 3 available as two separate pouches of pan masala and chewing tobacco’ 7KLVJLPPLFNZRXOG IDOOXQGHUWKHFXVWRPHUDFFHVVDQGYDOXHPDUNHWLQJDSSURDFKHV. 0DQ\JXWNDPDQXIDFWXUHUVDUHIROORZLQJWKHVDPHVWUDWHJ\DQGVRPHFKDUJHDKLJKHUSULFHIRU WKHSDLUHGVDFKHWVWKDQIRUWKHSUHYLRXVIRUPRIWKHSURGXFW7KHQHZSDFNDJLQJGRHVQRWDIIHFW the company’s business much, except to increase packaging costs. Manufacturers also have to VKHOORXWPRUHPRQH\WRVXSSRUWWKHGLVWULEXWRUVDQGSD\UHWDLOHUFRPPLVVLRQVDQGEULEHV,WLV ORJLFDOWREHOLHYHWKDWDSRUWLRQRIWKLVLVEHLQJWUDQVIHUUHGWRXVHUVDVSULFHVKDYHVKRWXS WRVLQFHWKH)66$EDQZHQWLQWRHIIHFW ,Q $QGKUD 3UDGHVK GRRUWRGRRU GHOLYHU\ DQG WHOHPDUNHWLQJ DUH WKH WHFKQLTXHV DGRSWHG E\ PDQXIDFWXUHUVIROORZLQJWKHEDQ7KH\UHORFDWHGWKHVWRFNIURPZDUHKRXVHVWRWKHRXWVNLUWVRI XUEDQ DUHDV DQG GHYHORSHG WKHVH DOWHUQDWLYH PDUNHWLQJ FKDQQHOV ZKLFK HQDEOH SHUVRQDOLsed 4 VHUYLFH 7KHEDQRQJXWNDVDOHVKDVUHYLYHGWKHGHPDQGIor the traditional ‘pan’. Customers used to gutka 4 are buying pouches at Rs 3 per sachet or switching over to ‘pan’ at the same price Gateway Products to SLT 6LQFH WKH JXWND EDQ SDFNHWV RI DUHFD QXW PL[WXUHV ZLWKRXW WREDFFR KDYH EHFRPH FRPPRQO\ DYDLODEOHEHFDXVHJXWNDFDQQRWEHRSHQO\VROG$UHFDQXWRUVXSDUL, can be a ‘gateway’ to future WREDFFR XVH HVSHFLDOO\ ZKHQ FRQYHQLHQWO\ DQG DWWUDFWLYHO\ SDFNDJHG LQ ORZSULFHG VLQJOH SRUWLRQV 7KHUH LV D SHUFHSWLRQ DPRQJ KHDOWK SURIHVVLRQDOV WKDW WKH SUHYDOHQFH RI DQG GHSHQGHQFHRQDUHFDQXWSURGXFWXVHLQ,QGLDLVLQFUHDVLQJUDSLGO\ HVSHFLDOO\DPRQJ\RXWKDQG 4 WKDWWKLVRIWHQOHDGVWRWREDFFRXVHHVSHFLDOO\WKHXVHRIJXWND $UHFDQXWLQWKHIRUPRIVZHHW VXSDULDQGSDQPDVDODLVQRZ HDVLO\DYDLODEOHLQUXUDODQGXUEDQDUHDVXVXDOO\DWWKHVDPHSODFHV ZKHUHWREDFFRLVVROGDQGWKHUHDUHQRDJHOLPLWVWRSXUFKDVHDQGXVHWKLVVXEVWDQFH 134 Smokeless Tobacco and Public Health in India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hDGEULJKWH\HFDWFKLQJDQGDWWUDFWLYHEDFNJURXQGFRORXUV \HOORZUHGDQGEOXH 2QHRIWKHVH WZREUDQGVZDVNQRZQDV0RJDOLDSRSXODU,QGLDQFDUWRRQFKDUDFWHU$QRWKHUEUDQGZDVQDPHG 5LWLNDIWHUDSRSXODU,QGLDQPRYLHDFWRU+ULWKLN5RVKDQ2QHVDFKHWRIWKH5LWLNEUDQGRIDUHFD QXWVKRZHGDSLFWXUHRI\RXQJER\LQFORWKHVVLPLODUWRZKDWWKHDFWRUZRUHLQKLVILUVWPRYLH ZKLFKFDWDSXOWHGKLPWRIDPH3DFNDJLQJIRUWKH0LODQEUDQGRIVXSDULZDVQRWFRORXUIXODQG RSHQO\VWDWHGLWVDUHFDQXWFRQWHQWVto be a ‘proprietary food product’. All these areca nut sachets ZHUHPDUNHWHGDVhaYLQJSOHDVDQWIODYRXUs 0RJDOL NHVDU >VDIIURQ@VFHQWHG 5LWLN PLQWVXSDUL DQG NHVDUVFHQWHG VXSDUL DQG 0LODQ FODVVLF VXJDQGKL VXSDUL ZKLFK PHDQV FODVVLF VFHQWHG 5 IODYRXUHGDUHFDQXW Price 7KHLQFUHDVHGEODFNPDUNHWSULFHRIJXWNDSURGXFWVDQGUHGXFHGFRQVXPSWLRQE\\RXQJFDVXDO XVHUVZKRSUHYLRXVO\FRQVWLWXWHGWKHPDLQJURXSRIFRQVXPHUVDUHJLYHQDVWKHPDMRUUHDVRQVIRU WKHGHFOLQHLQGDLO\WXUQRYHURIJXWND HVWLPDWHGE\UHWDLOHUVDIWHUWKHEDQDVIRXQGLQWKH UDSLGLPSDFWDVVHVVPHQWRIUHWDLOHUVE\9+$,2QDYHUDJHEHIRUHWKHEDQDUHWDLOHUXVHGWRVHOO SRXFKHVRIJXWNDZRUWKDQDYHUDJHRI5V2–2500 a day, but after the ban, retailers’ net daily 45 saleVZHUHUHGXFHGWR5V–DGD\ Promotion $VWXG\RIWKHZHEVLWH RIWKH05*URXSPDQXIDFWXUHURI6RQL3DQ.LQJ0DVW0XJKDO*XWND DQG 0XJKDO 3DQ 0DVDOD VKRZV WKDW WKHLU PDUNHWLQJ VWUDWHJLHV KDYH LQFOXGHG DGRSWLQJ D FXVWRPHUFHQWULFDSSURDFK assessing the ‘needs’ of the market, maintaining a loyal client base, 5 DQG ZRUGRIPRXWK SXEOLFLW\ %HLQJ LQ WKH WREDFFR EXVLQHVV WKH\ IDFH OHJDO DQG UHJXODWRU\ SUHVVXUHV WKDW SURKLELW WKHP IURP XVLQJ WUDGLWLRQDO PRGHV RI DGYHUWLVLQJ VR ZRUGRIPRXWK 52 SXEOLFLW\KDVEHFRPHDFUXFLDOPHDQVRIFRPPXQLFDWLQJDERXWWKHLUSURGXFW . The MR Group’s focus on the customer is well illustrated by the company’s constant efforts to expand its market base by ‘catering to new and unexplored demographic profiles, as regXODWLRQVLQ ,QGLDGRQRW allow them to cater to children below 18 years’. Their website claims that ‘in spite of handicaps, WKHFRPSDQ\KDVPDQDJHGWRDFKLHYHWKHLUVDOHVWDUJHWGXHWRWKHLUOR\DOFXVWRPHUEDVHFXOWLYDWHG 52 over many years’ 0DQXIDFWXUHUV FODLP RQ WKHLU ZHEVLWHV WKDW WKHLU IHHGEDFN V\VWHPV DUH YHU\ HIIHFWLYH 7KH\ FRQVLVW RI D 0DQDJHPHQW ,QIRUPDWLRQ 6\VWHP 0,6 DQG RQOLQH FRQQHFWLYLW\ ZLWK WKH DOO WKH FDUU\LQJ DQG IRUZDUGLQJ DJHQWV ZKROHVDOH GLVWULEXWRUV DQG VWRFNLVWV WKURXJK YLGHR FRQIHUHQFLQJHPDLOVDQGID[HV7KXVWKHPDQXIDFWXUHUVDUHDEOHWRUHFHLYHPLQXWHO\GHWDLOHG LQIRUPDWLRQDERXWWKHLUSURGXFWSHUIRUPDQFHFRQVXPHUIHHGEDFNQHZSURGXFWODXQFKHVSULFLQJ DQGGLIIHUHQWPDUNHWVWUDWHJLHVRIWKHLUFRPSHWLWRUV 7KH UDSLGLPSDFWDVVHVVPHQWRI9+$,VWXGLHGWKHLPSDFWRIWKHJXWNDEDQHVWDEOLVKHGE\)66$ 45 5XOHLQWZRVWDWHVRI,QGLD0DGK\D3UDGHVKDQG0DKDUDVKWUD LQ 2YHUDOOWKHEDQ 135 Chapter 7. Advertising and Marketing of Smokeless Products VXFFHHGHG LQ FXUWDLOLQJ ERWK WKH VXSSO\ DQG YLVXDO GLVSOD\ RI JXWND ,W FRQVLGHUDEO\ UHGXFHG DFFHVV IRU FDVXDO XVHUV FKLOGUHQ DQG ZRPHQ %ODFN PDUNHW WUDGLQJ IURP RWKHU VWDWHV ZDV 53 VXSSO\LQJDOLPLWHGDPRXQWRIJXWNDSDFNDJHV Customer-Centric Approach 6RPH PDQXIDFWXUHUV OLNH '6 *URXS PDNHU RI 5DMQLJDQGKD SXEOLVKHG QHZVSDSHU DGYHUWLVHPHQWVFODLPLQJWKDWWKHLU6/7SURGXFWVGRQRWFRQWDLQWREDFFRRUQLFRWLQH )LJXUH Figure 7.10: An advertisement for pan masala claims that the product does not contain tobacco or nicotine 3KRWRJUDSKFRXUWHV\RI 9+$,3KRWREDQN 5HFRJQL]LQJWKHJDSVLQLPSOHPHQWDWLRQRIWKH)66$5XOHVLQ$SULOWKH6XSUHPH&RXUW GLUHFWHGVWDWHVand 5 8QLRQ 7HUULWRULHVWRUHSRUWRQWKHLUFRPSOLDQFHZLWKWKHEDQRQJXWND DQG SDQ PDVDOD FRQWDLQLQJ WREDFFR VWDWLQJ that ‘manufacturers were misOHDGLQJ SHRSOH DQG 54 FUHDWLQJFRQIXVLRQDQGVHOOLQJJXWNDDQGSDQPDVDODLQVHSDUDWHVDFKHWV’ SAVE: Solutions, Access, Value, and Education $ VWXG\ RI VKRSV LQ 0XPEDL UHYHDOHG WKDW JXWND FRQWLQXHG WR EH VROG LQ VLGH VWUHHWV WR UHJXODU FXVWRPHUV ZLWK SULFHV KDYLQJ PRUH WKDQ GRXEOHG IURP 5V SHU VDFKHW WR 5V 7KH QHZHU SURGXFW UHSODFHPHQWV LGHQWLILHG E\ WKH 0XPEDL VWXG\ ZHUH VFHQWHG VXSDUL PL[HV ZLWK IODYRXUVDQGVFHQWVVLPLODUWRJXWND, VROGHLWKHUDORQHRUDORQJZLWKDVPDOOHUVHSDUDWHSRXFKRI WREDFFRDW5V–SHUSDLU+RZHYHUPDQXIDFWXUHUVKDYHKDGWRXQGHUWDNHFRQVLGHUDEOHUHWDLOHU HGXFDWLRQ DV VKRSNHHSHUV ZHUH UHOXFWDQW WR VWRUH WKH QHZ WZLQ YHUVLRQV DQG PL[HV IHDULQJ SHQDOWLHV ,QGXVWU\ DJHQWV FRQYLQFHG WKH VKRS RZQHUV WKDW RQO\ JXWND LV EDQQHG EXW WKH QHZ SURGXFWVDUHQRWKHQFHWKH\DUHVDIHWRNHeSDQGVell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mokeless Tobacco and Public Health in India &RRSHUDWLRQ/WGWKH67$DQGWKH$OO,QGLD.DWWKD)DFWRULHV$VVRFLDWLRQSUHVHQWHGLQFRUUHFW LQIRUPDWLRQLQRUGHUWRFUHDWHFRQIXVLRQDPRQJWKHSXEOLFDQG HQIRUFHPHQWDJHQFLHVLQWKHVWDWHV WKDW KDGQRW\HWLPSOHPHQWHGWKHEDQ7KLVGHFHSWLYHVWUDWHJ\ZDVDSOR\E\WKHJXWNDLQGXVWU\WR VFXWWOHWKH)66$,QRWLILFDWLRQDQGLWVQHZUXOHV )LJXUH Figure 7.11: Advertisements published by the Smokeless Tobacco Association, October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ndia TV feature ‘Rajshree Pan Masala news break’ EHWZHHQ QHZVSURJUDPPHV 1'79 $DM 7DN,QGLDWHOHYLVLRQQHZSURJUDPPHV–-XQH 7KH9+$,DVVHVVPHQWVKRZVWKDWWKHUHWDLOHUUHVSRQGHQWVDUHDZDUHRIWKHLPSOHPHQWDWLRQDQG NQRZWKHH[DFWGDWHZKHQWKHQRWLILFDWLRQFDPHLQWRIRUFH7KHVDOHRIJXWNDDQGSDQPDVDODKDV QRWVWRSSHGFRPSOHWHO\LQWKHVKRSVEHFDXVHWKH\FDQJHWVXSSOLHVRIWKHSURGXFWVGHOLYHUHGULJKW WRWKHLUVKRSV6HOOLQJJXWNDJLYHVWKHPDJRRGPDUJLQ DQGWKHGHPDQGIURPUHJXODUXVHUVLVQRW \HW UHGXFHG'XULQJWKH LQWHUYLHZVWKHUHWDLOHUV VXSSRUWHGWKHEDQEXW WKH\DOVR DVVHUWHGWKDW 45 sDOHVZRXOGFRQWLQXHDVORQJDVWKHVXSSO\H[LVWV CHALLENGES AND SUCCESSES 6/7LVDPXOWLIDFHWHGFKDOOHQJHDQGDNH\H[DPSOHRIKRZWKHSURILWLQWHUHVWVRIDIHZGRPLQDWH RYHUWKHLQGLUHFWFRVWVERUQHE\WKHQDWLRQLQWKHIRUPRIGLVHDVHVDQGKHDOWKFDUHFRVWV 3ROLF\ DFWLRQV E\ JRYHUQPHQW RYHU WKH \HDUV KDYH FRQWLQXDOO\ EHHQ GLOXWHG RU GHIHDWHG E\ WKH 6/7 industry’s purported contribution to the economy, employment, government income, and UHYHQXH,Q,QGLDWKHFOLPDWHIRUWREDFFRDGYHUWLVLQJPDUNHWLQJDQGSURPRWLRQDODFWLYLWLHVLQ WKHODVWIHZGHFDGHVKDVFKDQJHGGUDPDWLFDOO\VHYHUDOWLPHV,QWKHSURFHVVWREDFFRDGYHUWLVLQJ 137 Chapter 7. 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Women and Smokeless Tobacco: Special Considerations XQGHUZHLJKW>%0, NJPð@LQZRPHQH[SUHVVHGDVRGGVUDWLR>25 – @ZDV KLJKHU WKDQ LQ PHQ >25 – @ ZKHQ FRPSDULQJ 6/7 XVHUV WR QRQXVHUV 25V IRU XQGHUZHLJKWLQFUHDVHGZLWKGDLO\IUHTXHQF\RI6/7XVHDIWHUDGMXVWLQJIRUDJHDQGHGXFDWLRQDO VWDWXV$WHYHU\GRVHZRPHQKDGDKLJKHUULVNRIEHLQJXQGHUZHLJKWWKDQPHQ8VHRIWZRRU PRUH6/7W\SHVZDVDVVRFLDWHG ZLWKVLJQLILFDQWO\KLJKHUULVNRIXQGHUZHLJKWWKDQXVHRIPLVKUL RUEHWHOTXLGDORQH 7DEOH Table 8.1: Mean body weight, BMI; prevalence of underweight and OR for underweight (adjusted for age, education, mother tongue, and religion); by SLT use status, in the Mumbai Cohort Study Weight kg Mean BMI Prevalence% of BMI Adjusted OR for Variables n ± SE ± SE <18.5 underweight (<18.5) 1HYHUXVHUV 23 WR 0LVKUL WR 0LVKULRWKHU WR %HWHOTXLG 3 WR 2WKHUWREDFFR WR $UHFDQXW WR 16 Note: 6( VWDQGDUGHUURU Source: 3HGQHNDUHWDO ,QDVDPSOHRI ZRPHQDJHs – \HDUV IURP WKH – 1DWLRQDO )DPLO\ +HDOWK 6XUYH\ 1)+6 LQ ,QGLDQ VWDWHV ORZHU %0, ZDV VLJQLILFDQWO\ DVVRFLDWHG ZLWK FKHZLQJ WREDFFR S 7DEOH ,QDQXQRUGHUHGPXOWLQRPLDOPXOWLYDULDEOHPRGHO XVLQJ%0, 2 – NJP DV WKH UHIHUHQFH 25 IRU XQGHUZHLJKW %0, NJP ZDV > FRQILGHQFHLQWHUYDO &, –@DIWHUDGMXVWLQJIRUDJHUHOLJLRQQXPEHURIFKLOGUHQFXUUHQW VPRNLQJDOFRKROXVHKLVWRU\RIWXEHUFXORVLVWUHDWPHQWDQGPDODULD Table 8.2: Distribution of women ages 15–49 [n (%)] across 7 categories of BMI, by use of chewing tobacco, in the NFHS-2 sample from 26 Indian states BMI Sample BMI BMI BMI BMI BMI BMI Variables 17– size <16 16–16.9 18.5–22.9 23–24.9 25–9.9 >30 18.49 1RQXVHUV 3 5 7REDFFR 4444 FKHZHUV Source: 5HSURGXFHGIURP6XEUDPDQLDQDQG6PLWK $QRWKHUVWXG\IRFXVHGRQZRPHQZKRKDGOLYHELUWKVLQDKRVSLWDOLQ3XQHLQ DQG ZKRVHPDWHUQDOZHLJKWVZHUHUHFRUGHGDWGHOLYHU\$PRQJPLGGOHDQGORZHUVRFLDOFODVV ZRPHQ FKHZHUV ZHLJKHG NJ ZKHUHDV RI WKH QRQXVHUV ZHLJKHG NJ 7KH FRQGLWLRQDOPD[LPXPOLNHOLKRRGHVWLPDWH F0/( RGGVUDWLRIRUZHLJKLQJ NJLQZRPHQRI ORZHUDQGPLGGOHVRFLRHFRQRPLFFODVVZKRGHOLYHUHGEHWZHHQ–ZHHNVZDV – IRU WKRVH ZKR GHOLYHUHG DW ZHHNV RU ODWHU WKH F0/( ZDV – 6LPLODUO\ LQ D SRSXODWLRQEDVHG FRKRUW VWXG\ LQ 0XPEDL RI 6/7 FKHZHUV DQG RI QRQFKHZHUV 146 Smokeless Tobacco and Public Health in India ZHLJKHG NJ GXULQJ – PRQWKV RI SUHJQDQF\ S 8QDGMXVWHG 25 IRU %0, LQ 22 6/7XVHUVZDV – 6/7XVHLVDOVRDVVRFLDWHGZLWKDQDHPLDLQSUHJQDQWDQGQRQSUHJQDQWZRPHQ,QDVWXG\XVLQJ 1)+6GDWDRn3 HYHUPDUULHGZRPHQDJHs – \HDUVIURPWKHVWDWHRI0HJKDOD\DWKRVH ZKRZHUHWREDFFRXVHUVKDGDWLPHVKLJKHUULVNRIDQDHPLD – DIWHUDGMXVWPHQWIRU DJH XUEDQ RU UXUDO UHVLGHQFH HGXFDWLRQ ZHDOWK LQGH[ SUHJQDQF\ VWDWXV QXWULWLRQDO VWDWXV 23 RFFXSDWLRQDOVWDWXVDQGFKLOGUHQHYHUERUQ ,QDFRKRUWVWXG\RQSUHJQDQWZRPHQLQ0XPEDL PHDQ KDHPRJORELQ OHYHOV ZHUH VLJQLILFDQWO\ ORZHU LQ 6/7 XVHUV JGO LQ FRPSDULVRQ ZLWK QRQXVHUV JGOS 25IRUPDWHUQDODQDHPLD +E JGO DVVRFLDWHGZLWK6/7XVH ZDV &, – DIWHUDGMXVWPHQWIRUDJHRIPRWKHUHGXFDWLRQVRFLRHFRQRPLFVWDWXV W\SH RI UHVLGHQFH ORZHU %0, SDULW\ YHJHWDULDQ RU QRQYHJHWDULDQ IRRG LQWDNH DQG 22 KDHPRGLOXWLRQGXULQJSUHJQDQF\ 7KHZKROHGLVWULEXWLRQRIKDHPRJORELQZDVVKLIWHGWRZDUGV 22 WKHOHIWLQ6/7XVHUVLQFRPSDULVRQZLWK QRQXVHUV )LJXUH Figure 8.1: Distribution of haemoglobin level by SLT use status 22 Source: 6XEUDPRQH\DQG*XSWD 1)+63 UHSRUWHGWKDWDPRQJ ZRPHQVXUYH\HG DJHs – WKH SUHYDOHQFH RI PLOG – JGO PRGHUDWH – JGO DQGVHYHUH JGO DQDHPLDZDVDQG UHVSHFWLYHO\ LQZRPHQXVLQJWREDFFR DQGDQGLQZRPHQZKRGLG QRWXVHWREDFFRDIWHUDGMXVWLQJ IRUDOWLWXGHRIUHVLGHQFH S 5LVNUDWLRVFDOFXODWHGIRUPLOG PRGHUDWHDQGVHYHUHDQDHPLDLQ6/7XVHUZRPHQLQFRPSDULVRQWRQRQXVHUVZHUH – 24 – DQG –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hapter 8. Women and Smokeless Tobacco: Special Considerations GLVDGYDQWDJHLQZRPHQ6/7XVHUVFDQSUHYHQWDFFHVVWRQXWULWLRXVIRRG and UHGXFHG SODVPD 34 OHYHOVRIVHYHUDODQWLR[LGDQWYLWDPLQVKDYHEHHQUHSRUWHGLQ6/7XVHUV Oral Diseases $OWKRXJK SDQ PDVDOD DQG WREDFFR SURGXFWV DUH RIWHQ DGYHUWLVHG DV PRXWK IUHVKHQHUV ZRPHQ ZKRXVHWKHVHSURGXFWVKDYHVHYHUHRUDOKHDOWKSUREOHPVLQFRPSDULVRQZLWK QRQXVHUV VHHDOVR 35 FKDSWHU 8VHUVH[SHULHQFHPRUHSODTXHDQGLQIODPPDWLRQLQWKHRUDO FDYLW\ UHFHVVLRQRI JXPV H[SRVHG URRW VXUIDFHV RI WHHWK LQFUHDVHG SHULRGRQWDO SRFNHWV DQG WRRWKORVV &OLQLFDO ORVVRIDWWDFKPHQWRISHULRGRQWDOILEUHVLQFUHDVHVZLWKGXUDWLRQRI6/7XVH 2UDOLQIODPPDWLRQ IURPWREDFFRDQGDUHFDQXWXVHIXUWKHULQFUHDVHVWKHULVNRIRUDOFDQFHU SUREDEO\EHFDXVHRIan LQFUHDVHLQHQGRJHQRXVQLWUDWLRQDQGWKHIRUPDWLRQRIWR[LQV :RPHQFRQVXPLQJWREDFFRSURGXFWVZLWKDUHFDQXWFDQDOVRGHYHORSDQH[WUHPHO\GHELOLWDWLQJ DQG SRWHQWLDOO\ PDOLJQDQW DQG SUHFDQFHURXV FRQGLWLRQ FDOOHG RUDO VXEPXFRXV ILEURVLV 26) :RPHQ PD\ KDYH PRUH V\PSWRPDWLF GLIILFXOW\ DVVRFLDWHG ZLWK 26) WKDQ PHQ—IRU H[DPSOH GLIILFXOW\ RSHQLQJ WKH PRXWK GLIILFXOW\ HDWLQJ EXUQLQJ VHQVDWLRQ DOWHUHG WDVWH VHQVDWLRQ DQG GLIILFXOW\LQVZDOORZLQJ Cancer 34 :RPHQZKRXVH6/7RUSDQPDVDODKDYHDQLQFUHDVHGULVNRIRUDODQGSKDU\QJHDOFDQFHUV DQG WKLVULVNLQFUHDVHVZLWKWKHGXUDWLRQDQGIUHTXHQF\RI6/7XVH :RPHQDSSHDUWREHPRUH YXOQHUDEOHWRWKHFDUFLQRJHQLFHIIHFWVRI6/7DQGSDQPDVDODWKDQPHQ 7DEOH ,QD PHWDanalysis WKDW LQFOXGHG SXEOLVKHG VWXGLHV RI RUDO FDQFHU ZRPHQ KDG D VXEVWDQWLDOO\ KLJKHUULVNRIRUDOFDQFHU>25 – FRPSDUHGWR LQPHQ – @ Women’s JUHDWHUULVNVRIRUDOFDQFHUPD\KDYHDYDULHW\RIFDXVHVZKLFKFDQRQO\EHK\SRWKHVLVHGDWWKLV WLPH Adverse Reproductive Effects 7KHHYLGHQFHVKRZVWKDW6/7XVHE\SUHJQDQW ZRPHQUHVXOWVLQ DVLJQLILFDQWO\KLJKHUULVNRI FRPSOLFDWLRQVIRUWKHZRPDQDQGWKHIHWXV$QLQWHUYHQWLRQDOVWXG\RQSUHJQDQWZRPHQLQUXUDO 0DKDUDVKWUDIRXQGDKLJKHUULVNRISUHJQDQF\FRPSOLFDWLRQV—LQFOXGLQJIHWDOGLVWUHVV >55 – @ SUHJQDQF\LQGXFHG K\SHUWHQVLRQ 3,+ >55 – @ DQWHSDUWXP KDHPRUUKDJHROLJRK\GUDPQLRVSRO\K\GUDPQLRVDQGSRVWSDUWXPKaHPRUUKDJH>55 – 3 @—DPRQJXVHUVLQFRPSDULVRQWRQRQXVHUV +LJKHUULVNRIIHWDOGLVWUHVV>55 – @DQGSUHJQDQF\LQGXFHGK\SHUWHQVLRQ>55 – @ZHUHDOVRREVHUYHG Table 8.3: Increased risk of oral cancer among SLT user women in comparison to SLT user men SLT type, Risk in SLT users in Adjustment Study Sample Reference, location risk comparison to non-users for potential details description comparison Women Men confounders 1DQGDNXPDUHWDO &DVH LQFLGHQW 7REDFFR 25 25 0DWFKHGE\ 45 FRQWURO FDVHVDQG FKHZLQJ – – S DJHVH[ 3RSXODWLRQ%ased VWXG\ FRQWUROV FDQFHU S UHVLGHQWLDO &DQFHU5HJLVWU\ VXVSHFWV VWDWXV .LGZDL0HPRULDO ,QVWLWXWH%DQJDORUH 148 Smokeless Tobacco and Public Health in India SLT type, Risk in SLT users in Adjustment Study Sample Reference, location risk comparison to non-users for potential details description comparison Women Men confounders -D\DOHNVKPLHWDO 3URVSHFWLYH ZRPHQ &XUUHQW 55 – 55 $JH IROORZXS DQGPHQ WREDFFR – HGXFDWLRQ s .DUXQDJDSDOO\.HUDOD VWXG\IRU DJH – FKHZHUVYV LQFRPH DQG FKLOGUHQ QHYHUXVHUV ELGLVPRNLQJ DJHV– DQGDOFRKRO years XVHLQPHQ 0XZRQJHHWDO 1HVWHG LQFLGHQW %HWHOTXLG 25 25 0DWFKHGE\ 43 FDVH RUDOFDQFHUV FKHZHUV – – DJH 7ULYDQGUXP FRQWURO FRQWUROV SDQFKD\DWK VWXG\LQD DQGUHVSRQVH UDQGRPLVHG VWDWXVWR FRQWUROOHG LQWHUYLHZ WULDO %DODUDPHWDO &DVH FDQFHU %HWHOTXLG 25 – 25 – $JHVWXG\ %DQJDORUH0DGUDV FRQWURO FDVHV FKHZLQJ FHQWUH DQG7ULYDQGUXP VWXG\ FRQWUROV HGXFDWLRQ DQG VPRNLQJDQG GULQNLQJLQ PHQ 44 :DKL &DQFHU 34 &KHZLQJ 3UHYDOHQFH 3UHYDOHQFH 1RWDGMXVWHG s 0DLQSXULGLVWULFW QHDU UHJLVWU\ LQGLYLGXDOVDJH 0DLQSXUL UDWHUDWLRLQ UDWHUDWLRLQ $JUD VWXG\ LQUXUDODQG WREDFFR FKHZHUV FKHZHUV XUEDQDUHDV &, – – LQ LQFKHZHUV FKHZHUVZKR ZKRVPRNHG VPRNHG – – Note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did QRW PDWFK IRU JHVWDWLRQDO DJH DW GHOLYHU\ ZKLFK LV DQ LPSRUWDQW OLPLWDWLRQ %LUWKZHLJKWLVDQLPSRUWDQWGHWHUPLQDQWRIQHRQDWDODQGLQIDQWPRUELGLW\DQGPRUWDOLW\ +LJKO\ VLJQLILFDQWDQGFRQVLVWHQWELUWKZHLJKWUHGXFWLRQVKDYHEHHQGHPRQVWUDWHGZLWKPDWHUQDO6/7XVH in DOPRVW DOO ,QGLDQ VWXGLHV DIWHU DGMXVWPHQW IRU D UDQJH RI SRWHQWLDO FRQIRXQGHUV 7DEOH ,Q D VWXG\ XQGHUWDNHQ LQ $KPHGDEDG 6/7 XVH ZDV QRW DVVRFLDWHG ZLWK ORZ ELUWKZHLJKW LQ PXOWLYDULDWH DQDO\VLV PRVW OLNHO\ EHFDXVH RI RYHUDGMXVWPHQW E\ D YDULHW\ RI 53 SUR[LPDWHYDULDEOHV ,QDFRKRUWVWXG\Rf SUHJQDQW ZRPHQLQ 0XPEDL 7DEOH WKH ZKROH GLVWULEXWLRQ RI ELUWKZHLJKW ZDV VKLIWHG WRZDUG WKH OHIW LQ XVHUV FRPSDUHG WR QRQXVHUV )LJXUH S 7KUHH VWXGLHV KDYH GHPRQVWUDWHG VLJQLILFDQW GRVH–UHVSRQVH HIIHFWV RI PDWHUQDO 6/7 XVH RQ ELUWKZHLJKW 7DEOH 5 +LJK OHYHOV RI FRWLQLQH KDYH EHHQ 149 Chapter 8. Women and Smokeless Tobacco: Special Considerations GHPRQVWUDWHG LQ PDWHUQDO EORRG FRUG EORRG DQG DPQLRWLF IOXLG LQ PLVKUL XVHUV LQ D VWXG\ LQ 54 0XPEDL )LJXUH3 Table 8.4: Birthweight in relation to maternal SLT use in studies from India (2000–2013) Study details Sample Results Comments 5XUDOILHOGSUDFWLFH $VLPSOHUDQGRPVDPSOHRI $GMXVWHG55IRUWREDFFR $GMXVWHGIRUODUJHQXPEHURI DUHDRIPHGLFDO ELUWKVVHOHFWHGIURPDOO XVHUV S IRUORZ SRWHQWLDOFRQIRXQGHUV FROOHJH.RONDWD ELUWKVWKDW KDGDYDOLG ELUWKZHLJKW /%: 4 :HVW%HQJDO address Q +RVSLWDOVLQ WHUP/%:EDELHVDQG $GMXVWHG25 &, $GMXVWHGIRUODUJHQXPEHURI 0DKDUDVKWUD WHUPPDWFKHGFRQWUROV – SRWHQWLDOFRQIRXQGHUV +RVSLWDOUXUDO /%:VLQJOHWRQOLYH RIFDVHVDQGRI 2QO\ELUWKVEHWZHHQDQG 0DKDUDVKWUD ELUWKVDQGQRUPDO FRQWUROZHUHWREDFFRXVHUV ZHHNVRIJHVWDWLRQERUQ ZHLJKWVLQJOHWRQOLYHELUWKV S 25 &, WRPRWKHUV – –\HDUVRIDJH 1DJSXU0DKDUDVKWUD OLYH/%:VLQJOHWRQV 0DWHUQDOWREDFFRXVHQRW &DVHVDQGFRQWUROVGLIIHUHG 52 DQGPDWFKHGFRQWUROV DVVRFLDWHGZLWK/%: VLJQLILFDQWO\LQSODFHRI UHVLGHQFHKHLJKWZHLJKW ELUWKLQWHUYDO ,QWHUYHQWLRQVWXG\ SUHJQDQWZRPHQ 0HDQELUWKZHLJKWRIEDELHVRI 8VHUVDQGQRQXVHUVZHUH UXUDO0DKDUDVKWUD LQFOXGLQJPLVKULXVHUV PLVKULXVHUVwas J FRPSDUHG 3 OHVVWKDQEDELHVRI QRQXVHUV S 1)+6ZRPHQDJHs %LUWKZHLJKWIURP 2GGVUDWLR IRU/%:ZDV RIDOOWREDFFRFKHZHUV – KHDOWKFDUGVRI &,– VPRNHGDVZHOO – HOLJLEOHELUWKV 3RSXODWLRQEDVHG ZRPHQUHFUXLWHG $GMXVWHG25 IRU/%: was $GMXVWHGIRUVHYHUDO 0XPEDL GXULQJ–PRQWKVRI &,– FRQIRXQGHUV JHVWDWLRQDQGIROORZHGXS XQWLOGHOLYHU\ Figure 8.2: Distribution of birthweight by maternal SLT use status Source: *XSWDDQG6XEUDPRQH\ 150 Smokeless Tobacco and Public Health in India Table 8.5: Impact of duration, quantity, frequency, or type of maternal SLT use on mean birthweight (BW) or low birthweight (LBW) Study author/date Type and location of study Findings 3 3UDWLQLGKLHWDO ,QWHUYHQWLRQVWXG\UXUDO 0HDQELUWKZHLJKWE\JHVWDWLRQDODJH 0HDQELUWKZHLJKWZLWK 0DKDUDVKWUD ZKHQPRWKHUVWRSSHGXVLQJPLVKUL \HDUVRIPLVKULXVH 1RQXVHU J 6WRSSHGDWZNV J 1RQXVHU J 6WRSSHGDWZNV J \UV J 8VHGWKURXJKRXWSUHJQDQF\ J Sޒ ) Sޒ *XSWDDQG6XEUDPRQH\ 3RSXODWLRQEDVHGFRKRUW 5HGXFWLRQLQPHDQELUWKZHLJKWZLWKIUHTXHQF\RI6/7XVH VWXG\0XPEDL –WLPHVGD\ J WLPHVGD\ J S 9HUPDHWDO -DEDOSXU0HGLFDO&ROOHJH %LUWKZHLJKWZLWKTXDQWLW\RI6/7XVHG +RVSLWDO 1RQXVHU J 8VHGޒJGD\ J 8VHG– JGD\ J 8VHG– JGD\ J 8VHGޓJGD\ J ) Sޒ Figure 8.3: Cotinine levels in maternal blood, cord blood, and amniotic fluid of 12 mishri user mothers who delivered at a Ghatkopar Hospital in Mumbai, 1992 (numbered 1–12 on x-axis) 2 500 2 000 1 500 maternal blood cord blood 1 000 amniotic fluid 500 0 0123456789101112 54 Source: 6DUNDUHWDO 2 ,QDQLQWHUYHQWLRQDOVWXG\LQUXUDO0DKDUDVKWUDTXLWWLQJ6/7XVHGXULQJSUHJQDQF\LPSURYHGWKH ELUWKZHLJKW RI LQIDQWV GHOLYHUHG E\ WKHVH ZRPHQ ,Q WKLV VWXG\ RI PLVKUL XVHUV VWRSSHGXVHE\ZHHNVJHVWDWLRQUHGXFHGFRQVXPSWLRQRUVWRSSHGDWZHHNVDQGWKH 3 UHPDLQLQJGLGQRWFKDQJHWKHLU SUDFWLFHRIXVLQJPLVKUL DWDOO %LUWKZHLJKWUHGXFWLRQZDV 54 JUHDWHVWLQWKRVHZKRFRQWLQXHGXVHWKURXJKRXWSUHJQDQF\ 7DEOH 5 151 Chapter 8. Women and Smokeless Tobacco: Special Considerations ,Q D SRSXODWLRQEDVHG VWXG\ LQ 0XPEDL 6/7 XVH ZDV DVVRFLDWHG ZLWK DYHUDJH UHGXFWLRQ LQ JHVWDWLRQDODJHRIGD\V &I 3– 3UHWHUPGHOLYHULHVZHUHHDUOLHUE\GD\V &, –GD\V 7KHUHZDVDGRVH–UHVSRQVHUHODWLRQEHWZHHQ6/7XVHDQGJHVWDWLRQDODJH OLJKW 6/7XVHUVDQGKHDY\6/7XVHUVGHOLYHUHG DQG GD\VHDUOLHUWKDQQRQXVHUVUHVSHFWLYHO\ S 7KHSHUFHQWDJHRILQIDQWVGHOLYHUHGSUHWHUPE\6/7XVHUVLQFRPSDULVRQWRQRQXVHUV LQFUHDVHGDVJHVWDWLRQDODJHGHFUHDVHGIURPZHHNV–ZHHNV–ZHHNVWR ZHHNV S 6LPLODUWRWKHVHILQGLQJVDQLQWHUYHQWLRQVWXG\ZLWK SUHJQDQWZRPHQLQUXUDO0DKDUDVKWUD VKRZHGWKDWRIPLVKUL XVHUVDQGRIQRQXVHUVKDGSUHYLRXVSUHWHUPGHOLYHULHV7KH 3 UHODWLYHULVNRISUHWHUP GHOLYHU\DPRQJPLVKUL XVHUVZDV &,– ,QWKH3XQH VWXG\DPRQJPLGGOHDQGORZHUVRFLRHFRQRPLFZRPHQZKRKDGOLYHELUWKV6/7XVHUVKDG WLPHVKLJKHUULVNIRUGHOLYHU\DW–ZHHNV &,– DQGWLPHVKLJKHUULVNRI GHOLYHULQJDWZHHNVRUOHVV &, – LQFRPSDULVRQZLWK QRQXVHUV 6WXGLHV RQ VWLOOELUWK DQG VSRQWDQHRXV DERUWLRQ LQ DVVRFLDWLRQ ZLWK PDWHUQDO 6/7 XVH DUH VXPPDULVHGLQ7DEOH$ IHWXV ERUQDIWHUDWOHDVWZHHNVRIJHVWDWLRQWKDWGid QRWEUHDWKHRU VKRZDQ\RWKHUHYLGHQFHRIOLIHLVGHILQHGDVDVWLOOELUWK3HULQDWDOPRUWDOLW\UHIHUVWRERWKODWe IHWDO VWLOOELUWK DQGHDUO\QHRQDWDOGHDWKV ILUVWZHHNRIOLIH 8QDGMXVWHG ULVN RI VWLOOELUWK LQ 6/7 XVHU ZRPHQ LQ HSLGHPLRORJLFDO VWXGLHV ZDV 3– WLPHV KLJKHU WKDQ LQ QRQXVHUV DQG ULVN RI VSRQWDQHRXV DERUWLRQV DQG VWLOOELUWKV FRPELQHG ZDV WLPHV KLJKHU $ FDVH FRQWURO VWXG\ DFURVV FHQWUHV UHYHDOHG WKDW WKH 55 XQDGMXVWHG25 RISHULQDWDOGHDWKLQQHZERUQVRI6/7XVHUVZDV &,– Table 8.6: Stillbirth and spontaneous abortion in relation to maternal SLT use (India) Study, sample Results Comment 3RSXODWLRQEDVHGVWXG\ +5DGM IRUVWLOOELUWK 'RVH–UHVSRQVHHIIHFWZLWKLQFUHDVLQJIUHTXHQF\ 0XPEDL &,– IRU6/7XVHUV RIGDLO\XVH +RVSLWDOV$KPHGDEDG RIPRWKHUVRIVWLOOERUQ EDELHV 2YHUDGMXVWPHQWE\SUR[LPDWHIDFWRUVDWWHQXDWHG XVHGWREDFFRYV RIOLYHELUWKV WKHRGGVUDWLRLQUHJUHVVLRQ >UDWHUDWLR &,– @ S FXUUHQWO\PDUULHG 6SRQWDQHRXVDERUWLRQDQGVWLOOELUWK &KHZHUVPD\LQFOXGHVPRNHUVDQGDOFRKRO ZRPHQZKRUHSRUWHGDQ\IHWDO UDWHZDVSHULQZRPHQZKR GULQNHUV ORVV DQGWREDFFRXVHQRQXVH FKHZHGWREDFFRSHULQQRQ 25DWWHQXDWHGDOLWWOHDIWHUDGMXVWPHQW IURPWKH1)+6 – XVHUV>UDWHUDWLR &,– S @ LQIDQWVGHOLYHUHGLQ3XQH 5DWHUDWLRIRUVWLOOELUWKLQFKHZHUV $QWHQDWDOFDUHSDULW\ZHUHVLPLODU KRVSLWDO &,– ,QWHUYHQWLRQVWXG\UXUDO RXWRIFKHZHUVKDGVWLOOELUWKs YV 8VHUVDQGQRQXVHUVZHUHFRPSDUDEOH 3 0DKDUDVKWUD 3 RXWRIQRQXVHUV UDWHUDWLR &,– ,QWKHFRKRUWRISUHJQDQWZRPHQLQ0XPEDLDPRQJZRPHQZKRKDGhad DSUHYLRXV SUHJQDQF\WKHKD]DUGUDWLR +5 IRUVWLOOELUWKZDV &,– DIWHUDGMXVWPHQWIRUD UDQJHRISRWHQWLDOFRQIRXQGHUV )LJXUH4 152 Smokeless Tobacco and Public Health in India Figure 8.4: Cumulative survival of babies born after 20 weeks to SLT users and non-users, by days of gestation at delivery 5 Source: *XSWDDQG6XEUDPRQH\ Adverse Effects on Family Health 7REDFFR XVHUV VXIIHU LQFUHDVHG HSLVRGHV RI KRVSLWDOLVDWLRQ DQG RXWRISRFNHW H[SHQGLWXUHV IRU KHDOWK FDUH ZKLFK WKUHDWHQ WKHLU ILQDQFLDO wellEHLQJ DQG WKHLU DELOLW\ WR SURYLGH HVVHQWLDO QXWULWLRQIRUWKHir IDPLOies ZKLFKDGYHUVHO\DIIHFWs IDPLO\KHDOWK Mother’s use of SLT is also DVVRFLDWHGZLWKXVHRIPHGLFDOFDUH 1)+63 UHSRUWHGWKDW DVLJQLILFDQWO\VPDOOHUSURSRUWLRQRI users’ infants were treated at a health facility for acute respiratory infections compared with non XVHrs’ infants (61% vs. 70%, respectively; S DOWKRXJK DVLJQLILFDQWO\JUHDWHUSURSRUWLRQRI LQIDQWV RIWREDFFRXVHU ZRPHQKDGV\PSWRPV RIDFXWHUHVSLUDWRU\LQIHFWLRQ LQ WKHWZRZHHNV 25 SUHFHGLQJWKHVXUYH\FRPSDUHGWRQRQusers’ infants (7.3% YV S OTHER SLT-RELATED ISSUES IN WOMEN Use of Multiple SLT Products 7KH*OREDO$GXOW7REDFFR6XUYH\ *$76 UHSRUWHGWKDW –RIDOOZRPHQLQWKH VWDWHV RI 0L]RUDP 1DJDODQG &KDWWLVJDUK $UXQDFKDO 3UDGHVK 2GLVKD 0DGK\D 3UDGHVK DQG 0DQLSXUXVHG6/7LQPXOWLSOHIRUPV.HUDODKDGDKLJKHUUHODWLYHSUHYDOHQFHRIPXOWLSOH6/7 XVHDOWKRXJKLWKDGDORZHURYHUDOOSUHYDOHQFH,QDODUJHSRSXODWLRQEDVHGVWXG\LQ0XPEDL RI ZRPHQDJHDQGDERYHXVHGPXOWLSOH6/7SURGXFWV6RPHXVHGPLVKUL DQG EHWHO TXLG ZLWK WREDFFR DQG XVHG RWKHU FRPELQDWLRQV $ VWXG\ RI IHPDOH DGROHVFHQWV DJHs – \HDUV VHOHFWHG E\ VLPSOH UDQGRP VDPSOLQJ IURP WKH YLOODJHV VXUURXQGLQJ WKH .DVWXUED 5XUDO +HDOWK 7UDLQLQJ &HQWUH :DUGKD IRXQG WKDW KDG XVHG 6/7LQWKHSDVWGD\VXVHGGU\VQXIIWRFOHDQWHHWKXVHGWREDFFRLQWKHIRUPRI JXWNDDQGXVHGWREDFFRDQGOLPH RQHIRXUWKRIXVHUVXVHGWZRRUPRUHIRUPVRI6/7 In FRQWUDVWSRSXODWLRQEDVHGVXUYH\VFRQGXFWHGGXULQJ – DQGLQ IRXQGWKDWXVHRI PXOWLSOH 6/7 SURGXFWV ZDV UDUHO\ UHSRUWHG WR WKHVH VWXGLHV VXUYH\HG PRUH WKDQ YLOODJHUV LQ ILYH ZLGHO\ GLIIHUHQW GLVWULFWV UHSUHVHQWLQJ D EURDG VSHFWUXP RI WKH SRSXODWLRQRI,QGLD LQWKHVWDWHVRI$QGKUD3UDGHVK%LKDU.HUDOD*XMDUDW DQG*RD 153 Chapter 8. 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The message that ‘SLT is an essential household commodity’ is unsaid, but is DXWRPDWLFDOO\SHUFHLYHGE\ZRPHQ Figure 8.5: Positioning of smokeless tobacco strips [‘Gai’ (cow brand) and ‘Singham’ (lion brand)] in stores among essential daily use commodities such as ‘Rin’ washing powder, ‘Kissan’ jam, and Pantene’ shampoo Source: &KDXGKU\DQG&KDXGKU\ $OPRVWDOOVKRSV LQFOXGLQJPLONRXWOHWVZKLFKDUHIUHTXHQWHGE\ZRPHQWREX\GDLO\XVHLWHPV DQGJURFHULHVVWRFNYDULHWLHVRI6/7SURGXFWV $VSDWLDODQDO\VLVLQDW\SLFDOORZLQFRPH FRPPXQLW\ LQ 0XPEDL GRFXPHQWHG WKDW DOO UHVLGHQWV FRXOG UHDFK D WREDFFR RXWOHW ZLWKLQ – IHHWRIWKHLUKRPHV 7KLVVWXG\DOVRGRFXPHQWHGWKDWLQJHQHUDOJURFHU\VKRSVVHOOLQJ6/7 ZHUHPXFKPRUHQXPHURXVLQWKHFRPPXQLW\WKDQVKRSVWKDWRQO\VROGWREDFFRSURGXFWV*$76 India VKRZed WKDW RI ZRPHQ FRPSDUHG WR RI PHQ SXUFKDVHG 6/7 SURGXFWVIURPVWRUHVWKDWVHOOGDLO\XVHFRPPRGLWLHV ,Q DGGLWLRQ WREDFFREDVHG WRRWKSDVWHV WRRWKSRZGHUV DQG KHUEDO GHQWLIULFHV WKDW FRQWDLQ WREDFFR are commonly available in ‘medical’ or pharmaceutical shops, along with stocks RI RWKHUWRRWKSDVWHVWRRWKEUXVKHVKHDOWKGULQNVPXVFOHEXLOGLQJIRRGVDQGPHGLFLQHV Women Face More Problems Stopping SLT Use 6/7FHVVDWLRQVHHPVPRUHGLIILFXOWIRUZRPHQWKDQPHQ:RPHQDSSHDUWREHOHVVLQWHUHVWHGLQ TXLWWLQJ6/7XVHWKDQPHQ are $FFRUGLQJWR *$76India DERXWRI6/7XVHU ZRPHQZHUHQRWLQWHUHVWHGLQTXLWWLQJFRPSDUHGZLWK WKHRIPDOHVZKRZHUHQRWLQWHUHVWHG LQ TXLWWLQJ $ERXW RI GDLO\ 6/7 XVHU ZRPHQ KDG PDGH DQ DWWHPSW WR TXLW LQ WKH SDVW PRQWKVLQFRQWUDVWWR RIPDOHV :RPHQ DOVR H[SHULHQFH PRUH DQ[LHW\ DQG VWUHVV WKDQ PHQ ZKLOH WU\LQJ WR TXLW 7KH\ ZRUU\ ZKHWKHUWKH\ZLOOEHDEOHWRFRQWLQXHWKHLUFKRUHVZKHQWKH\TXLWEHFDXVHWKH\EHOLHYHWKDWXVLQJ 155 Chapter 8. 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Women and Smokeless Tobacco: Special Considerations 0XZRQJH55DPDGDV.6DQNLOD5HWDO5ROHRIWREDFFRVPRNLQJFKHZLQJDQGDOFRKROGULQNLQJLQWKHULVNRI RUDO FDQFHU LQ 7ULYDQGUXP ,QGLD D QHVWHG FDVHFRQWURO GHVLJQ XVLQJ LQFLGHQW FDQFHU FDVHV 2UDO 2QFRO :DKL317KHHSLGHPLRORJ\RIRUDODQGRURSKDU\QJHDOFDQFHU$UHSRUWRIWKHVWXG\LQ0DLQSXULGLVWULFW8WWDU 3UDGHVK,QGLD%XOO:RUOG+HDOWK2UJDQ 1DQGDNXPDU$7KLPPDVHWW\.76UHHUDPDUHGG\10HWDO$SRSXODWLRQEDVHGFDVHFRQWUROLQYHVWLJDWLRQRQ FDQFHUVRIWKHRUDOFDYLW\LQ%DQJDORUH,QGLD%U-&DQFHU -D\DOHNVKPL3$*DQJDGKDUDQ3$NLED6.RUL\DPD&1DLU552UDOFDYLW\FDQFHUULVNLQUHODWLRQWRWREDFFR FKHZLQJDQGELGLVPRNLQJDPRQJPHQLQ.DUXQDJDSSDOO\.HUDOD,QGLD .DUXQDJDSSDOO\FRKRUWVWXG\&DQFHU 6FL 6LQJKDO 6 *XSWD 3& 'LNVKLW 5 -KD 3 ,QFUHDVHG ULVN RI FRURQDU\ KHDUW GLVHDVH LQ IHPDOH VPRNHUV /DQFHW DXWKRUUHSO\ $JUDZDO3&KDQVRUL\D0.DXO..(IIHFWRIWREDFFRFKHZLQJE\PRWKHUVRQSODFHQWDOPRUSKRORJ\,QGLDQ 3HGLDWU ,QWHUQDWLRQDO,QVWLWXWHIRU3RSXODWLRQ6FLHQFHV ,,36 DQG25&0DFUR1DWLRQDO)DPLO\+HDOWK6XUYH\ 1)+6 0XPEDL ,QWHUQDWLRQDO ,QVWLWXWH IRU 3RSXODWLRQ 6FLHQFHV >FLWHG $XJ @ $YDLODEOH IURP KWWS ZZZPHDVXUHGKVFRPSXEVSGI6565SGI 0XPEDUH660DLQGDUNDU*'DUDGH5 160 Smokeless Tobacco and Public Health in India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aGROHVFHQWVRI WKHWULEDOaUHDVLQ0DKDUDVKWUD-&OLQ'LDJQ5HV :LQVRFN $5 $UHFD QXW EHWHO TXLGV DQG aVVRFLDWHG SURGXFWV ,Q 0LOOHU 30 HG 3ULQFLSOHV RI aGGLFWLRQ FRPSUHKHQVLYHaGGLFWLYHEHKDYLRUVDQGdLVRUGHUV 9ROVWHG 1HZ 161 Chapter 8. Women and Smokeless Tobacco: Special Considerations 0DYDODQNDU'97ULYHGL&5*UD\ 5+/HYHOVDQGULVNIDFWRUVIRUSHULQDWDO PRUWDOLW\ LQ $KPHGDEDG,QGLD %XOO:RUOG+HDOWK2UJDQ 5DMDUDP6 =RWWDUHOOL /.6XQLO76$QDVVHVVPHQWRI IHWDOORVVDPRQJFXUUHQWO\ PDUULHG ZRPHQLQ,QGLD- %LRVRF6FL 9HUPD5&&KDQVRUL\D0.DXO..(IIHFWRIWREDFFRFKHZLQJE\PRWKHUVRQIHWDORXWFRPH,QGLDQ3HGLDWU 162 Chapter 9 Smokeless Tobacco and All-Cause Mortality 0DQJHVK63HGQHNDU3*DQJDGKDUDQ2 +HDOLV6HNKVDULD,QVWLWXWHIRU3XEOLF+HDOWK1DYL0XPEDL 2$PULWD,QVWLWXWHRI0HGLFDO6FLHQFHVDQG5HVHDUFK&HQWUH&RFKLQ Smokeless Tobacco and Public Health in India INTRODUCTION 3RSXODWLRQEDVHG HYLGHQFH IRU HOHYDWHG ULVN RI DOOFDXVH PRUWDOLW\ LQ WREDFFR XVHUV KDV EHHQ H[DPLQHGE\ODUJHVFDOHVWXGLHVPDLQO\IURP:HVWHUQFRXQWULHV+RZHYHUPRVWRIWKHVHVWXGLHV RQO\ H[DPLQH PRUWDOLW\ UHODWHG WR WREDFFR VPRNLQJ ,Q ,QGLD ZKHUH WKH QDWLRQDOO\ UHSUHVHQWDWLYH*OREDO$GXOW7REDFFR6XUYH\ *$76 UHSRUWHGWKDW RIDGXOWV \HDUV DQG ROGHU XVH VPRNHOHVV WREDFFR 6/7 LW LV LPSRUWDQW WR NQRZ WKH LPSDFW RI VPRNHOHVVWREDFFRXVHRQPRUWDOLW\7KHHDUOLHVWV\VWHPDWLFVWXGLHVRQWKHKHDOWKHIIHFWVRI6/7 XVHZHUHFRQGXFWHGLQ ,QGLDIURP WKHHDUO\ V WKURXJKWKH V ,QWKLV FKDSWHUZH SUHVHQW D UHYLHZ RI WKH DYDLODEOH HYLGHQFH RQ 6/7 DQG DOOFDXVH PRUWDOLW\ GHULYHG HVSHFLDOO\ IURP,QGLDQVWXGLHV MORTALITY STUDIES Effects of SLT Use 'XULQJ WKH VFRKRUW VWXGLHV RQWREDFFRXVHUVZHUH UHSRUWHGIURPWKUHHGLIIHUHQW SDUWVRI India IQDOOWKHVHDUHDVWRJHWKHUSHRSOHDJHDQGDERYHZHUHLQWHUYLHZHGDQGWKH W\SHRIWREDFFRXVHGZDVUHFRUGHG7KLVVHFWLRQGHVFULEHVWKHUHVXOWVRIWKHVHDQGRWKHUFRKRUW VWXGLHVZKLFKDUHVXPPDULsHGLQ7DEOH ,QWKHILUVWDQGODUJHVWRIWKHVHVWXGLHVFRQGXFWHG EHWZHHQ and DWRWDORI LQGLYLGXDOVDERYHWKHDJHRI\HDUVZHUHLQWHUYLHZHGDERXWWREDFFRXVHDQGH[DPLQHGIRURUDO SUHFDQFHURXV OHVLRQV LQ D KRXVHWRKRXVH VXUYH\ LQ $PEHJDRQ DQG-Xnnar talukas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hapter 9. Smokeless Tobacco and All-Cause Mortality Table 9.1: Results of cohort studies on SLT use and all-cause mortality Male SLT users Female SLT users Study Number of Years of Age Adjustments population Participants follow-up (years) Risk ratio parameter (95% CI or p value) ,QGLD 55 55 $JH .HUDOD 55 GXDOXVHUV (UQDNXODP ,QGLD 55 55 PDLQO\ $JH $QGKUD FKHZHUV 55 GXDO 6ULNDNXODP XVHUV ,QGLD 35– 55 2 – 55 – $JHHGXFDWLRQ 0DKDUDVKWUD 0XPEDL ,QGLD 343 +5 – 8QDGMXVWHG .HUDOD +5 – $JH 7ULYDQGUXP +5 – 0XOWLYDULDWH 34– +5 – 0XOWLYDULDWH – +5 – 0XOWLYDULDWH – +5 – 0XOWLYDULDWH 6ZHGHQ PHQ 35– 55 – — $JHUHJLRQ 35–54 55 – 55– 55 – 6ZHGHQ PHQ 2 +5 – — 0XOWLYDULDWH 86$ &36 PHQ +5 – — 0XOWLYDULDWH 86$ &362 PHQ +5 – — 0XOWLYDULDWH 55 UHODWLYHULVN +5 KD]DUGUDWLR &, FRQILGHQFHLQWHUYDO ,Q D PRUH UHFHQW VWXG\ LQ 0XPEDL WREDFFRDVVRFLDWHG PRUWDOLW\ ZDV UHSRUWHG LQ D FRKRUW RI PHQDQGZRPHQDJH\HDUVDQGDERYHUHFUXLWHGGXULQJWKH\HDUV WR 7his FRKRUWZDVIROORZHGXSIRUDQDYHUDJHRI\HDUVEHWZHHQ and when GHDWKV ZHUHUHFRUGHG2IDWRWDORI SHUVRQ\HDUVREVHUYHGIRUPHQZHUHDPRQJ6/7 XVHUVDPRQJVPRNHUVDQGDPRQJQRQXVHUV)RUZRPHQLQSHUVRQyears RIREVHUYDWLRQ ZHUH DPRQJ6/7XVHUVDPRQJVPRNHUVDQGDPRQJQRQ XVHUV$PRQJWKHZRPHQ6/7XVHUVWKHDGMXVWHGUHODWLYHULVN 55 RIDOOFDXVHPRUWDOLW\ZDV &, – IRU DOO DJHV DQG &, – IRU WKH DJH JURXS – \HDUV IRU PHQ WKHVH 55 ZHUH &, – DQG &, – UHVSHFWLYHO\ 7DEOH 7KHLQWHULPUHVXOWVUHSRUWHGDIWHUDIROORZXSRILQGLYLGXDOV ZHUHTXLWHVLPLODU $GGLWLRQDOO\WKHDJHVSHFLILFPRUWDOLW\UDWHVDPRQJIHPDOH6/7XVHUVZHUH UHSRUWHGWREHKLJKHUWKDQWKRVHDPRQJQRQXVHUVLQDOODJHJURXSV $FRKRUWVWXG\LQLWLDWHGLQ LQDUXUDODUHDRI.HUDODDOVRLQYHVWLJDWHGDOOFDXVHPRUWDOLW\LQ UHODWLRQWR6/7XVH 6RPHDGXOWVDJHG\HDUVDQGROGHUZHUHUHFUXLWHGLQWRWKHVWXG\ DQGZHUHUHJXODUO\IROORZHGXSIRUDPHDQGXUDWLRQRI\HDUV,QWKLVVWXG\EHWHOTXLGZLWK 166 Smokeless Tobacco and Public Health in India WREDFFRZDVWKHPRVWFRPPRQO\XVHGFKHZLQJSUHSDUDWLRQ DQGRQO\RIFKHZHUVXVHG FRPPHUFLDOSUHSDUDWLRQV$OWKRXJKKD]DUGUDWLRV +5 IRUVSHFLILFFDXVHVVXFKDVFDQFHUZHUH VLJQLILFDQWO\KLJKHULQ6/7XVHUV WREDFFRFKHZHUV DSSDUHQWO\WKHUHZDVUHYHUVDORIULVNIRUDOO cause mortality among SLT users (‘chewing with tobacco’) after adjustments. 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(SLGHPLRO *XSWD 3& 0HKWD )6 3LQGERUJ -- 0RUWDOLW\ DPRQJ UHYHUVH FKXWWD VPRNHUV LQ 6RXWK ,QGLD %0- *XSWD3&3HGQHNDU063DUNLQ'06DQNDUDQDUD\DQDQ57REDFFRDVVRFLDWHGPRUWDOLW\LQ0XPEDL %RPED\ India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pOO71\UpQ2&DQFHUDQGPRUWDOLW\ DPRQJXVHUVDQG QRQXVHUVRIVQXV,QW-&DQFHU +HQOH\ 6- 7KXQ 0- &RQQHOO & &DOOH (( 7ZR ODUJH SURVSHFWLYH VWXGLHV RI PRUWDOLW\ DPRQJ PHQ ZKR XVH VQXIIRUFKHZLQJWREDFFR 8QLWHG6WDWHV &DQFHU&DXVHV&RQWURO 170 Smokeless Tobacco and Public Health in India 3HGQHNDU 06 *XSWD 3& +HEHUW -5 +DNDPD 0 -RLQW HIIHFWV RI WREDFFR XVH DQG ERG\ PDVV RQ DOOFDXVH PRUWDOLW\LQ0XPEDL,QGLD UHVXOWVIURPDSRSXODWLRQEDVHGFRKRUWVWXG\$P-(SLGHPLRO 3HGQHNDU066DQVRQH**XSWD3&$VVRFLDWLRQRIDOFRKRODOFRKRODQGWREDFFRZLWKPRUWDOLW\ ILQGLQJVIURP DSURVSHFWLYHFRKRUWVWXG\LQ0XPEDL %RPED\ ,QGLD$OFRKRO 3HGQHNDU 06 *XSWD 5 *XSWD 3& $VVRFLDWLRQ RI EORRG SUHVVXUH DQG FDUGLRYDVFXODU PRUWDOLW\ LQ ,QGLD 0XPEDL&RKRUW 6WXG\$P-+\SHUWHQV 171 Chapter 10 Smokeless Tobacco Use and Cancer 6XUHQGUD6KDVWUL3DQNDM&KDWXUYHGL6RXUDY'DWWD $GLWL6KDVWUL2 7DWD0HPRULDO&HQWUH0XPEDL 2$OEHUW(LQVWHLQ&ROOHJHRI0HGLFLQH%URQ[1<86$ Smokeless Tobacco and Public Health in India INTRODUCTION 7KHFDQFHUEXUGHQLQ,QGLDLVODUJH ZLWK WRPLOOLRQFDQFHUSDWLHQWVDWDQ\JLYHQWLPHDQG DERXWPLOOLRQQHZFDVHVGLDJQRVHG HYHU\\HDU1HDUO\KDOIRIDOOFDQFHUFDVHVLQ,QGLD die HYHU\\HDU $QHVWLPDWHGFDQFHUVLQWKHFRXQWU\DUHWREDFFRUHODWHG $PRQJWKHVHFDQFHUV RI WKH RUDO FDYLW\ DQG SKDU\Q[ DUH LPSRUWDQW SXEOLF KHDOWK SUREOHPV ZLWK QHDUO\ QHZ FDVHV DPRQJPHQDQGDPRQJZRPHQLQ ,QGLDHDFK \HDU7KHPRUWDOLW\UDWHVIRUWKHVH 2 FDQFHUVLQ ,QGLD DUHDOVRKLJKFRPSDUHGWR WKHUHVW RIWKHZRUOG 7DEOH 7KHEXUGHQRI FDQFHUVRQWKHKHDOWKV\VWHPLVVXFKWKDWH[LVWLQJWUHDWPHQWIDFLOLWLHVDQGILQDQFLDODOORFDWLRQVDUH 3 LQDGHTXDWHWRWUHDWWKHFXUUHQWORDd Table 10.1: Incident cancers of lip, oral cavity, and pharynx in India and in high-income and low- and middle-income countries of the world India High-income countries Low- and middle-income countries Cancer site Incidence Mortality Incidence Mortality Incidence Mortality MFMF M FMF M F M F /LSDQGRUDOFDYLW\ 3KDU\Q[ 7RWDO 2 Source: */2%2&$1 )HUOD\HWDO ,Q ,QGLD DERXW PLOOLRQ DGXOWV XVH WREDFFR LQ RQH IRUP RU DQRWKHU 2I WKLV QXPEHU 4 PLOOLRQXVHVPRNHOHVVWREDFFR 6/7 LQYDULRXVIRUPXODWLRQV 7KHPRVWFRPPRQIRUPVRI 4 6/7XVHLQFOXGHNKDLQLEHWHOTXLG SDQ DQGJXWND DVGHVFULEHGHOVHZKHUHLQWKHPRQRJUDSK 7KH,QWHUQDWLRQDO$JHQF\IRU5HVHDUFKRQ&DQFHU ,$5& VWDWHGWKDWWKHUHLVsufficient HYLGHQFH 5 WKDW6/7LVFDUFLQRJHQLFDQGWKDWLWFDXVHVFDQFHUVRIWKHRUDOFDYLW\DQGSDQFUHDV ,QWKH ,$5& DOVR FRQFOXGHG WKDW EHWHO TXLG ZLWK RU ZLWKRXW WREDFFR FDXVHV RUDO SKDU\QJHDO DQG RHVRSKDJHDOFDQFHUV 9ROXPLQRXVGDWDGHPRQVWUDWHVWKHFDUFLQRJHQLF DQGRWKHUWR[LFHIIHFWVRI 5 6/7 VHHFKDSWHU ,QWKLVFKDSWHUZHSUHVHQWWKHUHFHQWHSLGHPLRORJLFDOHYLGHQFHSULPDULO\ IURP,QGLDQVRXUFHVOLQNLQJ6/7XVHZLWKDOOFDQFHUVDQGZLWK FDQFHUVLQVSHFLILF VLWHV ASSOCIATION WITH CANCER All Cancers ,QIRUPDWLRQ RQ WKH UHODWLRQVKLS EHWZHHQ VPRNHOHVV WREDFFR XVH DQG DOO FDQFHUV FRPELQHG LV DYDLODEOHIURPWZRFRKRUWVWXGLHV,QDFRKRUWVWXG\RI LQGLYLGXDOVLQ0XPEDL,QGLDZLWK IROORZXSDIWHUDQDYHUDJHRI\HDUVIURPWKHEDVHOLQHKRXVHWRKRXVHVXUYH\WKHDJH DQGHGXFDWLRQDGMXVWHGUHODWLYHULVN 55 IRUPRUWDOLW\IURPDOOFDQFHUV QHRSODVPV IRUZRPHQ 6/7 XVHUV ZDV > FRQILGHQFH LQWHUYDO &, –@ )RU PHQ 6/7 XVHUV WKH FRUUHVSRQGLQJ55ZDV &, – 7KH55V ZHUHVWUDWLILHGDQGFRPSXWHGRQO\ DPRQJ QRQVPRNHUV—WKDW LV QR SDUWLFLSDQW ZKR XVHG ERWK 6/7 DQG VPRNHG ZDV LQFOXGHG DPRQJWKH6/7XVHUV 7DEOH 175 Chapter 10. Smokeless Tobacco Use and Cancer Table 10.2: Number of deaths and relative risks* by cause of death and tobacco use Cause of death (ICD-10 code) Never used tobacco Used smokeless tobacco Men 1HRSODVPV>&–& @ 'HDWKV 55 &, – 2UDODQGSKDU\Q[QHRSODVPV >&–&@ 'HDWKV 55 &, – 5HVSLUDWRU\QHRSODVPV>&– & @ 'HDWKV 55 &, – Women 1HRSODVPV>&–& @ 'HDWKV 55 &, – 2UDODQGSKDU\QJHDOQHRSODVPV >&–&@ 'HDWKV 55 &, – $JH DQGHGXFDWLRQDGMXVWHGUHODWLYHULVN 55 E\XVLQJ&R[PRGHO Source: *XSWDHWDO5 ,Q DQRWKHU FRKRUW RI PHQ LQ 0XPEDL ZLWK SHUVRQ\HDUV RI REVHUYDWLRQ WKH LQFLGHQFH RI DOO W\SHV RI FDQFHUV ZDV FDOFXODWHG E\ PDWFKLQJ WKH FRKRUW PHPEHUV ZLWK WKH GDWDEDVHRIWKH3RSXODWLRQ%DVHG&DQFHU5HJLVWU\0XPEDL7KHDGMXVWHGKD]DUGUDWLR +5 IRU DVVRFLDWLRQRI6/7XVHZLWKWKHLQFLGHQFHRIDOOFDQFHUVDPRQJQRQVPRNHUVZDV &, – DGMXVWHG IRU DJH HGXFDWLRQ UHOLJLRQ PRWKHU WRQJXH DQG ERG\ PDVV LQGH[ VHH 7DEOH 176 Smokeless Tobacco and Public Health in India Table 10.3: Adjusted* site-specific HRs and 95% CIs by SLT use, based on incidence cancers in the Mumbai Cohort Study, 1991–2003 Cancer site Non-users SLT users 1HRSODVPV & n +5 &, – /LSRUDOFDYLW\DQGSKDU\Q[ &– n 44 +5 &, 'LJHVWLYHRUJDQV &– n +5 &, 2HVRSKDJXV & n +5 &, 6WRPDFK & n +5 &, /LYHUand LQWUDKHSDWLFELOHGXFWV & n +5 &, 3DQFUHDV & n 5 +5 &, 5HVSLUDWRU\DQGLQWUDWKRUDFLFRUJDQV &– n +5 &, /DU\Q[ & n +5 &, %URQFKXVand lXQJ & n 34 +5 &, 0DOHJHQLWDORUJDQ &– n 33 +5 &, +D]DUGUDWLRV +5V ZHUHDGMXVWHGIRUDJHHGXFDWLRQUHOLJLRQPRWKHUWRQJXHDQGERG\ PDVVLQGH[ %0, Source: 3HGQHNDUHWDO 177 Chapter 10. 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Cardiovascular Diseases and Other Health Consequences of Smokeless Tobacco Use &, – DQGWKH25IRUGHYHORSLQJQXFOHDUFDWDUDFWZDVHYHQKLJKHUDW &, – 7KH SUHYDOHQFH FDWDUDFW ZDV PDUNHGO\ KLJKHU DPRQJ 6/7 XVHUV FRPSDUHG WR VPRNHUV DQGQRQWREDFFRXVHUV Infertility in Men /LIHVW\OHKDELWVVXFKDVWREDFFRVPRNLQJKDYHEHHQUHSRUWHGWRLQIOXHQFHIHUWLOLW\E\LPSDFWLQJ VSHUPFRQFHQWUDWLRQIXQFWLRQDQGTXDOLW\ 7KHLPSDFWRIVPRNHOHVVWREDFFRXVH RQIHUWLOLW\LV OHVVFOHDU,QDFOLQLFEDVHGFURVVVHFWLRQDOVWXG\RILQIHUWLOHPHQLQ0XPEDL6/7XVHZDV DVVRFLDWHGZLWKDGHFUHDVHLQVSHUPFRXQWPRWLOLW\PRUSKRORJ\DQGYLDELOLW\ RESEARCH GAPS 'HVSLWHWKHIDFWWKDW,QGLDLVKRPHWRPRUHWKDn 80% of the world’s SLT users, limited research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needed RQFHVVDWLRQVWUDWHJLHVWKDWFDQKHOS6/7XVHUVTXLWDVZHOODV SROLF\ UHVHDUFK RQ DGYDQFLQJ WREDFFR FRQWURO VWUDWHJLHV WR UHGXFH 6/7 XVH 6XFK GDWD FDQ FRQWULEXWH WR HYLGHQFHLQIRUPHG DGYRFDF\ DQG WREDFFR FRQWURO HIIRUWV WR FRPEDW 6/7 XVH LQ ,QGLD CONCLUSIONS 6/7XVHZDVSUHYLRXVO\WKRXJKWWREHIUHHRIVLJQLILFDQWDGYHUVHHIIHFWVDQGZDVDGYRFDWHGDVD KDUPUHGXFWLRQVWUDWHJ\LQFLJDUHWWHVPRNHUV&XUUHQWHYLGHQFHUHIXWHVWKLVDVVXPSWLRQKRZHYHU DQGVXJJHVWVWKDW6/7XVHLVDVVRFLDWHGZLWKFDUGLRYDVFXODUGLVHDVH0RVWVWXGLHVVXJJHVWWKDW FDUGLRYDVFXODUULVNLVORZHUDPRQJ6/7XVHUVWKDQDPRQJVPRNHUVEXWKLJKHUWKDQDPRQJQRQ XVHUV RI WREDFFR 6WXGLHV IURP WKH ,QGLDQ VXEFRQWLQHQW UHODWHG WR VPRNHOHVV WREDFFR DQG LWV HIIHFWVRQWKHFDUGLRYDVFXODUDQGother systems are limited. 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Cardiovascular Diseases and Other Health Consequences of Smokeless Tobacco Use 1HOVRQ%6+HLVFKREHU%%HWHOQXW DFRPPRQGUXJXVHGE\QDWXUDOL]HGFLWL]HQVIURP,QGLD)DU(DVW$VLDDQd WKH6RXWK3DFLILF,VODQGV$QQ(PHUJ0HG 7D\ORU 5) DO-DUDG 1 -RKQ /0 &RQUR\ '0 %DUQHV 1& %HWHOQXW FKHZLQJ DQG DVWKPD /DQFHW $\R 202 Chapter 12 Oral Health Consequences of Smokeless Tobacco Use 9LMD\0DWKXU7DQXSUL\D*XSWD20DQX5DM0DWKXU3 3DOXUL5DPD0XUWL4 $OO,QGLD,QVWLWXWHRI0HGLFDO6FLHQFHV1HZ'HOKL 2-DPLD0LOOLD'HQWDO&ROOHJH1HZ'HOKL 33XEOLF+HDOWK)RXQGDWLRQRI,QGLD1HZ'HOKL 4)RUPHUO\ZLWKWKH%DVLF'HQWDO5HVHDUFK8QLWDQG:+2&ROODERUDWLQJ&HQWUHIRU2UDO&DQFHU3UHYHQWLRQ7DWD ,QVWLWXWHRI)XQGDPHQWDO5HVHDUFK0XPEDLDQG 5HWLUHG 3URIHVVRURI2UDO3DWKRORJ\ )RUPHU'LUHFWRU6FKRRORI 'HQWLVWU\)DFXOW\RI0HGLFDO6FLHQFHV7KH8QLYHUVLW\RIWKH:HVW,QGLHV6W$XJXVWLQH7ULQLGDGDQG7REDJR:HVW Indies Smokeless Tobacco and Public Health in India INTRODUCTION $VRIPLOOLRQSHRSOHLQ,QGLDXVHDJUHDWYDULHW\RIVPRNHOHVVWREDFFR 6/7 SURGXFWV VHH $SSHQGL[ RI ZKLFK NKDLQL JXWND DQG EHWHO TXLG ZLWK WREDFFR SDQ DUH WKH PRVW IUHTXHQWO\XVHG 7KXV6/7XVHUVUHSUHVHQWDYDVWSRROVXVFHSWLEOHWRDGYHUVHRUDODQGJHQHUDO KHDOWKFRQVHTXHQFHV6/7LVRIWHQXVHGLQFRPELQDWLRQZLWKRWKHULQJUHGLHQWVLQFOXGLQJDUHFD QXW Areca catechu ZKLFKDOVRKDVLPSRUWDQWFRQVHTXHQFHVIRURUDOKHDOWK%RWK6/7DQGDUHFD QXW GHOLYHU PDQ\ GHOHWHULRXV FDUFLQRJHQLF DQG WR[LF SURGXFWV VHH FKDSWHU FROOHFWLYHO\ HQGDQJHULQJ RUDO KHDOWK 7KLV FKDSWHU GLVFXVVHV WKH KHDOWK FRQVHTXHQFHV RI WKH ZKROH 6/7 SURGXFWUDWKHUWKDQLWVWREDFFRFRQWHQWDORQH 7KHPRVWVHULRXVRUDOKHDOWKLPSOLFDWLRQRI6/7XVHLVRUDOFDQFHUZKLFKLVGLVFXVVHGDORQJZLWK RWKHUFDQFHUVLQFKDSWHU7KLVFKDSWHUJLYHVDQRYHUYLHZRIRWKHUVHULRXVRXWFRPHVVXFKDV SUHFDQFHURXV OHVLRQV DQG FRQGLWLRQV FXUUHQWO\ FDOOHG SRWHQWLDOO\ PDOLJQDQW GLVRUGHUV E\ WKH 2 :RUOG +HDOWK 2UJDQL]DWLRQ :+2 :RUNLQJ *URXS ZKLFK LQFOXGH RWKHU PXFRVDO 3 OHVLRQVWKDWDUHOHVVOLNHO\WREHFRPHFDQFHUV DQGWKHLPSDFWRI6/7XVHRQSHULRGRQWDOKHDOWK DQGRWKHUGHQWDOHIIHFWV ORAL PRECANCEROUS LESIONS AND CONDITIONS (POTENTIALLY MALIGNANT DISORDERS) 9DULRXV WHUPV DUH XVHG LQ WKH OLWHUDWXUH WR GHQRWH WKLV FDWHJRU\ 7KH WHUP precancer UHIHUV WR DSSDUHQWO\ EHQLJQ PXFRVDO DOWHUDWLRQV WKDW FDQ LQ WKH ORQJ UXQ XQGHUJR PDOLJQDQW 2 WUDQVIRUPDWLRQ 3ULPDU\SUHYHQWLRQRIRUDOFDQFHUFRQVLVWVRIUHFRJQLVLQJDQGPDQDJLQJWKHVH SRWHQWLDO PDOLJQDQFLHV ZKLFK KLJKOLJKW WKH QHHG IRU FXUELQJ 6/7 XVH ([WHQVLYH SLRQHHULQJ 4 ORQJWHUPVWXGLHVRQWKHVHOHVLRQVLQ,QGLD KDYHSURGXFHGYDOXDEOHLQIRUPDWLRQRQWKHQDWXUDO KLVWRU\RISUHFDQFHU 5 ,Q WKH:+2:RUNLQJ*URXSGLVWLQJXLVKHGEHWZHHQSUHFDQFHURXVOHVLRQVDQGFRQGLWLRQV 7KH:RUNLQJ*URXSGHILQHGDprecancerous lesionDVDPRUSKRORJLFDOO\DOWHUHGWLVVXHLQZKLFK FDQFHU LV PRUH OLNHO\ WR RFFXU WKDQ LQ LWV DSSDUHQWO\ QRUPDO FRXQWHUSDUW ([DPSOHV LQFOXGHG OHXNRSODNLDHU\WKURSODNLDDQGSDODWDONHUDWRVLVLQUHYHUVHVPRNHUV$ precancerous condition ZDV GHILQHG DV D JHQHUDOLVHG VWDWH DVVRFLDWHG ZLWK D VLJQLILFDQWO\ LQFUHDVHG ULVN IRU FDQFHU 3UHFDQFHURXV FRQGLWLRQV LQFOXGHG VXEPXFRXV ILEURVLV DFWLQLF NHUDWRVLV OLFKHQ SODQXV DQG GLVFRLG OXSXV HU\WKHPDWRVXV 7KH FRQVHQVXV YLHZ RI DQRWKHU :+2 :RUNLQJ *URXS LQ was ‘to refer to all clinical presentations that carry a risk of cancer under the term “poWHQWLDOO\ 2 malignant disorders” /HXNRSODNLD HU\WKURSODNLD SDODWDO OHVLRQV LQ UHYHUVH VPRNHUV RUDO VXEPXFRXV ILEURVLV OLFKHQ SODQXV GLVFRLG OXSXV HU\WKHPDWRVXV DQG D IHZ RWKHU KHUHGLWDU\ GLVRUGHUVZHUHIURP WKHQRQZDUGVFRQVLGHUHGSRWHQWLDOO\PDOLJQDQW GLVRUGHUV7KHVHGLVRUGHUV DQGWKHLUUHODWLRQWR6/7XVHDUHGHVFULEHGLQWKHVHFWLRQVEHORZ Leukoplakia Definition Leukoplakia was defined by the WHO (1978) as ‘a white patch or plaque that cannot be 5 characterised clinically or pathologically as any other disease’ ,QWHUQDWLRQDO:RUNLQJ*URXSV KDYHDPHQGHGWKLVGHILQLWLRQVHYHUDOWLPHVVLQFH,QWKH:+2:RUNLQJ*URXSUHGHILQHG leukoplakia as ‘white plaques of questionable risk, having excluded (other) known diseases or 2 disorders that carry no increased risk for cancer’ /HXNRSODNLDLVDFOLQLFDOWHUPDQGFDUULHVQR 205 Chapter 12. Oral Health consequences of Smokeless Tobacco Use KLVWRORJLFFRQQRWDWLRQ7KHPRVWLPSRUWDQWPLFURVFRSLFIHDWXUHRISURJQRVWLFYDOXHKRZHYHULV WKHSUHVHQFHRIHSLWKHOLDOG\VSODVLD Epidemiology of SLT Use and Leukoplakia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linical Aspects /HXNRSODNLDLVGLDJQRVHGXQGHUWZRFDWHJRULHVKRPRJHQHRXVDQGQRQKRPRJHQHRXVGHSHQGLQJ 2 upon the patient’s clinical appearance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igure 12.1: Homogenous leukoplakia (A) and nodular leukoplakia (B) in the buccal mucosa $ % 3KRWRJUDSKFRXUWHV\RI'U9LMD\0DWKXU 206 Smokeless Tobacco and Public Health in India /HXNRSODNLDVJHQHUDOO\DUHFRUUHODWHGZLWKDSDUWLFXODURUDOVLWHDQGW\SHRIXVH)RUH[DPSOH OHXNRSODNLDDPRQJEHWHOTXLGFKHZHUVRFFXUVPRUHRIWHQRQWKHEXFFDOPXFRVDZKHUHWKHEHWHO TXLGLVSODFHGZKHUHDVOHXNRSODNLDDVVRFLDWHGZLWKNKDLQLXVHRFFXUVPRUHLQWKHDQWHULRUUHJLRQ 3 ZKHUHWKHNKDLQLLVKDELWXDOO\KHOG Natural History ,QD\HDUIROORZXSVWXG\DPRQJ,QGLDQYLOODJHUVRIWKH FDVHVIRXQGDPRQJEHWHOTXLG FKHZHUVSURJUHVVHGWRFDQFHULQFRQWUDVWWRRIWKHOHXNRSODNLDFDVHVREVHUYHGDPRQJGXDO XVHUV /HXNRSODNLD OHVLRQV DVVRFLDWHG ZLWK EHWHO TXLG XVH ZHUH OHVV SHUVLVWHQW DQG UHJUHVVHG VSRQWDQHRXVO\ PRUH RIWHQ +RPRJHQHRXV OHXNRSODNLD VKRZHG PDOLJQDQW WUDQVIRUPDWLRQLQDQGQRGXODUOHXNRSODNLDLQRIFDVHV )LJXUH Figure 12.2: (A) Nodular leukoplakia in the buccal mucosa at the site of placement of betel quid; and (B) showing cancer development after two years $ % 3KRWRJUDSKFRXUWHV\RI'U9LMD\0DWKXU 7KH UHODWLYH ULVN 55 IRU PDOLJQDQW WUDQVIRUPDWLRQ RI KRPRJHQHRXV OHXNRSODNLD ZDV ZKHUHDVWKH55IRUPDOLJQDQWWUDQVIRUPDWLRQRIQRGXODUOHXNRSODNLDZDVZKHQFRPSDUHG ZLWKSHRSOHZKRSUDFWLFHGVRPHNLQGRIWREDFFRXVHEXWGLGQRWKDYHDQ\OHVLRQV 7DEOH 207 Chapter 12. Oral Health consequences of Smokeless Tobacco Use Table 12.1: Relative risk for malignancy associated with various precancerous lesions and conditions $YHUDJH 1R RI 7UDQVIRUPDWLRQ SHU 3UHFDQFHUOHVLRQFRQGLWLRQ 7RWDOQR IROORZXS RUDO 5HODWLYHULVN SHU\HDU SHULRG \HDUV FDQFHUV 1RGXODUOHXNRSODNLD 6XEPXFRXVILEURVLV 25 3 2WKHUV 8OFHUDWHGOHXNRSODNLD +RPRJHQHRXVOHXNRSODNLD 3 /LFKHQSODQXV 344 1RQHRIWKHDERYH 4 1RQVSHFLILFGLDJQRVHVVXFKDVXOFHUVEHQLJQJURZWKVUHGDUHDV Source:*XSWDHWDO Management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rythroplakia Definition Erythroplakia was defined as ‘a fiery red patch that cannot be characterised clinically or 5 pathologically as any other definable condition’ Epidemiology 4 $ VWXG\LQ,QGLDGHVFULEHGHU\WKURSODNLDDVDUDUHOHVLRQ $QRUDOFDQFHUVFUHHQLQJWULDOLQ ,QGLDFRQGXFWHG LQWKH\HDUUHSRUWHGHU\WKURSODNLDFDVHVDPRQJSHRSOH$ERXW RIWKHHU\WKURSODNLDFDVHVRFFXUUHGLQWKHWR\HDUROGDJHJURXS7KHDGMXVWHGRGGV UDWLR 25 IRUHU\WKURSODNLDZDV &, – IRULQGLYLGXDOVZKRKDGHYHUFKHZHGWREDFFR DIWHUFRQWUROOLQJIRUDJHVH[HGXFDWLRQERG\PDVVLQGH[VPRNLQJDQGGULQNLQJ7KHUHZDVD VWURQJ GRVH–UHVSRQVH UHODWLRQVKLS LQFOXGLQJ KLJK ULVN IRU FKHZHUV ZKR VZDOORZHG WKH MXLFH FRPSDUHGWRWKRVHZKRGLGQRW&KHZHUVZKRNHSWWKHTXLGLQWKHPRXWKRYHUQLJKWDOVRVKRZHG KLJKHUULVNFRPSDUHGWRWKRVHZKRGLGQRWUHWDLQWKHFKHZLQJTXLGRYHUQLJKW Precancerous Nature (U\WKURSODNLDFDUULHVKLJKPDOLJQDQWSRWHQWLDO0LFURVFRSLFDOO\ RIHU\WKURSODNLDOHVLRQVLQ FDVHVHULHVIURPWKH8QLWHG6WDWHVVKRZHGHLWKHUVTXDPRXVFHOOFDUFLQRPDRUPRGHUDWHWRVHYHUH 4 HSLWKHOLDOG\VSODVLD,QDQ,QGLDQVHULHVRIQLQHFDVHVIRXUVKRZHGHSLWKHOLDOG\VSODVLD 208 Smokeless Tobacco and Public Health in India Management $ELRSV\LVPDQGDWRU\LQDOOFDVHVRIHU\WKURSODNLD'HSHQGLQJRQWKHPLFURVFRSLFIHDWXUHVWKH SUHIHUUHG PDQDJHPHQW RSWLRQ ZRXOG EH VXUJHU\ DQG UHJXODU IROORZXS ZLWK KDELW FHVVDWLRQ (U\WKRSODNLDVKRXOGEHWUHDWHGVRRQDIWHUGLDJQRVLV Oral Submucous Fibrosis Definition 2UDO VXEPXFRXV ILEURVLV 26) LV D FKURQLF GLVRUGHU FKDUDFWHULVHG E\ ILEURVLV RI WKH OLQLQJ PXFRVD RI WKH XSSHU GLJHVWLYH WUDFW LQYROYLQJ WKH RUDO FDYLW\ RURSKDU\Q[ DQG IUHTXHQWO\ WKH 2 XSSHU WKLUG RI WKH RHVRSKDJXV 7KH RUDO PXFRVD EHFRPHV VWLII GXH WR ILEURVLV RI WKH lamina propriaUHVXOWLQJLQDOLPLWHGRUDORSHQLQJ )LJXUH 7KLVFRQGLWLRQLVDKLJKULVNSRWHQWLDOO\ PDOLJQDQWGLVRUGHU Figure 12.3: (A) Limited oral opening and (B) fibrous bands (arrow) in the buccal mucosa in oral submucous fibrosis $ % 3KRWRJUDSKFRXUWHV\RI'U9LMD\0DWKXU Epidemiology 26)LVDVVRFLDWHGZLWKXVHRISURGXFWVWKDWFRQWDLQDUHFDQXWVXFKDVEHWHOTXLG SDQ JXWND PDZD DQG SDQ PDVDOD 3UHYDOHQFH DQG LQFLGHQFH RI 26) KDYH EHHQ VKRZQ WR EH KLJKHU LQ 6RXWK ,QGLD VSHFLILFDOO\ LQ WKH (UQDNXODP GLVWULFW RI .HUDOD FRPSDUHG WR RWKHU DUHDV RI WKH FRXQWU\$ VWXG\LQ(UQDNXODPUHSRUWHGWKDWWKHSUHYDOHQFHRI26)ZDVSHU SHUVRQ\HDUV7KHDQQXDODJHDGMXVWHGLQFLGHQFHUDWHZDVSHUSHUVRQ\HDUVDPRQJ PHQDQGSHUSHUVRQ\HDUVDPRQJZRPHQ$OOQHZFDVHVZHUHREVHUYHGDPRQJEHWHO TXLGFKHZHUV SHUSHUVRQ\HDUVLQPHQDQG SHULQZRPHQ Trends 26)KDVDVVXPHGHSLGHPLFSURSRUWLRQVFRUUHVSRQGLQJZLWKWKHLQFUHDVHLQXVHRIYDULRXVDUHFD QXWSUHSDUDWLRQVVXFKDVJXWNDPDZDDQGSDQPDVDOD $KRVSLWDOEDVHGVWXG\RI26) FDVHVIRXQGWKDWWKHSUHYDOHQFHRI26)DPRQJRXWSDWLHQWVZDVSHULQWKH\HDU DQGSHULQ 209 Chapter 12. Oral Health consequences of Smokeless Tobacco Use Aetiology $OWKRXJK YDULRXV IDFWRUV KDYH EHHQ SRVWXODWHG DV SRVVLEOH FDXVDO IDFWRUV RYHUZKHOPLQJ HSLGHPLRORJLFDQGH[SHULPHQWDOHYLGHQFHLPSOLFDWHVDUHFDQXWXVHLQGHSHQGHQWO\RUZLWK6/7 LQ FDXVLQJ 26) 7KLV HYLGHQFH LV GHULYHG IURP FDVH VHULHV FURVVVHFWLRQDO FRKRUW DQG HYHQ LQWHUYHQWLRQ VWXGLHV VHH FKDSWHU 7DEOHV DQG GHPRQVWUDWH HYLGHQFH RI WKLV 22 UHODWLRQVKLSDQGRIDGRVH–UHVSRQVHHIIHFW Table 12.2: Association of submucous fibrosis with areca nut chewing Cases Controls Relative Product use No. % No. % risk 1RSURGXFWXVH $UHFDQXW QRWPDZD 5 $UHFDQXW QRWLQFOXGLQJWREDFFR 4 2 3 0DZD 0DZDDQGRWKHUSURGXFWV 2YHUDOO Source:*XSWDHWDO S Table 12.3: Relationship between duration of chewing (in years), frequency of chewing (per day), and occurrence of submucous fibrosis Chewing Cases Controls Relative frequency No. % No. % risk 'XUDWLRQ LQ\HDUV –5 17 29% 10 47% 1.0 – 16 27% 5 24% 1.9 26 44% 6 29% 2.5 )UHTXHQF\ SHUGD\ –5 16 27% 10 47% 1.0 – 37 63% 10 48% 2.3 610%15%3.8 7RWDO 59 100% 21 100% Source:*XSWDHWDO $VWXG\IRXQGWKDW RI26)FDVHVZHUHSDQPDVDODDQGJXWNDXVHUV . 3DQPDVDOD XVHUVGHYHORSHG26)ZLWKLQRQH\HDURIVWDUWLQJXVH LQFRQWUDVWEHWHOTXLGFKHZHUVWRRNWZLFH DVORQJWRGHYHORS26),Qa FDVHFRQWUROVWXG\RI26)FDVHVLQ WKHUHODWLYHULVNRI 23 GHYHORSLQJ26)LQJXWNDXVHUVZDVZLWKDVWURQJGRVH–UHVSRQVHUHODWLRQVKLS Clinical Aspects 26) LV D GHELOLWDWLQJ GLVHDVH FDXVLQJ VWLIIHQLQJ RI WKH PXFRVD ZKLFK OHDGV WR SURJUHVVLYH GLIILFXOW\LQ RSHQLQJWKHPRXWK ,QHDUOLHUHSLGHPLRORJLFVWXGLHV DQG WKLV GLVHDVH 210 Smokeless Tobacco and Public Health in India ZDVPRUHRIWHQVHHQLQPLGGOHDJHGDGXOWVDQGZRPHQ&XUUHQWO\26)LVRFFXUULQJPRUH RIWHQLQ\RXQJHUSHRSOH ,QDUHSRUWRISDUWLFLSDQWVLQ26)FDVHVSUHGRPLQDQWO\ RFFXUUHGDPRQJ\RXQJHUDJHJURXSV DWDJHV– DQGDPRQJPHQ ,QD 23 VWXG\RIUHVSRQGHQWVRFFXUUHGLQDJHV–DQGLQDJHV25–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atural History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anagement 26) LV GLIILFXOW WR PDQDJH $OWKRXJK VHYHUDO WUHDWPHQW PRGDOLWLHV KDYH EHHQ VXJJHVWHG LQFOXGLQJVXUJLFDORSWLRQVWKHUHGRHVQRWVHHPWREHDQ\FRQVHQVXVWUHDWPHQWWKDWKHOSVUHVWRUH WKH QRUPDO WH[WXUH RI WKH RUDO PXFRVD DQG UHGXFH WKH ULVN IRU FDQFHU GHYHORSPHQW 'LVFRQWLQXDWLRQRI6/7SURGXFWVPD\SUHYHQWIXUWKHUSURJUHVVLRQLQVHYHULW\DQGORZHUWKHULVN IRUPDOLJQDQWSRWHQWLDODQGOLPLWLQJXVHRI6/7ZLWKDUHFDQXWUHVXOWVLQDORZHULQFLGHQFHRI 26) Oral Lichen Planus Definition /LFKHQSODQXVLVSULPDULO\DGHUPDWRORJLFGLVRUGHULQZKLFKYDULRXVPXFRVDOVXUIDFHVPD\EH LQYROYHGLQGHSHQGHQWO\FRQFXUUHQWO\ZLWKFXWDQHRXV VNLQ LQYROYHPHQWRURQHDIWHUWKHRWKHU 7KHRUDOPXFRVDKRZHYHULVPRUHIUHTXHQWO\DIIHFWHGWKDQRWKHUPXFRVDOVLWHV7KHFDXVHRI OLFKHQSODQXVLVSUREDEO\UHODWHGWRLPPXQHV\VWHPIXQFWLRQLQJ,QWHUHVWLQJO\WREDFFRXVHVHHPV WRSOD\DUROHLQLWVQDWXUDOKLVWRU\7KHPDOLJQDQWSRWHQWLDORIWKLVFRQGLWLRQLVXQFOHDU 211 Chapter 12. Oral Health consequences of Smokeless Tobacco Use Epidemiology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linical Aspects 2UDOOLFKHQSODQXVLVJHQHUDOO\GLDJQRVHGRQWKHEDVLVRIWKHSUHVHQFHRIDSDOHUHWLFXODURUODFH OLNHSDWWHUQRIstriaeRQWKHRUDOPXFRVDRUWRQJXH6HYHUDOFOLQLFDOIRUPVRIWKLVGLVRUGHUDUH UHFRJQLVHG WKHHURVLYHRUXOFHUDWLYHW\SHZKLFKFRQVWLWXWHVRIWKHRUDOOHVLRQVVHHPVWR KDYH PRUH PDOLJQDQW SRWHQWLDO ,Q D FRKRUW VWXG\ LQ ,QGLD RUDO OLFKHQ SODQXV RFFXUUHG SUHGRPLQDQWO\DPRQJZRPHQ DQGWKHEXFFDOPXFRVDZDVWKHPRVWIDYRXUHGORFDWLRQ Natural History $ ORQJWHUP IROORZXS PHDQ \HDUV RI RUDO OLFKHQ SODQXV FDVHV VKRZHG FDQFHU GHYHORSPHQWLQRQO\WKUHHSDWLHQWV ZKRKDGHURVLYHOHVLRQV RIWKHVHWKUHHWZRZHUHEHWHO TXLGFKHZHUV,QDQRWKHU\HDUIROORZXSVWXG\RILQGLYLGXDOVZLWKRUDOOLFKHQSODQXVWKH 55IRUPDOLJQDQWWUDQVIRUPDWLRQZDV 7DEOH ZKLFKZDVQRW VLJQLILFDQW S! 2UDOOLFKHQSODQXVRIWHQUHJUHVVHGDQGVRPHWLPHVUHFXUUHG WKHUHJUHVVLRQUDWHVZHUHKLJKHVWLQ QRQXVHUVRIWREDFFRDQGORZHVWLQSHRSOHZKRXVHGERWKFKHZLQJDQGVPRNLQJSURGXFWV OTHER MUCOSAL EFFECTS Betel Chewer’s Mucosa Definition Betel chewer’s mucosa (BCM) or (pan chewer’s encrustation) is a benign condition characterised E\DWKLFNEURZQLVKEODFNFRORXUHGHQFUXVWDWLRQRQWKHEXFFDOPXFRVDDQGPDQGLEXODUJURRYH ZKLFKDUHWKHXVXDOVLWHVZKHUHWKHTXLGLVSODFHG7KLVHQFUXVWDWLRQFDQHDVLO\EHVFUDSHGRII ZLWKJDX]HDQGGLVDSSHDUVZKHQEHWHOTXLGFKHZLQJLVGLVFRQWLQXHG Epidemiology 7KHDQQXDODJHadjusted incidence of betel chewers’ mucosa was 28.0 per 1PDOHEHWHOTXLG FKHZHUVDQGSHUDPRQJZRPHQEHWHOTXLGFKHZHUVDFFRUGLQJWRWKH VWXG\E\ *XSWDDQGFROOHDJXHV%&0ZDVDOVRREVHUYHGLQRI SDWLHQWVH[DPLQHGLQDGHQWDO 32 KRVSLWDOVHWXSLQ0DQLSDO.DUQDWDND Natural History %&0GRHVQRWVHHPWRFDUU\DQ\PDOLJQDQWSRWHQWLDO2IWKHOHVLRQVIROORZHGXSRYHUD \HDU SHULRG E\ *XSWD DQG FROOHDJXHV QRQH SURJUHVVHG WR FDQFHU ZHUH SHUVLVWHQW UHJUHVVHGDQG UHFXUUHG 212 Smokeless Tobacco and Public Health in India Tobacco–Lime User’s Lesion Definition $WKLFN\HOORZLVKZKLWHOHVLRQRFFDVLRQDOO\ZLWKORRVHWDJVRIWLVVXHRFFXUVZKHUHWREDFFR– OLPH HJ NKDLQL LV KHOG LQ WKH PRXWK $ VWXG\ E\ %KRQVOH DQG FROOHDJXHV IRXQG WKDW SUHYDOHQFHRIWKLVOHVLRQDPRQJYLOODJHUVLQ0DKDUDVKWUDZDV PRUHRIWHQDPRQJ 33 PHQ $V LW LV VLPLODU LQ DSSHDUDQFH WR OHXNRSODNLD WREDFFR–lime user’s lesion may be PLVGLDJQRVHG8QOLNHOHXNRSODNLDWKLVOHVLRQFDQEHVFUDSHGRIIDQGLWZLOOGLVDSSHDULIXVHRI WREDFFRSOXVOLPH LV GLVFRQWLQXHG +LVWRORJLFDO FKDUDFWHULVWLFV LQFOXGH SDOH SDUDNHUDWLQOLNH VXUIDFHOD\HUVRIHSLWKHOLXPFRQWDLQLQJURXQGQXFOHDUUHPQDQWVEDOORRQLQJYDFXRODWHGFHOOVDQG HSLWKHOLDOK\SHUSODVLD 7REDFFR–lime user’s lesion as a specific entity appears to be a counterpart RIWKHEHWHO chewer’s mucosa described above; it does not show any malignant potential. Mucosal Staining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able 12.4: Studies of the effect of SLT use on periodontal health Type of study Author, year Study population Findings &URVVVHFWLRQDO 6LQJK HW DO Q 7KH LPSDFW RI 6/7 XVH ZDV VLJQLILFDQWO\ 33 Q WREDFFRXVHUV KLJKHU RQ DOO WKH SHULRGRQWDO KHDOWK LQGLFDWRUV VXFK DV SODTXH LQGH[ JLQJLYDO Q VPRNHUV LQGH[ FDOFXOXV FOLQLFDO DWWDFKPHQW ORVV Q VPRNHOHVVWREDFFRXVHUV JLQJLYDO UHFHVVLRQ PRELOLW\ IXUFDWLRQ Q XVLQJ ERWK VPRNHOHVV OHVLRQDQGSRFNHWGHSWK%RWKGXUDWLRQDQG WREDFFR DV ZHOO DV WREDFFR LQ IUHTXHQF\RI6/7XVHVLJQLILFDQWO\DIIHFWHG VPRNLQJIRUP SHULRGRQWDOKHDOWK &URVVVHFWLRQDO 1DJDUDMDSSD and 6/7 FKHZHUV DQG QRQ &KHZHUV H[SHULHQFHG D VOLJKWO\ KLJKHU 34 3UDVDG FKHZHUV DJH–\HDUV LQFLGHQFH RI SHULRGRQWDO GLVHDVH WKDQ QRQ FKHZHUV EXW WKH GLIIHUHQFH ZDV QRW VLJQLILFDQW &DVH FRQWURO 3DUPDU HW DO VXEMHFWV FKHZHUV DQG $ VLJQLILFDQWO\ KLJKHU QXPEHU RI TXLG 35 QRQFKHZHUV ZLWK D PHDQ FKHZHUV VXIIHUHG EOHHGLQJ IURP WKH JXPV DJHRIDQG 2UDO K\JLHQH VWDWXV RI TXLG Fhewers was \HDUVUHVSHFWLYHO\ VLJQLILFDQWO\GHWHULRUDWHG7KHHIIHFWRITXLG FKHZLQJ RQ WKH SHULRGRQWLXP—LH WKH RFFXUUHQFH RI SHULRGRQWDOSRFNHWV JLQJLYDO OHVLRQV DQG JXP UHFHVVLRQ—was VLJQLILFDQWO\KLJKHULQTXLGFKHZHUVWKDQLQ QRQFKHZHUV 213 Chapter 12. Oral Health consequences of Smokeless Tobacco Use Type of study Author, year Study population Findings &URVVVHFWLRQDO 6XPDQWK HW DO VXEMHFWV VXEMHFWVZHUH +LJKHU LQFLGHQFH RI SHULRGRQWDO GLVHDVHV SDQWREDFFRFKHZHUVDQG ZDVIRXQGLQSDQFKHZHUVZKRXVHd WREDFFR VXEMHFWV XVHG SDQ ZLWKRXW FRPSDUHGZLWKSDQFKHZHUVZKRGid QRWXVH WREDFFR WREDFFR ,W ZDV FRQFOXGHG WKDW DOWKRXJK EHWHO QXW KDV GHOHWHULRXV HIIHFWV RQ WKH SHULRGRQWLXP WKH V\QHUJLVWLF HIIHFW FUHDWHG E\ DGGLQJ WREDFFR WR EHWHO QXW UHVXOWV LQ D PRUH VHYHUH LPSDFW RQ WKH SHULRGRQWDO WLVVXHV 7KHVH VWXGLHV KDYH DOVR VKRZQ 6/7 XVH WR EH DVVRFLDWHG ZLWK JLQJLYDO LQIODPPDWLRQ DQG DWWDFKPHQW ORVV DQG D GRVH–UHVSRQVH UHODWLRQVKLS KDV EHHQ IRXQG EHWZHHQ 6/7 XVH DQG SHULRGRQWDO GLVHDVH $ UHYLHZ RI WKUHH VWXGLHV QRWHG DQ DVVRFLDWLRQ EHWZHHQ JXWNa FRQVXPSWLRQ DQG SHULRGRQWDO LQIODPPDWLRQ 25V IRU WKHVH VWXGLHV ZHUH >&, –@ >&, – @DQG>&, –@ EFFECTS ON DENTAL TISSUES Dental Caries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ther Dental Effects 8VHRI6/7ZLWKDUHFDQXWKDVDOVREHHQUHFRJQLVHGWROHDGWRWRRWKZHDUGHQWDOVHQVLWLYLW\Dnd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mokeless Tobacco and Public Health in India JHQHUDOKHDOWKDUH HGXFDWLQJWKHSXEOLFRQWKHRUDOKHDOWKFRQVHTXHQFHVRI6/7XVHHQOLVWLQJ FRQWLQXHG VXSSRUW RI UHOHYDQW DJHQFLHV IRU WKLV SXUSRVH LQYROYLQJ RUDO KHDOWK SURIHVVLRQDOV LQ FXUELQJ 6/7 XVH DQG GHYHORSLQJ DSSURSULDWH LQIUDVWUXFWXUH DQG VXSSRUW WR PDQDJH WKH SRWHQWLDOO\PDOLJQDQWFRQGLWLRQV /LPLWHG GDWD IURP ,QGLDQ VWXGLHV KDYH VKRZQ 6/7 XVH PLJKW EH UHVSRQVLEOH IRU JLQJLYDO LQIODPPDWLRQ DWWDFKPHQW ORVV DQG WRRWK ZHDU 6WXGLHV HYDOXDWLQJ WKH DVVRFLDWLRQ RI 6/7 DQG GHQWDOFDULHVUHPDLQLQFRQFOXVLYH 215 Chapter 12. 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Chemistry and Toxicology of Smokeless Tobacco ULSHQHG 7REDFFR DOVR FRQWDLQV D QXPEHU RI SK\WRVWHUROV VXFK DV FDPSHVWHUROV DV ZHOO DV FKROHVWHURODOFRKROVSKHQROLFVFKORURJHQLFDFLGUXWLQFDUER[\OLFDFLGVWHUSHQHVSRO\SKHQROV DONDQHV DURPDWLF K\GURFDUERQV DOGHK\GHV NHWRQHV DPLQHV QLWULOHV N- and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ypes of Carcinogens and Other Toxins in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a@S\UHQH %>a@3D3$+FRPSRXQG DQ ,$5& *URXS FDUFLQRJHQ KDYH EHHQ UHSRUWHG IRU VHYHUDO SURGXFWV LQFOXGLQJ JXWND NKDLQL 4 FUHDP\ VQXII SURGXFWV DQG VHYHUDO PL[WXUHV RI ]DUGD DQG DUHFD QXW VXSDUL $UHFD QXW D FRQVWLWXHQWRIDQXPEHURIRWKHU6/7SURGXFWVSUHSDUDWLRQVSURGXFHGDQGXVHGLQ,QGLDLVDOVR FODVVLILHGE\,$5&DVD*URXSFDUFLQRJHQ $PRQJ WKH OLVWHG FDUFLQRJHQV WKH 761$V N’QLWURVRQRUQLFRWLQH 111 DQG PHWK\OQLWURVDPLQR S\ULG\O EXWDQRQH 11. 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Chemistry and Toxicology of Smokeless Tobacco IARC IARC Compound/substance Compound/substance Group Group 4-(methylnitrosamino)-1-(3- Benz[a]anthracene (B[a]A) 1 2B pyridyl)-1-butanone (NNK) Dibenz[a,h]anthracene Volatile N-nitrosamines 2A (DB[ah]A) N-nitrosodimethylamine (NDMA) 2A Benzo[b]fluoranthene (B[b]F) 2B N-nitrosopyrrolidine (NPYR) 2B Benzo[j]fluoranthene (B[j]F) 2B N-nitrosopiperidine (NPIP) 2B Benzo[k]fluoranthene (B[k]F) 2B N-nitrosomorpholine (NMOR) 2B Indeno[1,2,3-cd]pyrene (IcdP) 2B N-nitrosodiethanolamine (NDELA) 2B Naphthalene (NAP) 2B Nitrosamino acids Metals/metalloids N-nitrososarcosine (NSAR) 2B Arsenic 1 Inorganic compounds Beryllium 1 Nitrate (due to nitrosation activity Cadmium in the body) 2A 1 Nitrite (due nitrosation activity in Lead the body) 2A 2B Volatile aldehydes Nickel 1 Formaldehyde 1 Polonium-210 1 Acetaldehyde 2B Chromium 1,3 Fermentation-related compound Mycotoxins Ethyl carbamate (urethane) 2A Aflatoxins (mixtures of) 1 Plant Material Ochratoxin A 2B Areca nut (Ingredient of betel Sterigmatocystin quid) 1 2B *Substances are grouped according to available evidence on their carcinogenicity: Group 1 = Carcinogenic to humans Group 2A = Probably carcinogenic to humans (limited evidence); sufficient evidence for carcinogenicity to animals Group 2B = Possibly carcinogenic to humans as regarding evidence in humans and animals Group 3 = Not classifiable as to its carcinogenicity to humans Group 4 = Probably not carcinogenic to humans Sources: WHO, IARC Monograph Vol. 37 (pp. 62–78)2. WHO, IARC Monograph Vol. 89 (pp. 57–60, 427, 432, 553)4. WHO, IARC Monograph Vol. 100E (pp. 268–269)5. Varma et al., 199123. IARC 2014117. Quantities of Carcinogens in Tobacco Leaves and SLT Products Tobacco Leaves 2QHVWXG\ UHSRUWHGWUDFHDPRXQWVRI11.DQG111LQJUHHQOHDYHVRIWKHN. tabacum and N. rustica VSHFLHVZKLOHOHYHOVRIWKHVHVXEVWDQFHVLQGU\WREDFFRZHUHVHYHUDOWLPHVKLJKHU,QRQH VHDVRQPDWXUHJUHHQOHDYHVRIN. rustica JURZQLQ,QGLDZHUHIRXQGWRFRQWDLQXSWRQJJ RI11.QJJRI111DQGQJJRI1$7 DOOPHDVXUHGLQGU\ZHLJKWRIWREDFFR ZKLOH LQ VXQGULHG WREDFFR WKH OHYHOV RI 11. DQG 111 ZHUH QJJ DQG QJJ WREDFFR UHVSHFWLYHO\ ,Q FRPSDULVRQ OHYHOV RI11. DQG 111 LQ VXQdried N. tabacum were QJJDQG QJJWREDFFR 224 Smokeless Tobacco and Public Health in India Mishri 7KH OHYHOV RI SUHIRUPHG 111 DQG 1$7 LQ DTXHRXV H[WUDFWV RI PLVKUL ZHUH KLJKHU WKDQ LQ WREDFFRXVHGLQWKH SUHSDUDWLRQ RIPLVKUL $WS+FRQFHQWUDWLRQs RI111LQPLVKULDQGLQWKH WREDFFRXVHGWRSUHSDUHLWZere DQGSSE UHVSHFWLYHO\ZKLOHDQLQFUHDVHLQ11.OHYHO ZDVQRWREVHUYHG %>a@3ZDVQRWGHWHFWHGLQWREDFFRXVHGIRUPDNLQJPLVKULEXW%>a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a@3wHUHDOVRUHSRUWHG Chewing Tobacco Products 7KHSUHVHQFHRISUHIRUPHG111DQG1$7LQGLIIHUHQWFKHZLQJWREDFFRSURGXFWVVROGLQ,QGLD 33 KDV EHHQ ZLGHO\ UHSRUWHG +LJK OHYHOV RI 111 – JJ DQG 11. – JJ ZHUHIRXQGLQFKHZLQJWREDFFR GU\VQXIIFRQWDLQHG–JJRI111DQG–JJ 33 34 RI11. 2WKHUUHVHDUFKHUVKDYHUHSRUWHGDKLJKOHYHORI111LQNKDLQL . $FRPSUHKHQVLYH VWXG\RIWKHDPRXQWRI761$VIRXQGLQVPRNHOHVVWREDFFRSURGXFWVUHYHDOHGKLJKOHYHOVRI 35 1111$71$%DQG11.LQWKHVHSURGXFWV VHH7DEOH Table 13.2: Tobacco-specific nitrosamines, nitrate, nitrite, and nicotine in Indian smokeless tobacco and related products b 761$V ȝJJ Nitrate Nitrite Nicotine Product/ brand c c d NNN NAT NAB NNK ȝJJ ȝJJ (mg/g) Khaini Raja 76.9 13.8 8.83 28.4 705 1,020 21.3 Hans Chhap 39.4 4.83 3.78 2.34 1,090 1,410 19.6 Zarda Goa 1000 8.36 1.98 0.48 3.09 966 2.20 14.6 MoolchandSuper 6.47 0.64 0.46 1.64 1,320 ND 15.0 Sanket 999 7.77 1.51 0.36 1.99 1,910 2.08 65.0 Baba120 4.81 1.40 0.19 1.07 1,700 1.63 44.2 Shimla 19.9 1.53 1.19 2.61 1,360 2.53 13.8 Other tobacco HathiChhap 2.75 1.53 0.23 0.85 2,760 1.97 39.5 GaiChhap 19.2 11.9 1.57 2.61 2,950 8.40 47.8 Miraj 1.74 0.35 0.12 0.08 1,420 13.6 15.6 Mishri Shahin 4.21 2.55 0.15 0.87 1,720 5.18 21.0 Gutka Star 555 0.47 0.07 0.02 0.13 417 1.61 6.77 225 Chapter 13. Chemistry and Toxicology of Smokeless Tobacco b 761$V ȝJJ Nitrate Nitrite Nicotine Product/ brand c c d NNN NAT NAB NNK ȝJJ ȝJJ (mg/g) Manikchand 0.38 0.05 0.01 0.12 43.9 2.00 3.22 Zee 0.32 0.05 0.01 0.08 62.3 3.42 3.31 Tulsi Mix 0.69 0.07 0.02 0.31 184 2.58 5.67 Wiz 0.31 0.04 0.02 0.13 215 2.82 1.67 Kuber 0.32 0.03 0.01 0.12 47.3 4.50 1.23 Pan Parag 0.44 0.06 0.02 0.12 332 2.84 2.67 Zatpat 1.09 0.08 0.05 0.43 171 1.99 5.48 Vimal 0.09 0.01 ND 0.04 268 1.58 6.82 Josh 0.49 0.08 0.03 0.20 252 1.74 11.4 Supari Goa ND ND ND ND 7.5 4.71 NA Moolchand ND ND ND ND 8.5 2.48 NA Rajnigandha ND ND ND ND 8.8 3.34 NA Sanket ND ND ND ND 8.5 4.27 NA Shimla ND ND ND ND 8.0 6.56 NA Creamy snuff/toothpaste IPCO 3.32 0.53 0.11 1.31 580 ND 4.71 Dentobac 2.52 1.49 0.07 2.16 232 ND 7.71 Snuff Click 0.56 0.38 0.02 0.24 2,260 ND 71.4 Tooth powder Baidyanath 0.04 ND ND ND 48.6 ND 0.72 New Roshanjyot ND ND ND ND 11.6 1.25 0.25 Dabur 0.04 ND ND ND 27.6 ND 0.58 Reference snuff Kentucky IS3 3.39 3.15 0.25 0.94 3.86 6.35 36.2 ND = Not detected. NA = Not analysed. Source: Stepanov et al., 200535. $QRWKHUVWXG\ HVWLPDWHGOHYHOVRIPRLVWXUHS+QLWULWHQLWUDWHQLFRWLQHDQGRWKHUWREDFFR VSHFLILFDONDORLGVLQDEUDQGRIXQSURFHVVHGFKHZLQJWREDFFR]DUGDDQGWKUHHEUDQGVRIPLVKUL aQGSURFHVVHGELGLWREDFFR1LFRWLQHFRQWHQWZDVKLJKHVWLQ XQSURFHVVHGFKHZLQJWREDFFR and VHFRQGKLJKHVWLQ ]DUGD7KHVHWZRSURGXFWVDOVRVKRZHGKLJKFRQWHQWRIQRUQLFRWLQHZKLFKLV FRQYHUWHGWRFDUFLQRJHQLF111GXULQJFXULQJRIWREDFFROHDYHV 7DEOH 226 Smokeless Tobacco and Public Health in India Table 13.3: Comprehensive data on moisture, pH, and alkaloid content of chewing tobacco products Nor- Ana- Mois Nico- Nico- nico- basine Anat- Tobacco -ture Nitrate Nitrite tine* tine† tine† † abine† Cotinine† product %pH(mg/g) ȝJJ (mg/g) (mg/g) (mg/g) (mg/g) (mg/g) (mg/g) Pandharpuri 3.99 5.15 4.66 23.05 55.25 54.77 17.11 0.31 0.63 0.37 Zarda 11.58 5.02 5.00 30.80 25.79 26.20 10.23 0.09 0.92 0.15 Mishri brand 7.69 6.33 6.49 11.07 5.52 6.02 0.46 0.05 0.04 0.10 1 Mishri brand 5.80 7.12 2.26 9.25 18.90 23.08 3.66 0.07 0.38 0.43 2 Rawa 9.52 5.18 8.56 9.01 14.35 16.91 4.23 0.72 0.91 0.09 tobacco‡ Rawa 4.29 5.89 4.49 16.40 5.60 4.99 0.34 0.74 0.09 0.11 mishri§ Bidi tobacco 10.26 5.09 1.15 13.43 37.70 35.15 3.41 0.10 1.53 0.16 * As detected by ultraviolet spectrophotometry (UV-SP). †Detected by gas chromatography–flame ionisation (GC-FID) ‡ Rawa tobacco is unmanufactured tobacco in the form of a coarse powder made mostly of shredded ribs that is used in making bidis. § Rawa mishri is roasted tobacco in a coarse powder form. Source: Pakhale et al., 199736. $QRWKHUVWXG\H[DPLQHGWKHFKHPLFDOFRPSRVLWLRQRIGLIIHUHQW6/7SURGXFWVXVHGLQ,QGLD DQGIRXQGWKDW]DUGDKDGWKHKLJKHVWS+5DMD.KDLQLKDGWKHKLJKHVWQLFRWLQHFRQWHQW'DEXU red WRRWKSRZGHU ODO GDQW PDQMDQ KDGWKHKLJKHVWQLWUDWHOHYHODQG&OLFN(XFDO\SWXV IRUPHUO\VROG LQ,QGLD KDGWKHKLJKHVWFDGPLXPDQGDUVHQLFOHYHOV 7DEOHSURYLGHVLQIRUPDWLRQRQWKHPLQLPXPDQGPD[LPXPYDOXHVIRUS+DPPRQLDWRWDO FDUERQDWHQLFRWLQH11111.% D 3FDGPLXPDUVHQLFDQGQLWUDWHFRQWHQWLQYDULRXVWREDFFR SURGXFWV Snuff 2QHVWXG\RQVQXIIGHWHFWHGDQXPEHURIFDUFLQRJHQLFDQGFRFDUFLQRJHQLF3$+sand DQRWKHU 33 VWXG\UHSRUWHGWKHSUHVHQFHRISUHIRUPHG761$LQVQXIIVDPSOHVXVHGIRULQKDODWLRQ /HYHOVRI 111DQG11.LQGU\VQXIIZHUH–PJJDQG–PJJUHVSHFWLYHO\ Creamy Snuff +LJKOHYHOVRI111DQG11.ZHUHGHWHFWHG LQFUHDP\VQXIIDQGDKLJKQLFRWLQHFRQWHQW 35 ZDVDOVRUHSRUWHG Table 13.4: Chemical composition of smokeless tobacco products used in India Minimum Maximum Constituent value Brand value Brand pH 5.21 Baba Zarda 120 10.1 Lime Mix–Miraj Tobacco $PPRQLD ȝJJ 4.04 Baidyanath Red 5,280 GaiChhap Zarda Tooth Powder 227 Chapter 13. Chemistry and Toxicology of Smokeless Tobacco Minimum Maximum Constituent value Brand value Brand Total carbonate 140 Dabur Red Tooth 2,040 Baba Zarda 120 (ȝJJ Powder Nicotine (mg/g) 1.24 Raja Khaini 10.16 Dentobac Creamy Stuff 111 ȝJJ ND Click Eucalyptus 7.36 Baba Zarda 120 11. ȝJJ ND Click Eucalyptus 4.88 IPCO Creamy Stuff Benzo[a]pyrene < 0.0001 Click Eucalyptus 0.94 IPCO Creamy Stuff (ȝg/g) &DGPLXP ȝJJ 0.03 Click Eucalyptus 0.5 Baba Zarda 120 $UVHQLF ȝJJ 0.07 Click Eucalyptus 1.53 Shahin Mishri 1LWUDWH ȝJJ <0.01 Dabur Red Tooth 13.85 Lime Mix–Miraj Tobacco Powder ND = not detected. NNK = 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone. NNN = N’-nitrosonomicotine. Source: Gupta, 200437. Tuibur 2QHDQDO\VLVIRXQGWKDWWKH111FRQFHQWUDWLRQLQWXLEXUZDV WRQJJ Tobacco Used for Bidi Manufacture $VWXG\WKDWPHDVXUHGPRLVWXUHFRQWHQWS+QLWULWHQLWUDWHQLFRWLQHDQGRWKHUWREDFFRVSHFLILF DONDORLGVLQELGLWREDFFRIRXQGKLJKOHYHOVRIQLFRWLQH761$QLWULWHDQGQLWUDWH 7DEOH Betel Quid with Tobacco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oxic Metals in Smokeless Tobacco Products 2QHVWXG\GHWHFWHGWKHWR[LFPHWDOVDUVHQLF $V FDGPLXP &G OHDG 3E FRSSHU &X PHUFXU\ +J DQGVHOHQLXP 6H LQDOOVDPSOHVRIJXWND]DUGDFUHDP\VQXIINKDLQLPLVKULDQGRWKHU FKHZLQJWREDFFRSUHSDUDWLRQVVWXGLHG /HYHOVRI3E$V&GDQG&XH[FHHGHGWKHSHUPLVVLEOH GDLO\ DYHUDJH FRQVXPSWLRQ RI WKHVH PHWDOV 2I WKHVH WR[LF PHWDOV DUVHQLF DQG FDGPLXP DUH *URXSFDUFLQRJHQV FDUFLQRJHQLFWRKXPDQV DQGOHDGLVD*URXS$FDUFLQRJHQ FDUFLQRJHQLF LQH[SHULPHQWDODQLPDOVDQGSUREDEO\FDUFLQRJHQLFLQKXPDQV 228 Smokeless Tobacco and Public Health in India Chemistry of Non-Tobacco Ingredients in SLT Areca Nut $UHFDQXWWKHVHHGIURPWKHDUHFDSDOP Areca catechu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laked Lime 6ODNHG OLPH D FRPPRQ DONDOLQH DJHQW LV FRPSRVHG PDLQO\ RI FDOFLXP K\GUR[LGH EXW DOVR FRQWDLQVLURQPDJQHVLXPDQGDQXPEHURIWUDFHHOHPHQWV Catechu &DWHFKX LV WKH UHVLGXH UHVXOWLQJ IURP WKH KRW ZDWHU H[WUDFWLRQ RI KHDUWZRRG IURP WKH Acacia catechu WUHH7KHPDLQFRQVWLWXHQWVRIFDWHFKXDUHFDWHFKXWDQQLFDFLGTXHUFHWLQDQGFDWHFKX UHG6HYHUDOWUDFHHOHPHQWVKDYHDOVREHHQGHWHFWHG Silver Foil )ODNHVRIVLOYHUIRLODUHDGGHGWRVRPHSURGXFWVWRFRQYH\DVHQVHRIDGGHGZRUWKRUGHVLUDELOLW\ WRWKHSURGXFW,QJHVWLRQRIERWKPHWDOOLFVLOYHUDQGVLOYHUFRPSRXQGVLQVPDOOGRVHVRYHUSHULRGV RIPRQWKVWR\HDUVFDQUHVXOWLQDFRQGLWLRQFDOOHGDUJ\ULDRUDUJ\URVLVLQZKLFKWKHVNLQRUH\HV WDNHRQDEOXHRUEOXLVKJUH\FRORXU Betel Leaf %HWHOOHDIFRQWDLQVEHWHORLOZKLFKFRQWDLQVSKHQROVLQFOXGLQJFKDYLFROK\GUR[\FKDYLFRODQG HXJHQRO %HWHO OHDI DOVR FRQWDLQV YLWDPLQ & DQG FDURWHQHV 7UDFH HOHPHQWV VXFK DV LURQ PDQJHQHVHDQGVRGLXPDUHDOVRSUHVHQW Magnesium Carbonate 0DJQHVLXPFDUERQDWHFRPPRQO\IRXQGLQ JXWNDDQGSDQPDVDODLVDQDONDOLQHDVZHOODVDQ DQWLFDNLQJDJHQW,Q,QGLDXVHRIPDJQHVLXPFDUERQDWHLVSHUPLWWHGRQO\LQVSHFLILFIRRGLWHPV XQGHU 5XOH RI WKH )RRG 6DIHW\ DQG 6WDQGDUGV )RRG 3URGXFWV 6WDQGDUGV DQG )RRG $GGLWLYHV 5HJXODWLRQV 7REDFFR DQG QLFRWLQH DUH DOVR SURKLELWHG DV LQJUHGLHQWV LQ DQ\ IRRGLWHPXQGHU5XOHRIWKHse rHJXODWLRQV8QGHUWKHVHUHJXODWLRQVDQGXQGHU6HFWLRQ D RIWKH)RRG6DIHW\DQG6Wandards $FWWKH&RPPLVVLRQHURI)RRG6DIHW\RID sWDWHLV HPSRZHUHGWR SURKLELW IRURQH \HDULQ WKHLQWHUHVW RI SXEOLFKHDOWK WKHPDQXIDFWXUH 229 Chapter 13. Chemistry and Toxicology of Smokeless Tobacco VWRUDJHGLVWULEXWLRQ RUVDOHRIDQ\DUWLFOHRIIRRGLQWKHHQWLUHsWDWH ,QWKLVPDQQHUSDQPDVDOD an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Typically, tolerance is prominent and a withdrawal syndrome frequently occurs when the substance use is interrupted. The term addiction also conveys the sense that such substance use has a detrimental effect on society, as well as on the individual.3 %\YLUWXHRISRVVHVVLQJDOOWKHDERYHTXDOLWLHVH[FHSWLQWR[LFDWLRQWREDFFRFDQEHFRQVLGHUHGD KLJKO\DGGLFWLYHVXEVWDQFHOLNHRWKHUVXEVWDQFHVRIDGGLFWLRQ The 1986 U.S. Surgeon General’s report, The Health Consequences of Using Smokeless 4 Tobacco FRQFOXGHGWKDWWKHXVHRIVPRNHOHVVWREDFFRSURGXFWVFDQOHDGWRQLFRWLQHGHSHQGHQFH RUDGGLFWLRQDQGWKDWWKHRYHUDOOPDJQLWXGHRIQLFRWLQHH[SRVXUHLVVLPLODUIRUERWKVPRNLQJDQG VPRNHOHVVWREDFFR 7KH 1988 U.S. Surgeon General’s report The Health Consequences of Smoking: Nicotine 5 Addiction KDG WKUHH PDMRU FRQFOXVLRQV DERXW DGGLFWLRQ WR QLFRWLQH FLJDUHWWHV DQG RWKHU IRUPVRIWREDFFRDUHDGGLFWLYH QLFRWLQHLVWKHFKHPLFDOLQWREDFFRWKDWFDXVHVWKLVDGGLFWLRQ DQG WKH SKDUPDFRORJLFDO DQG EHKDYLRXUDO SURFHVVHV WKDW GHWHUPLQH WREDFFR DGGLFWLRQ DUH VLPLODUWRWKRVHWKDWGHWHUPLQHDGGLFWLRQWRGUXJVVXFKDVKHURLQDQGFRFDLQH 245 Chapter 14. Smokeless Tobacco: Addiction, Withdrawal and Cessation /LNH DOO DGGLFWLRQV WREDFFR DGGLFWLRQ DOVR LQFOXGHV LQWHUDFWLRQV DPRQJ PDQ\ IDFWRUV SKDUPDFRORJ\ LQGLYLGXDO JHQHWLF PDNHXS FRQGLWLRQHG UHVSRQVHV DV ZHOO DV VRFLDO DQG HQYLURQPHQWDO IDFWRUV VXFK DV SURGXFW PDUNHWLQJ :KHWKHU VPRNHG RU VPRNHOHVV IRUPV RI WREDFFRDUHXVHGQLFRWLQHSURGXFHVWKHVDPHNLQGRISV\FKRDFWLYHHIIHFWV VWLPXODWLRQDURXVDO RU UHOD[DWLRQ PRRG PRGXODWLRQ DQG HQKDQFHPHQW RI WKH VHQVH RI ZHOOEHLQJ UHGXFWLRQ RI DQ[LHW\DQGLPSURYHPHQWRIFRJQLWLYHIXQFWLRQLQJ 7REDFFRLVFRQVXPHGUHSHDWHGO\WRREWDLQ WKHVHUHLQIRUFLQJHIIHFWV 7KH 'LDJQRVWLF DQG 6WDWLVWLFDO 0DQXDO ,9 '60,9 DQG WKH ,QWHUQDWLRQDO &ODVVLILFDWLRQ RI 'LVHDVHVWK UHYLVLRQ ,&' KDYH JLYHQFULWHULD IRU QLFRWLQHGHSHQGHQFH WKH GLDJQRVWLF WHUP WKDW LQFOXGHV ERWK DGGLFWLRQ DQG WKH RXWGDWHG WHUP habituation $OWKRXJK GHYHORSHG IRU VPRNLQJWKHVHFULWHULDIRUQLFRWLQHGHSHQGHQFHDUHDSSOLFDEOHWRVPRNHOHVVWREDFFRDVZHOO VHH WH[WER[ 6PRNHOHVVWREDFFRGHOLYHUVQLFRWLQHWRWKHXVHUZKLFKOHDGVWRDGGLFWLRQDOVRUHIHUUHG WRDVSK\VLFDOGHSHQGHQFH 246 Smokeless Tobacco and Public Health in India Box 14.1: Criteria for nicotine dependence, adapted from two sources DSM-IV criteria for nicotine dependence 7KUHHRUPRUHRIWKHIROORZLQJDWDQ\WLPHLQWKHVDPHPRQWKSHULRG x 7ROHUDQFH 6PRNHU6/7XVHUQHHGVLQFUHDVHGDPRXQWVRIQLFRWLQHWRDFKLHYH WKH GHVLUHGHIIHFW RUH[SHULHQFHVGLPLQLVKHGHIIHFWZLWKFRQWLQXHGXVHRIWKHVDPHDPRXQW x ([SHULHQFHRIZLWKGUDZDOV\PSWRPV x 1LFRWLQHRIWHQWDNHQLQODUJHUDPRXQWVRURYHUDORQJHUSHULRGWKDQLQWHQGHG x 3HUVLVWHQWRUXQVXFFHVVIXOHIIRUWVWRFXWGRZQRUFRQWUROXVH x 6SHQGLQJ D JUHDW GHDO RI WLPH LQ DFWLYLWLHV QHFHVVDU\ WR REWDLQ QLFRWLQH RU UHFRYHU IURP LWV HIIHFWV x ,PSRUWDQWVRFLDORFFXSDWLRQDORUUHFUHDWLRQDODFWLYLWLHVJLYHQXSRUUHGXFHGEHFDXVHRIQLFRWLQH XVH x 1LFRWLQH XVH FRQWLQXHG GHVSLWH NQRZOHGJH RI KDYLQJ D SHUVLVWHQW RU UHFXUUHQW SK\VLFDO RU SV\FKRORJLFDOSUREOHPWKDWLVOLNHO\WRKDYHEHHQFDXVHGRUH[DFHUEDWHGE\LW ICD-10 criteria for nicotine dependence $ FOXVWHU RI EHKDYLRXUDO FRJQLWLYH DQG SV\FKRORJLFDO RFFXUUHQFHV WKDW GHYHORS DIWHU UHSHDWHG XVH RI WREDFFRQLFRWLQH x ,QFUHDVHGWROHUDQFH x 6RPHWLPHVSK\VLFDOZLWKGUDZDOV\PSWRPV x $VWURQJGHVLUHWRWDNHQLFRWLQH x 'LIILFXOW\FRQWUROOLQJXVH x +LJKHUSULRULW\JLYHQWRQLFRWLQHXVHWKDQWRRWKHUDFWLYLWLHVDQGREOLJDWLRQV x 3HUVLVWLQJXVHGHVSLWHKDUPIXOHIIHFWV Sources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group of symptoms of variable clustering and degree of severity which occur on cessation or reduction of use of a psychoactive substance that has been taken repeatedly, usually for a prolonged period and/ or in high doses The syndrome may be accompanied by signs of physiological disturbance. A withdrawal syndrome is one of the indicators of a dependence syndrome. It is also the defining characteristic of the narrower psycho-pharmacological meaning of dependence.3 247 Chapter 14. 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Advocacy and Policy Measures Counter-Campaigns 6LQFH$SULOZKHQVWDWHVVWDUWHGHQIRUFLQJEDQVRQJXWNDDQGSDQPDVDODWKH6/7LQGXVWU\ KDVFRQGXFWHG DQDWLRQZLGHSDLGPHGLDFDPSDLJQGHFODULQJWKLVEDQXQMXVW7RFRXQWHUWKH6/7 industry’s misleading advertising campaign, PHFI, in collaboration with VHAI and MoHFW, RUJDQLVHGDMRLQWSUHVVFRQIHUHQFHLQ2FWREHU )LJXUH 7KHSUHVVFRQIHUHQFHSUHVHQWHG WKH VFLHQWLILF DQG OHJDO MXVWLILFDWLRQ IRU WKH EDQ KLJKOLJKWHG WDFWLFV XVHG E\ WKH LQGXVWU\ WR VXEYHUW WKH ODQGPDUN OHJLVODWLRQ GLVFXVVHG LPSOHPHQWDWLRQ DQG HQIRUFHPHQW RI WKH EDQ DQG GHVFULEHGVWHSVWRWDNHWRZDUGDQDWLRQZLGHEDQ7KLV1*2leGDGYRFDF\HDUQHGPHGLDVSDFHLQ VHYHQUHVSHFWHGQDWLRQDOQHZVSDSHUVQDWLRQDOZLUHDJHQFLHVDQGRQILYHPDMRUWHOHYLVLRQQHZV FKDQQHOV Figure 15.3: Press conference on the SLT industry’s misleading ads 3KRWRJUDSKVFRXUWHV\RI3KRWREDQN3+), Youth as Messengers An exhibit titled ‘Pictures save lives: Choose and save millions’, launched at the India International Trade Fair on Children’s Day, 14 November 2010, is an example of advocacy by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mokeless Tobacco and Public Health in India Figure 15.4: Students’ interactive exhibit Figure 15.5: Students meet with a about SLT warning labels member of Parliament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effeFWLYH JUDSKLF ZDUQLQJ LPDJHV VXFK DV Whe gruesome picture of ‘oral cancer’ introduced on SLT products on 1 December 2011. Social Media Optimisation 7REDFFRFRQWURODGYRFDWHVLQ,QGLDKDYHLQFUHDVLQJO\XVHGVRFLDOPHGLDWRVHQVLWLVH\RXWKDQG HQJDJH D ZLGHU DXGLHQFH $Q RQOLQH PDVV DZDUHQHVV FDPSDLJQ titled ‘Chew on this’ >KWWS ZZZFKHZRQWKLVLQFKHZRQWKLV@KLJKOLJKWHGWKHGDQJHUVRI6/7XVH )LJXUH Figure 15.6: Webpage of the ‘Chew on This’ online campaign 3KRWRJUDSKFRXUWHV\RI3KRWREDQN+5,'$< 6RFLDO PHGLD ZHUH DOVR XVHG DV SDUW RI WKH RWKHU 6/7UHODWHG FDPSDLJQV GLUHFWHG DW \RXWK Opinion polls on the ‘Youth for Health’ Facebook page (ZZZIDFHERRNFRP\RXWKIRUKHDOWK 265 Chapter 15. Advocacy and Policy Measures JHQHUDWHGVXSSRUWIRUJUXHVRPHSLFWRULDOZDUQLQJVRQWREDFFRSURGXFWV6RFLDOPedia were DOVRD 22 crucial part of the ‘Pictures save lives: Choose and save millions’ campaign (Figure 15. Figure 15.7: Facebook campaign to ban SLT in all states 3KRWRJUDSKFRXUWHV\RI3KRWREDQN+5,'$<. Curbing Surrogate Advertisement of SLT Products 5HJXODUPRQLWRULQJIRXQGWKDWVXUURJDWHDGYHUWLVHPHQWVRIWREDFFRSURGXFWVZHUHGLVSOD\HGDW PDQ\EXV\'HOKLPHWURVWDWLRQVLQ+HDOWKDGYRFDWHVIURP+5,'$<ZURWHOHWWHUVXUJLQJ WKH 0DQDJLQJ 'LUHFWRU RI 'HOKL 0HWUR 5DLO &RUSRUDWLRQ '05& WR UHPRYH DOO LQGLUHFW RU VXUURJDWHDGYHUWLVHPHQWVRISDQPDVDOD )LJXUH 7KLVLQFLGHQWEURXJKWWROLJKWWKHIDFW WKDW '05& DGYHUWLVLQJ JXLGHOLQHV SHUPLWWHG VXUURJDWH DGYHUWLVLQJ LQ '05& VWDWLRQV ZLWK DSSURYDOIURP0LQLVWU\RI,QIRUPDWLRQDQG%URDGFDVWLQJ Figure 15.8: SLT advertisements in DMRC buses 3KRWRJUDSKFRXUWHV\RI3KRWREDQN+5,'$< $QRWKHUQRWHZRUWK\HIIRUWWRFXUEVXUURJDWHDGYHUWLVHPHQWVZDVFDUULHGRXWE\DQ1*2EDVHGLQ *XMDUDWWhe Faith Foundation, which runs a project called ‘IQGLUHFW$GYHUWLVHPHQW)UHH*XMDUDW by 2012’ WKDWOHGWRWKHUHPRYDORIDERXW KRDUGLQJVRISDQ PDVDODDQGJXWNDLQ9DGRGDUD GLVWULFW 6XFK YLRODWLRQV RI SURKLELWLRQV DJDLQVW VXUURJDWH DGYHUWLVHPHQWV DW HYHQWV KDYH EHHQ 266 Smokeless Tobacco and Public Health in India UHSRUWHGWRWKH6WDWHDQG'LVWULFW/HYHO6WHHULQJ&RPPLWWHHIRU7REDFFR&RQWUROLQ*XMDUDW and 9DGRGDUD Government Efforts That Support Advocacy and Policy Initiatives Surveillance and Monitoring 6HYHUDOVXUYHLOODQFHHIIRUWVOHGE\WKHJRYHUQPHQW—WKH*OREDO$GXOW7REDFFR6XUYH\ *$76 WKH *OREDO National Consultation on SLT (April 2011) and Intradepartmental Coordination 7KH*$76,QGLD UHSRUWUHYHDOHGWKDWVPRNHOHVVWREDFFR XVHZDVWKHPRVWZLGHVSUHDG IRUPRIWREDFFRXVHGE\ Indians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igure 15.9: Experts at the National Consultation on SLT, 2011 3KRWRJUDSKFRXUWHV\RI3KRWREDQN3+), 7KH H[SHUW JURXS UHFRPPHQGHG D FRPSOHWH EDQ RQ 6/7 SURGXFWLRQ VXSSO\ DQG GLVWULEXWLRQ FRXQWU\ZLGHE\QRWLI\LQJ)66UHJXODWLRQ,PPHGLDWHO\DIWHUWKLVFRQVXOWDWLRQRUJDQLsDWLRQVOLNH 3+),ZRUNHGZLWKWKHPHGLDDQGJRYHUQPHQWWRJHWWKH)66UHJXODWLRQQRWLILHGLQ$XJXVW 7KHFRQVXOWDWLRQIXUWKHUUHFRPPHQGHGGHYHORSLQJDFRPSUHKHQVLYHSODQWRGHDOZLWKWKHVRFLDO DQGHFRQRPLFLPSOLFDWLRQVRIDWRWDOEDQRQVPRNHOHVVWREDFFRLQFOXGLQJWREDFFRFHVVDWLRQand ORVVRIUHYHQXHDQGOLYHOLKRRG WKH\DOVRPDGHUHFRPPHQGDWLRQVIRUWDFNOLQJLOOLFLWWUDGH 267 Chapter 15. Advocacy and Policy Measures Implementing FSSA Regulation 2.3.4 5HJXODWLRQV EDQQLQJ 6/7 UHTXLUHG LQWUDGHSDUWPHQWDO FRRUGLQDWLRQ DQG 0R+): VWHHUHG WKHVH GLVFXVVLRQV VXFFHVVIXOO\ WR DFKLHYH WKH GHVLUHG QRWLILFDWLRQ PRYHG E\ )66$, LQ $XJXVW 7KHSURFHVVRILPSOHPHQWLQJ )66$ 5HJXODWLRQFRQVLVWHGRIWKHIROORZLQJ x 2Q$XJXVWWKH)66$,&(2ZURWHDOHWWHUDOHUWLQJDOOIRRGFRPPLVVLRQHUVWRWKH XUJHQWQHHGIRUVWDWHVWRWDNHDFWLRQEHIRUH$XJXVWWRHQVXUHFRUUHFWLPSOHPHQWDWLRQRI WKH)665XOHVDQG5HJXODWLRQV x ,Q UHVSRQVH WR TXHULHV IURP YDULRXV VWDWHV ZLWK UHJDUG WR LPSOHPHQWDWLRQ RI WKH UHJXODWLRQVXQGHU)66$WKH6SHFLDO6HFUHWDU\0R+): LVVXHGDOHWWHURQ0D\ GLUHFWLQJWKHVWDWHVLQLPSOHPHQWLQJWKHEDQ x 3+),DOVRVHQWOHWWHUVZLWKVXSSRUWLQJJRYHUQPHQWGRFXPHQWVWR&KLHI0LQLVWHUV+HDOWK 0LQLVWHUV DQG IRRG FRPPLVVLRQHUV RI DOO WKH VWDWHV UHTXHVWLQJ WKHP WR LPSOHPHQW WKH 6/7EDQ2WKHURUJDQLsDWLRQVVXFKDV$)7&9+$,DQG9R79KHOGPHHWLQJVDQGSXEOLF HYHQWV ZLWK VWDWH IRRG FRPPLVVLRQHUV DQG RWKHU RIILFLDOV DQG XUJHG YDULRXV VWDWH DGPLQLVWUDWLRQV WR LPSOHPHQW WKH EDQ WKH\ DOVR VXSSRUWHG WKH EDQ E\ GUDIWLQJ VWDWH RUGHUV x 7KH 9R79 FDPSDLJQ DQG FLYLO VRFLHW\ PHHWLQJV UDLVHG DZDUHQHVV DPRQJ WKH &KLHI 0LQLVWHUVEXUHDXFUDWVDQGNH\DGPLQLVWUDWRUVRIVRPHVWDWHVDERXWWKHVFRXUJHRI6/7 XVH6RPHVWDWHVLQYROYHGNH\0LQLVWULHVOLNH+RPH+HDOWK)LQDQFH$JULFXOWXUH)RRG DQG'UXJ$GPLQLVWUDWLRQDQG(GXFDWLRQDQGFRRUGLQDWHGZLWKWKH3ULQFLSDO6HFUHWDU\RI WKRVHVWDWHVWRREWDLQOHJDODSSURYDODQGSDVVWKHRUGHUV x $W WKH UHTXHVW RI VWDWH JRYHUQPHQWV WKDW ZHUH FRQVLGHULQJ HQIRUFHPHQW RI WKLV QRWLILFDWLRQ 3+), SURYLGHG WHFKQLFDO VXSSRUW E\ IRUPXODWLQJ D 6WDQGDUG 2SHUDWLQJ 3URFHGXUHGRFXPHQWWRLPSOHPHQWWKHEDQ 7DEOHSURYLGHVQRWLILFDWLRQDQGLPSOHPHQWDWLRQGDWHVRI)665HJXODWLRQE\VWDWHVDV RI2FWREHU,WDOVRLQGLFDWHV ZKHWKHUWKHWREDFFRLQGXVWU\FKDOOHQJHGWKHVHQRWLILFDWLRQVLQ WKHVHVWDWHV Table 15.1: Notification and implementation of FSS Regulations, 2011, Rule 2.3.424, by states (1) Challenged by industry litigation or (2) a Order of PIL was filed to notification State Date of notification/declaration implement the ban* 0DGK\D3UDGHVK 1RWLILFDWLRQGDWHG0DUFK ,PSOHPHQWHGIURP$SULO 268 Smokeless Tobacco and Public Health in India (1) Challenged by industry litigation or (2) a Order of PIL was filed to notification State Date of notification/declaration implement the ban* 4 5DMDVWKDQ 1RWLILFDWLRQGDWHG-XO\ 2UGHUSDVVHGE\VWDWH&RPPLVVLRQHURI 269 Chapter 15. Advocacy and Policy Measures (1) Challenged by industry litigation or (2) a Order of PIL was filed to notification State Date of notification/declaration implement the ban* 8WWDU3UDGHVK 'HFODUDWLRQSDVVHGRQ2FWREHU ,PSOHPHQWHGIURP$SULO Judicial Coordination 5HJXODWLRQRIWKH)RRG6DIHW\and 6WDQGDUGV$FW VSHFLILFDOO\WKH3URKLELWLRQDQG 24 5HVWULFWLRQVRQ6DOHV5HJXODWLRQV SURKLELWVVDOHRISURGXFWVWKDWFRQWDLQDQ\VXEVWDQFH LQMXULRXVWRKHDOWKDQGSURKLELWVXVLQJWREDFFRDQGQLFRWLQHDVLQJUHGLHQWVLQDQ\IRRGSURGXFWV )66$5HJXODWLRQ>RIWKH)RRG6DIHW\DQG6WDQGDUGV )RRG3URGXFWV6WDQGDUGVDQG)RRG $GGLWLYHV 5HJXODWLRQV@ UHVWULFWVXVHRIDQWLFDNLQJDJHQWVOLNHFDUERQDWHVRIFDOFLXPDQG PDJQHVLXPLQIRRGV7KLVODZKDVEHHQFKDOOHQJHGLQYDULRXVLQGXVWU\SHWLWLRQV7KHJRYHUQPHQW ILOHG D WUDQVIHU SHWLWLRQ—QDPHO\ Union of India & Another v. Dharampal Satyapal Ltd. and Others—IRUWUDQVIHURIFDVHVSHQGLQJEHIRUHYDULRXV+&VWRWKH+RQRXUDEOH6&WRDYRLGDQ\ DGYHUVH RUGHUV EHLQJ SDVVHG DJDLQVW WKH HQIRUFHPHQW RI )66 UHJXODWLRQ $W WKH VDPH WLPH LQGXVWU\SHWLWLRQVFKDOOHQJLQJDQHDUOLHU3)$UXOH 5XOH- ZKLFKZDVWUDQVIHUUHGWRWKH6& GXULQJ ZLOODOVREHKHDUGLQDGGLWLRQWRWKHUOI v. Dharampal WUDQVIHUSHWLWLRQ GHVFULEHG LQPRUHGHWDLOLQFKDSWHU Government–NGO Partnerships ,Q DGGLWLRQ WR ODZV EDQQLQJ 6/7 XVH 1*2V KDYH ZRUNHG FORVHO\ ZLWK sWDWH DQG &HQWUDO *RYHUQPHQWWRVXSSRUWRWKHUWREDFFRFRQWUROPHDVXUHVLQ,QGLD Tobacco Taxation 7KH$GGLWLRQDO6HFUHWDU\ 0R+): LQDOHWWHUWRWKH&KLHIDQG)LQDQFH6HFUHWDULHVRIDOOs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was also the Finance Minister. The Rajasthan Cancer Foundation’s partners in the 5HVRXUFH&HQWUHIRU7REDFFR&RQWURO 5&7 VXSSRUWHGWKHLULQLWLDWLYHE\HIIHFWLYHO\SHUVXDGLQJ WKH&KLHI0LQLVWHUDQGWKHVWDWHGHSDUWPHQWVRI)LQDQFHDQG0HGLFDODQG+HDOWKWRLQFUHDVHWKH 9$7RQDOOUHWDLOWREDFFRSURGXFWVIURPWRLQWKH\HDU ,QWKHVXEVHTXHQW ILVFDO\HDU2 WKH9$7ZDVUDLVHGWRDQGin LWZDVLQFUHDVHGWR— 270 Smokeless Tobacco and Public Health in India WKHKLJKHVWUDWHLQWKHFRXQWU\6LPLODUO\-DPPXDQG.DVKPLULQFUHDVHGWKH9$7IURPWR LQWKHILVFDO\HDU+RZHYHUDGYRFDF\HIIRUWVVKRXOG EHVWHSSHGXSWRUDLVH6/7 WD[HVWRWKHUHFRPPHQGHG–RIUHWDLOSULFHLQ,QGLD Table 15.2: Value-added tax (VAT) on all forms of tobacco (as of October 2012) 3UHYLRXV9$7 9$7IRU 6WDWH87 $QGKUD3UDGHVK %LKDU *XMDUDW 25 -DPPXDQG .DVKPLU 25 -KDUNKDQG .HUDOD 5DMDVWKDQ 8WWDU3UDGHVK Community Mobilisation: Tobacco-Free Villages ,QRUGHUWRWHVWDPRGHORIXVLQJVHOIKHOS JURXSVWRFUHDWHGHPDQGIRUWREDFFRFHVVDWLRQDWD FRPPXQLW\OHYHODGRZQVWUHDPDGYRFDF\FDPSDLJQLQYROYLQJORFDOLQIOXHQFHUVZDVLQLWLDWHGLQ $QGKUD3UDGHVKDQG*XMDUDWLQ %R[ 7KHH[LVWLQJLQIRUPDOJURXSVIRUVRFLDO EHQHILW ZHUH LGHQWLILHG DV UHVRXUFHV WR SURYLGH VXVWDLQDELOLW\ WR WKLV FDPSDLJQ $V D SDUW RI PHFI’s STEPS project, YLOODJHOHYHOselfKHOSJURXSVwere PRELOLVHG7KHVHJURXSVFRQVLVWed RI \RXWK UHSUHVHQWDWLYHV IRUPHU WREDFFR XVHUV $FFUHGLWHG 6RFLDO +HDOWK $FWLYLVWV $6+$V $X[LOLDU\ 1XUVH 0LGZLYHV $10V UHOLJLRXV OHDGHUV DQG $QJDQZDGL ZRUNHUV $QJDQZDGL ZRUNHUV DUH ZRPHQ VHOHFWHG IURP ORFDO FRPPXQLWies as IURQWOLQH KRQRUDU\ ZRUNHUs in FKLOG GHYHORSPHQWSURJUDPPHV WKH\DUH DOVRDJHQWs RIVRFLDOFKDQJHPRELOLsLQJFRPPXQLW\VXSSRUW IRUEHWWHUFDUHRI\RXQJFKLOGUHQJLUOV DQGZRPHQ 6HOIKHOSJURXSPHPEHUVZHUHWUDined in PRWLYDWLRQDOLQWHUYLHZLQJ VHH)LJXUH IRUDSLFWXUHRIWKHLUKDQGERRN 7KHPHPEHUVKDYH VRFLDO PHHWLQJV DQG SURYLGH WREDFFR XVHUV ZLWK EULHI DGYLFH RQ TXLWWLQJ )LJXUH 7KLV FRPPXQLW\OHYHODGYRFDF\ LQYROYLQJYLOODJH DQGSDQFKD\DWOHDGHUVKDVOHGWR G\QDPLFSROLF\ changes, sowing seeds for ‘Tobacco Free India’ and helping to change social norms to no WREDFFRXVH 271 Chapter 15. Advocacy and Policy Measures Box 15.2: Tobacco-free villages in India 7KH DGPLQLVWUDWLRQ RI 3RQJDOLSDNND YLOODJH LQ 9LVDNKDSDWQDP $QGKUD 3UDGHVK GHFODUed themselves ‘tobacco free’ on World No Tobacco Day 2012 as a result of systematic community efforts through PHFI’s 67(36 25 SURMHFW $OWHUQDWHOLYHOLKRRGs were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were LQ9LOOXSXUDPGLVWULFW 6KDQNDSXUD YLOODJH LQ +DU\DQD KDV an DJHROG WUDGLWLRQ RI QR WREDFFR XVH DV WKH YLOODJH SRSXODWLRQ DUH 2 SUHGRPLQDQWO\6LNK Figure 15.10: Self-help group handbook Figure 15.11: Self-help group meeting on SLT cessation 3KRWRJUDSKVFRXUWHV\RI3KRWREDQN3+), POLICY INITIATIVES %HFDXVHRIWKHDPSOHHYLGHQFHWKDWVPRNHOHVVWREDFFRFDXVHVVHYHUHKHDOWKHIIHFWV&HQWUDODQG VWDWHLQLWLDWLYHVKDYHUHSHDWHGO\UHJXODWHG6/7SURGXFWLRQDQGVDOH7DEOHEULHIO\GHVFULEHV LQFKURQRORJLFDORUGHUWKHQRWDEOHH[LVWLQJSROLFLHVWRUHJXODWHDQGEDQ6/7XVHWKDWKDYHEHHQ IRUPXODWHGDQGHQDFWHGDWWKH&HQWUDODQGVWDWHOHYHOV 272 Smokeless Tobacco and Public Health in India Table 15.3: Policies and orders to regulate smokeless tobacco use In India 273 Chapter 15. Advocacy and Policy Measures 274 Smokeless Tobacco and Public Health in India Box 15.3: State law to prohibit SLT: Goa case study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bench. The HC dismissed the manufacturers’ plea. This petition was moved to the SC by the manufacturers, but no VSHFLILFUHOLHIRIDQ\QDWXUHZDVJUDQWHGDQGWKHJXWNDEDQLQWKH6WDWHRI*RDUHPDLQVLQ HIIHFW )RUGHWDLOVVHH FKDSWHU $VLQGLFDWHGE\7DEOHSROLFLHVEHJXQLQWKH\HDUV –LQFOXGHGUHJXODWLQJ6/7XVH WKURXJK VWDWXWRU\ ZDUQLQJV RQ 6/7 SURGXFWV DQG SURKLELWLQJ VSLWWLQJ in SXEOLF SODFHV &HQWUDO &RPPLWWHH IRU )RRG 6WDQGDUGV UHFRPPHQGDWLRQV aJDLQVW XVH DQG DGPLQLVWUDWLYH RUGHUV IURP UDLOZD\VVFKRRODXWKRULWLHVDQGWKH0LQLVWU\RI,QGXVWU\DQG%URDGFDVWLQJUHJXODWLQJSURPRWLRQ DQG DGYHUWLVLQJ GLUHFW DQG LQGLUHFW RI 6/7 SURGXFWV %HWZHHQ DQG PDQ\ VWDWHV SDVVHG RUGHUV DJDLQVW WKH VDOH PDQXIDFWXUH VWRUDJH DQG GLVWULEXWLRQ RI JXWND LQYRNLQJ SURYLVLRQV RI WKH PFA, 1954. Maharashtra’s gutka ban was upheld by Bombay High Court. +RZHYHU WKH Godawat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ffectiveness of Public Interest Litigations (PILs) in Strengthening Implementation of SLT-Related Laws 7KHH[SHULHQFHVRI3,/VOLNHWKHAnkur Gutkha ODZVXLWDQGWKHBejon Mishra ODZVXLWDVZHOODV VR79LQWHUYHQWLRQDSSOLFDWLRQVLQVHYHUDOWREDFFRFRQWUROLVVXHVDQGUHVXOWVOLNHWKH3DFNDJLQJ and /DEHOOLQJ 5XOHV +HDOWK IRU 0LOOLRQV —DOO FOHDUO\ LQGLFDWH WKDW 3,/V DUH DQ HIIHFWLYH DGYRFDF\ WRRO 7KH FRXUWV LQ ,QGLD KDYH SURQRXQFHG SRVLWLYH MXGJHPHQWV DQG UHLQIRUFHG WKH 5LJKWWR+HDOWKLQWKHSXEOLFLQWHUHVW )RUIXUWKHUGHWDLOVVHHFKDSWHU Supreme Court Directive on Transfer of All Cases Pertaining to SLT Bans to the Apex Court 2QH SRZHUIXO DFWLRQ RI JRYHUQPHQW KDV EHHQ WKH WUDQVIHU RI LQGXVWU\ SHWLWLRQV FKDOOHQJLQJ 5HJXODWLRQRIWKH)665HJXODWLRQVWRWKHDSH[FRXUW7KLVGHFLVLRQUHVXOWHGIURPWKH ODZVXLWUnion of India & Anr. v. Dharampal Satyapal Ltd. & Ors. 7UDQVIHUULQJWKHVHSHWLWLRQVWR WKH6&ZDVDQDWWHPSWWRDYRLGGHFLVLRQVE\+&VLQYDULRXVSDUWVRIWKHFRXQWU\ZKLFKZRXOG DGYHUVHO\DIIHFWHQIRUFHPHQWRIWKH)66UHJXODWLRQEDQQLQJJXWND,QDGGLWLRQLQ LQGXVWU\ 275 Chapter 15. Advocacy and Policy Measures SHWLWLRQVWKDWFKDOOHQJHGHDUOLHU3)$UXOHV 5XOH- ZHUHWUDQVIHUUHGWRWKH6&7KHVHWUDQVIHU SHWLWLRQVDUHEHLQJKHDUGWRJHWKHUZKLFKHQVXUHVVLPLODUWUHDWPHQWRIWKHLVVXHDFURVVWKHZKROH FRXQWU\DVRI1RYHPEHU VHHFKDSWHU Community Empowerment: Demand Reduction Strategy to Complement Supply-Side Action Experiences in India’s tobaccoIUHH YLOODJHV VXFK DV 3RQJDOLSDNND LQ 9LVaNhDSDWQDP 6DQNKDSXUDLQ+DU\DQDDQG6DUIDEDGLQ1RLGDDIILUPWKDWHPSRZHULQJORFDOVHOIJRYHUQPHQWV 3DQFKD\DW ZLWKNQRZOHGJHRIWREDFFRKDUPVFDQOHDGWRSRVLWLYHSROLF\RXWFRPHVDQGPDNH 6/7EDQVDQDFFHSWDEOHQRUP,QDGGLWLRQWREDQVDQGFRPPXQLW\HGXFDWLRQLWLVLPSRUWDQWWR SURYLGH FHVVDWLRQ VXSSRUW DQG RSSRUWXQLWLHV WR WREDFFR XVHUV ZKR ZDQW WR TXLW WKLV DGGLFWLRQ WKHVHVXSSRUWVVKRXOGEHRIIHUHGDWWKHVXEGLVWULFWOHYHO Increased Vigilance and Suo Moto Crackdown Campaigns on Food Business Operators 5DLGV FDUULHG RXW E\ WKH IRRG VDIHW\ RIILFHUV DQG RWKHU HQIRUFHPHQW DJHQFLHV LQ -KDUNKDQG *XMDUDW DQG 5DMDVWKDQ EHWZHHQ -XO\ DQG 6HSWHPEHU SURYHd WR EH DQ HIIHFWLYH DZDUHQHVVDQGDGYRFDF\DFWLYLW\WKDWDOVRFXUEHGFURVVERUGHUVPXJJOLQJDQGLOOLFLWWUDGH)RRG DQGGUXJGHSDUWPHQWVLQPDQ\VWDWHVUHSRUWHGO\UDLGHGVHYHUDOGLVWULFWVDQGVHL]HGEDQQHGJXWND SURGXFWV Banning Gutka and Other SLT Products: Best Practices from Maharashtra 0DKDUDVKWUDLVDQH[DPSOHRIEHVWSUDFWLFHVZLWKUHJDUGWRHQDFWPHQWRI)665HJXODWLRQV Maharashtra’s order noWHG WKH SUHYDOHQFH RI 6/7 DQG WKH KDUPIXO HIIHFWV RI JXWND DQG SDQ PDVDODDQGJDYHH[DPSOHVRIDGXOWHUDWLRQ PDJQHVLXPFDUERQDWH 7KHVWDWHJRYHUQPHQWEDQQHG WKHPDQXIDFWXUHVWRUDJHGLVWULEXWLRQDQGVDOHRIDOOSDQ PDVDODDQGJXWNDSURGXFWV as well as RWKHU IRRG SURGXFWV FRQWDLQLQJ WREDFFR QLFRWLQH DQG PDJQHVLXP RU DQ\ SURGXFWV PDUNHWHG VHSDUDWHO\WREHFRPELQHGWRSURGXFH6/7RUSDQPDVDODDVILQDOSURGXFWV5HJXODWLRQRI WKH )66 5HJXODWLRQs UHVWULFWV XVH RI DQWLFDNLQJ DJHQWV OLNH FDUERQDWHV RI FDOFLXP DQG PDJQHVLXPLQ IRRGVH[FHSW ZKHUHVSHFLILFDOO\DOORZHGDQGHPSRZHUVWKHJRYHUQPHQW WR EDQ pan masala containing magnesium carbonate. Maharashtra’s adoption of this restriction and ban ZLOODLGLQSOXJJLQJWKHORRSKROHZKLFKDOORZVPDQXIDFWXUHUVWRVHOOYDULRXVLQJUHGLHQWVRIJXWND DQGWREDFFRSRZGHUVHSDUDWHO\LQGLIIHUHQWVDFKHWV CHALLENGES TO SLT POLICIES $V GHVFULEHG LQ WKLV FKDSWHU FRQVLGHUDEOH FKDOOHQJHV KDYH REVWUXFWHG HQIRUFHPHQW RI 6/7 SROLFLHV7KH)665HJXODWLRQsDGGUHVVHGVRPHRIWKHVHFKDOOHQJHVEXWHQIRUFLQJFXUUHQW UHJXODWLRQVDOVRSRVHVQXPHURXVQHZFKDOOHQJHVIRUVWDWHJRYHUQPHQWV Enforcing National Bans and Laws Preventing Smuggling and Tax Avoidance ,W LV FUXFLDO WKDW EDQV RWKHU WREDFFR FRQWURO ODZV DQG WREDFFR WD[DWLRQ ODZV DUH HQIRUFHG QDWLRQZLGHDQGWKDWDOOVWDWHVFRPSO\ZLWKWKHVHSROLFLHVXQLIRUPO\,IRQHVWDWHDOORZVWUDGHLQ JXWND DQG SDQ PDVDOD VPXJJOLQJ RI WKHVH SURGXFWV WR QHLJKERXULQJ VWDWHV EHFRPHV D KXJH FKDOOHQJH 7KHWREDFFRLQGXVWU\LV LQFUHDVLQJO\DGRSWLQJSUDFWLFHVVXFKDVVHOOLQJSDQ PDVDODDQGWREDFFR SRZGHUVHSDUDWHO\ XQGHUWKHVDPHEUDQGQDPHLQVWDWHV ZKHUHFXUUHQWO\RQO\ JXWNDLV EDQQHG 276 Smokeless Tobacco and Public Health in India )LJXUH 2 7KLV WDFWLF LV LQ GLUHFW FRQIOLFW ZLWK WKH VSLULW RI 6HFWLRQ RI WKH )66 5HJXODWLRQ EHFDXVH WKH FRQVXPHU LV DEOH WR PL[ WKHVH WZR VHSDUDWH SDFNHWV DQG FRQWLQXH FRQVXPLQJJXWND7KHLPSURYHPHQWLQSXEOLFKHDOWKWKDWLVWKHJRDORIWKH)66UXOHVZLOOQRWEH DFKLHYHG LIWKLVFLUFXPYHQWLRQRIODZLVQRWFKHFNHG Figure 15.12: Pan masala and tobacco packaged separately 3KRWRJUDSKFRXUWHV\RI3KRWREDQN+5,'$< Surrogate Advertising of SLT Products $OWKRXJK6HFWLRQRI&273$LPSRVHVDWRWDOEDQRQDOODGYHUWLVHPHQWRIWREDFFRSURGXFWVWKH )66$DOORZVDGYHUWLVLQJRISDQPDVDODDQGRWKHUSURGXFWV7KHWREDFFRLQGXVWU\DWWHPSWVWRWDNH IXOODGYDQWDJHRIWKLVLQFRQVLVWHQF\ WKH\HQJDJHLQPLVOHDGLQJVXUURJDWH DGYHUWLVLQJPDUNHWLQJ WREDFFRFRQWDLQLQJSURGXFWVDQGQRQWREDFFRFRQWDLQLQJSURGXFWV SDQ PDVDOD XQGHUWKHVDPH EUDQG QDPH DV H[SODLQHG LQ GHWDLO LQ FKDSWHU :KLOH )66$ DOVR SURKLELWV PLVOHDGLQJ DGYHUWLVHPHQWVWKHLQDGHTXDF\RILWVVWUDWHJLHVWRPRQLWRUVXFKYLRODWLRQVOLPLWVWKHVFRSHRIWhis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an on Export-Oriented Units Allowed by States &XUUHQWO\*XMDUDWLVWKHRQO\VWDWHLQ,QGLDZKLFKKDVQRWLILHGDJXWNDEDQEXWKDVDOORZHGRQH PDQXIDFWXUHUWRSURGXFH6/7IRUH[SRUWDOWKRXJKVHYHUDOFLYLOVRFLHW\ERGLHVDQGSXEOLFKHDOWK H[SHUWVKDGOREELHGIRUDFRPSOHWHEDQRQPDQXIDFWXUHRIJXWNDDQGSDQ PDVDODLQ*XMDUDW6XFK discriminatory measures by states jeopardise state governments’ ability to ensure that these SURGXFWVGRQRW OHDNLQWRWKHORFDOPDUNHW 277 Chapter 15. Advocacy and Policy Measures CONCLUSIONS $GYRFDF\ DQG SROLF\ HIIRUWV KDYH FRQWULEXWHG WR VXFFHVVIXO QRWLILFDWLRQ DQG HQIRUFHPHQW RI FXUUHQW6/7SURKLELWLRQDQGUHJXODWLRQLQ,QGLDZKLFKZLOOUHGXFHWKHLQFLGHQFHRIRUDOFDQFHULQ WKHORQJUXQ7KHFXUUHQWSROLWLFDOFRQVHQVXVXSKROGLQJWKHLQWHUHVWRISXEOLFKHDOWKRYHUWUDGHLV a remarkable achievement which strengthens India’s position as a leader in tobacco control at the JOREDOOHYHO 278 Smokeless Tobacco and Public Health in India REFERENCES *XSWD 3& 5D\ &6 6PRNHOHVV WREDFFR DQG KHDOWK LQ ,QGLD DQG 6RXWK $VLD 5HVSLURORJ\ GRL: M[ 1DLU8%DUWVFK+1DLU-$OHUWIRUDQHSLGHPLFRIRUDOFDQFHUGXHWRXVHRIWKHEHWHOTXLGVXEVWLWXWHVJXWNKD DQGSDQPDVDOD DUHYLHZRIDJHQWVDQGFDXVDWLYHPHFKDQLVPV0XWDJHQHVLV $URUD00DGKX5%DQQLQJsPRNHOHVVWREDFFRLQ,QGLD SROLF\a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hapter 15. 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GDWDEDVH@ *RYHUQPHQWRI,QGLD0LQLVWU\RI/DZDQG-XVWLFH7KH)RRG6DIHW\DQG6WDQGDUGV$FW WK $XJ >FLWHG $XJ@ $YDLODEOHIURP KWWS ZZZIVVDLJRYLQSRUWDOVSGIIRRGDFWSGI 7he %RPED\ 3ROLFH $FW >FLWHG 2FW @ $YDLODEOH IURP KWWS PDKDSROLFHJRYLQPDKDSROLFHMVSWHPSKWPOERPED\BSROLFHBDFWB SGI 280 Chapter 16 Litigation and Judicial Measures $PLW 3XEOLF+HDOWK)RXQGDWLRQRI,QGLD1HZ'HOKL 20LQLVWU\RI+HDOWKDQG)DPLO\:HOIDUH*RYHUQPHQWRI,QGLD1HZ'HOKL 3+HDOLV6HNKVDULD,QVWLWXWHIRU3XEOLF+HDOWK0XPEDL Smokeless Tobacco and Public Health in India INTRODUCTION /LWLJDWLRQ KHOSV LQVWLWXWLRQDOLVe ODZE\EULQJLQJ DERXW DMXGLFLDOLQWHUSUHWDWLRQDQGVDQFWLRQ ,W KHOSVHOXFLGDWe WKHGLYHUVHFRPSRQHQWVRIDFRPSUHKHQVLYHODZ DQGIDFLOLWDWHVDQDO\VLVRIWKHVH FRPSRQHQWV-XGLFLDOUHYLHZOLHVDWWKHKHDUWRIHIIHFWLYHLPSOHPHQWDWLRQRIDQ\OHJLVODWLRQDnd SURYLGHV PXFKQHHGHG FODULW\ RQ D ODZ $PRQJ WKH PDQ\ DQJOHV IURP ZKLFK WKH WREDFFR HSLGHPLFLQ,QGLDPXVWEHWDFNOHGOLWLJDWLRQDQGMXGLFLDOPHDVXUHVDUHIDVWHPHUJLQJDVHIIHFWLYH 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The Hon’ble Courts permit public interest litigatiRQDWWKHLQVWDQFHRISXEOLF VSLULWHGFLWL]HQVIRUWKHHQIRUFHPHQWRIFRQVWLWXWLRQDORUOHJDOULJKWV$Q\SXEOLFVSLULWHGFLWL]HQ can move the Hon’ble Courts for a public cause (in the interests of the public or public welfare) E\ILOLQJDSHWLWLRQXQGHU x Article 32 of the Constitution in the Hon’ble Supreme Court (the right to move the 6XSUHPH&RXUW x $UWLFOH RI WKH &RQVWLWXWLRQ LQ an Hon’ble High Court (the right to move a High &RXUW DQG x 6HFWLRQ RI WKH &ULPLQDO 3URFHGXUH &RGH LQ WKH 0DJLVWUDWH’s Court (a police or JRYHUQPHQWRIILFLDOPD\DSSURDFKD0DJLVWUDWHDERXWDSXEOLFQXLVDQFH The following paragraphs describe PILs and the resulting interventions by the Hon’ble Courts WKDWKDYHKHOSHGWRFRPEDWWKHPHQDFHRIWREDFFRLQJHQHUDODQG6/7LQSDUWLFXODU Protection of Minors (Not Limited to SLT) (Under COTPA, Section 6) In Jammu and Kashmir Voluntary Health and Development Association v. State and Others (2010)9, the Hon’ble Jammu and Kashmir High Court issued directions to the appropriate DXWKRULWLHV LQ YDULRXV GHSDUWPHQWV DQG PXQLFLSDO FRUSRUDWLRQV WR WDNH QHFHVVDU\ VWHSV WR 285 Chapter 16. Litigation and Judicial Measures LPSOHPHQWWKHSURYLVLRQVRI&273$LQSDUWLFXODU6HFWLRQ SURKLELWLRQRQVPRNLQJLQSXEOLF SODFHV DQG6HFWLRQ SURKLELWLRQRQVDOHRIWREDFFRSURGXFWVWRPLQRUVDQGQHDUHGXFDWLRQDO LQVWLWXWLRQV In Sumaira Abdulali v. Union of India the Hon’ble Bombay High Court directed 0LQLVWU\RI+HDOWKDQG)DPLO\:HOIDUH*RYHUQPHQWRI,QGia WRQRWLI\WKHLPSOHPHQWDWLRQRI 6HFWLRQ E RI&273$ZLWKUHVSHFWWRWKHSURKLELWLRQRIVDOHRIWREDFFRSURGXFWVZLWKLQ \DUGVRIDQHGXFDWLRQDOLQVWLWXWLRQ$VDUHVXOW6HFWLRQ E RI&273$ZDVQRWLILHGDQGFDPH LQWRIRUFHRQ6HSWHPEHU In World Lung Foundation South Asia v. Ministry of Health and Family Welfare WKH Hon’ble 'HOKL +LJK &RXUWLVVXHGGLUHFWLRQVWRWKHHQIRUFHPHQWDJHQFLHVIRUVWULFWHUHQIRUFHPHQW RIWKHSURKLELWLRQRQVDOHRIWREDFFRSURGXFWV ZLWKLQ \DUGVRIHGXFDWLRQDO LQVWLWXWLRQVDV VWLSXODWHGXQGHU6HFWLRQ E RI&273$ In Cancer Patients Aid Association v. State of Karnataka & Another (2009)12 the Hon’ble .DUQDWDND+LJK&RXUWLVVXHGWKHGLUHFWLRQVIRULPSOHPHQWDWLRQRI6HFWLRQ E RI&273$DQG IXUWKHUGLUHFWHGWKHPRQLWRULQJRIVXFKLPSOHPHQWDWLRQRQDPRQWKO\EDVLV The Hon’ble Kerala +LJK&RXUWLQKerala Voluntary Health Services v. Union of India LVVXHGGLUHFWLRQVWRDOOFRQFHUQHGDXWKRULWLHVIRULPSOHPHQWLQJWKHSURYLVLRQVSURKLELWLQJWKH sale RIFLJDUHWWHVDQGRWKHUWREDFFRSURGXFWVDVSHUWKH(GXFDWLRQDO,QVWLWXWLRQV5XOHVIUDPHG XQGHU&273$7KH&RXUWJDYHGLUHFWLYHVIRU VHWWLQJXS VFKRROSURWHFWLRQFRPPLWWHHs LQ HDFK VFKRRO LQ WKH VWDWH DQG D GLVWULFWOHYHO PRQLWRULQJ FRPPLWWHH LQ HDFK GLVWULFW RI WKH VWDWH WR SHULRGLFDOO\VXSHUYLVHWKHIXQFWLRQLQJRIWKHVFKRROSURWHFWLRQFRPPLWWHH)XUWKHUGLUHFWLYHZDV JLYHQ WR HVWDEOLVK D VWDWHOHYHO PRQLWRULQJ FRPPLWWHH FKDLUHG E\ WKH 6HFUHWDU\ +RPH 'HSDUWPHQWZKLFKZRXOGPHHWDWOHDVWRQFHLQ VL[PRQWKVWRHQVXUHHIIHFWLYHFRPSOLDQFHZLWK the Hon’ble Court’s directives. 7KHFDVHRINaya Bans Sarv Vyapar v. Union of India and Others ZDVLQLWLDWHGE\DQ DVVRFLDWLRQ RI ZKROHVDOH WUDGHUV RI WREDFFR SURGXFWV VHHNLQJ H[HPSWLRQ IURP 6HFWLRQ E RI &273$RQWKHSUHWH[WWKDWWKH\GR nRt sell their products to end users. The Hon’ble Delhi High &RXUWGLVPLVVHGWKHSHWLWLRQDQGRUGHUHGWKHWREDFFRDVVRFLDWLRQWRSD\FRVWVWRERWKWKH&HQWUDO DQG VWDWH JRYHUQPHQWV ZKLFK ZRXOG EH XWLOLVHG IRU DQWLWREDFFR LQLWLDWLYHV $Q DSSHDO >/3 & 1R V @ZDVILOHGDJDLQVWWKH+LJK&RXUWRUGHURQ)HEUXDU\DQG the Hon’ble Supreme Court ex parte VWD\HGWKH+LJK&RXUWMXGJPHQWZLWKWKHFRQGLWLRQWKDWWKH SHWLWLRQHUV ZRXOG WUDQVDFW WKHLU ZKROHVDOH EXVLQHVV RQO\ DIWHU SP DQG WKH\ ZRXOG QRW HQJDJHLQDQ\UHWDLOEXVLQHVV Pictorial Health Warnings on All Tobacco Products (Under COTPA, Sections 7, 8, 9) 7KH LPSOHPHQWDWLRQ RI SLFWRULDO KHDOWK ZDUQLQJV RQ DOO WREDFFR SURGXFWV LQ ,QGLD ZDV RQO\ SRVVLEOHGXHWRZULWSHWLWLRQVILOHGE\SXEOLFVSLULWHGJURXSV7KH*RYHUQPHQWRI,QGLDQRWLILHG WKH SLFWRULDO KHDOWK ZDUQLQJV DV D UHVXOW RI D 3,/ ILOHG E\ 5XPD .DXVKLN EHIRUH WKH Hon’ble Himachal High Court in the year 2006. Subsequently, in the writ petition Health for Millions Trust v. Union of India and Others filed before the Hon’ble Supreme Court of ,QGLD WKH JRYHUQPHQW DIWHU H[WHQVLYH GHOD\ DQG GLOXWLRQ RI SLFWRULDO ZDUQLQJV ILQDOO\ JDYH DQ undertaking on 6 May 2009 in the Hon’ble Court that pack warnings would be implemented IURP0D\ :KLOHWKLVOLWLJDWLRQLVVWLOOSHQGLQJEHIRUHWKH6XSUHPH&RXUWLQVXEVHTXHQW 286 Smokeless Tobacco and Public Health in India KHDULQJVRIWKHFDVHFLYLOVRFLHW\HYHQDIWHUWKHLQLWLDOYLFWRU\LQ KDVEHHQDEOHWRFRPSHO LPSOHPHQWDWLRQRIQHZKHDOWKZDUQLQJVE\WKH,QGLDQJRYHUQPHQW 7KHZDUQLQJVDUHFKDQJHG DIWHU – \HDUV WKLV SHQGLQJ OLWLJDWLRQ KHOSV LQ PRQLWRULQJ WKH LPSOHPHQWDWLRQ RI WKH QHZ ZDUQLQJV Point-of-Sale Advertisements of All Tobacco Products (Under COTPA, Section 5) 7KH0LQLVWU\RI+HDOWKQRWLILHGFHUWDLQUHVWULFWLRQVRQDGYHUWLVHPHQWVDWWKHSRLQWRIVDOHEXWWKH %RPED\+LJK&RXUWVWD\HGHQIRUFHPHQWRIWKHVHUHJXODWLRQVLQDQex parte SURFHHGLQJLQ 2QO\LQUHVSRQVHWRFLYLOVRFLHW\LQWHUYHQWLRQWKURXJKDVSHFLDOOHDYHSHWLWLRQILOHGE\WKH+HDOWK for Millions Trust did the Hon’ble Supreme Court of India set aside the Bombay High Court stay RUGHUZKLFKSDYHGWKHZD\IRULPSOHPHQWDWLRQRIWKH UXOHV Display of Tar and Nicotine Contents [Under COTPA, Section 7(5)] In Puneet Gupta v. Union of India and Others , at the direction of the Hon’ble Delhi +LJK&RXUWWKH*RYHUQPHQWJDYHDQXQGHUWDNLQJWKDWWKH\ZLOOFUHDWHWKHUHTXLVLWHLQVWLWXWLRQDO FDSDFLW\WRWHVWWKH QLFRWLQHDQGWDUFRQWHQWVRIWREDFFRSURGXFWVE\VHWWLQJXSWREDFFRWHVWLQJ ODERUDWRULHVWR HQIRUFHWKHSURYLVLRQVRI&273$6HFWLRQ ZKLFKPDQGDWHVGLVSOD\RIWDU DQGQLFRWLQHFRQWHQWVRQWKHSDFNVFRQWDLQLQJWREDFFRSURGXFWV Restrictions on the Tobacco Industry Regarding Tobacco Advertising, Promotion, and Sponsorship (TAPS) (Under COTPA, Section 5) The Hon’ble High Court of Gujarat in Amarsinh Z Choudhari v. Union of India LVVXHG GLUHFWLRQVWRWKH*XMDUDW6WDWH5RDG7UDQVSRUW&RUSRUDWLRQDQG$KPHGDEDG0XQLFLSDO7UDQVSRUW 6HUYLFHVIRUUHPRYDORIDGYHUWLVHPHQWVRIJXWNDDQGSDQPDVDODGLVSOD\HGRQWKHSXEOLFWUDQVSRUW YHKLFOHV The Hon’ble Karnataka High Court in the writ petition Institute of Public Health v. The State Government of Karnataka and Others GLUHFWHGWKH*RYHUQPHQWRI ,QGLDWR ZLWKGUDZ VSRQVRUVKLSH[WHQGHGE\WKH7REDFFR%RDUGRI,QGLDWRDWREDFFRLQGXVWU\–VSRQVRUHGHYHQWLQ 2FWREHU LQ FRPSOLDQFH RI 6HFWLRQ RI &273$ )XUWKHU RQ )HEUXDU\ DQ XQGHUWDNLQJZDVJLYHQE\WKH*RYHUQPHQWWKDWWKH\ZRXOGVWULFWO\DGKHUHWRDQGLPSOHPHQWWKH provisions of COTPA. The Government also assured that it would consider the Petitioner’s SURSRVDO RI D FRGH RI FRQGXFW IRU SXEOLF RIILFLDOV WR SUHYHQW LQWHUIHUHQFH IURP WKH WREDFFR LQGXVWU\ZKLOVWGHYHORSLQJDQGLPSOHPHQWLQJSXEOLFKHDOWKSROLFLHVDQGSURJUDPPHVSHUWDLQLQJ WRWREDFFRFRQWUROLQDFFRUGDQFHZLWK$UWLFOHRIWKH:RUOG+HDOWK2UJDQL]DWLRQ )UDPHZRUN &RQYHQWLRQRQ7REDFFR&RQWURO )&7& ZKLFK VWDWHV WKDWWREDFFR FRQWURO SROLFLHVVKRXOGEH 22 SURWHFWHGIURPFRPPHUFLDODQGYHVWHGLQWHUHVWV 23 In Bejon Mishra v. Union of India and Others the petitioner filed a PIL in the Hon’ble 'HOKL +LJK &RXUW IRU TXDVKLQJ WKH QRWLILFDWLRQ ZKHUHE\ VXEVLGLHV DQG H[HPSWLRQV WR WKH PDQXIDFWXUHUV RI JXWND DQG FKHZLQJ WREDFFR SURGXFWV ZHUH UHVWRUHG 7KLV QRWLILFDWLRQ ZDV WKHUHDIWHUZLWKGUDZQE\WKH*RYHUQPHQW Litigation by the Tobacco Industry In VHYHUDOLQVWDQFHVWKHWREDFFRLQGXVWU\WKURXJKIURQWJURXSVRULQGXVWU\EDVHGDVVRFLDWLRQV RU E\LWVHOIKDV ILOHGZULW SHWLWLRQV WR GHOD\LPSOHPHQWDWLRQRIWREDFFRFRQWURO OHJLVODWLRQUXOHV 287 Chapter 16. Litigation and Judicial Measures DQGQRWLILFDWLRQVDQGKDYHVXFFHHGHGLQGLOXWLQJWKHVHPHDVXUHV6RPHRIWKHVHOLWLJDWLRQVWKDW KDYHLPSDFWHGWKH6/7LQGXVWU\DUHDVIROORZV Against Pictorial Health Warnings (Under COTPA, Sections 7, 8, 9) 7KH WREDFFR LQGXVWU\ KDV ILOHG PRUH WKDQ FRXUW FDVHV LQ YDULRXV +LJK &RXUWV LQ ,QGLD WR FKDOOHQJHWKHUXOHVQRWLI\LQJWKHSLFWRULDOKHDOWKZDUQLQJVZKLFKinter alia UHTXLUHGWKHSLFWRULDO GHSLFWLRQRIWKHLOOHIIHFWVRIWREDFFRXVHRQDOOWREDFFRSDFNDJHV7KHLQGXVWU\FRQWHQGHGWKDW EHVLGHV &273$ WKH 5XOHV ZHre ultra vires $UWLFOHV D DQG J RI WKH 24 &RQVWLWXWLRQRI,QGLD +RZHYHUWKH*RYHUQPHQWZKLOHGHIHQGLQJWKH5XOHVVXEPLWWHG WKDWWKH5XOHVGLGQRWYLRODWHWKHIXQGDPHQWDOULJKWWRSUDFWLFHDQ\SURIHVVLRQRUWRFDUU\RQDQ\ RFFXSDWLRQ WUDGH RU EXVLQHVV XQGHU $UWLFOH J RI WKH &RQVWLWXWLRQ 3LFWRULDO KHDOWK ZDUQLQJVRQWREDFFRSURGXFWVDUHPHUHO\DUHDVRQDEOHUHVWULFWLRQLPSRVHGE\WKH5XOHVLQWKH LQWHUHVWRIWKHJHQHUDOSXEOLF7KH0LQLVWU\RI+HDOWKDQG)DPLO\:HOIDUHDOVRILOHGDWUDQVIHU petition to avoid any inconsistency in orders passed by different Hon’ble High Courts on the VDPH PDWWHU +HDULQJ WKH SHWLWLRQ LQ Union of India v. Gopal Corporation Ltd. & Others 25 , the Hon’ble Supreme Court transferred 31 writ pHWLWLRQV SHQGLQJ EHIRUH GLIIHUHQW Hon’ble High Courts before itself for a conclusive and final decision. Pursuant to the directive of WKHDSH[FRXUWWKH3LFWRULDO+HDOWK:DUQLQJ5XOHLVLQIRUFHDQGDOOWREDFFRSURGXFWVLQ ,QGLDZHUHUHTXLUHGWRGLVSOD\WKHVSHFLILHGSLFWRULDOKHDOWKZDUQLQJVVWDUWLQJRQ0D\ ,QWKHPDWWHURI M/S Raj Products v. State (Govt of NCT of Delhi) and Another WKH +LJK&RXUWRI'HOKLXSKHOGWKHRUGHURIWKH$GGLWLRQDO'LVWULFW-XGJHIRUFRQILVFDWLRQRI JXWND SRXFKHVRQWKHJURXQGVWKDWWKHSDFNHWV SDFNDJLQJ GLGQRWFRQIRUPZLWKWKHSURYLVLRQVRIWKH 3DFNDJLQJDQG/DEHOOLQJ5XOHVQRWLILHGIRULPSOHPHQWDWLRQRI6HFWLRQRI&273$ Against Depiction of Tobacco Use in Films (Under COTPA, Section 5) ,Q WKH *RYHUQPHQW RI ,QGLD QRWLILHG WKH 5XOHV XQGHU &273$ LPSRVLQJ UHVWULFWLRQV RQ GLVSOD\RIWREDFFRSURGXFWVRUWKHLUXVHLQILOPVDQGWHOHYLVLRQSURJUDPPHV+RZHYHUWKH5XOHV ZHUHFKDOOHQJHGLQMahesh Bhatt v. Union of India and Another and Kasturi and Sons v. Union of India . :KHQ Whe Hon’ble Delhi High Court quashed the Rules, the *RYHUQPHQW went in appeal to the Hon’ble Supreme Court of India, which VWD\HG implementation of the High Court’s Order. In the meantime the GRYHUQPHQW RI ,QGLD DIWHU PDNLQJ VRPH PRGLILFDWLRQV RI WKH 5XOHV UHQRWLILHG WKH 5XOHV vide QRWLILFDWLRQV GDWHG 2FWREHUZKLFKZHQWLQWRIRUFHRQ1RYHPEHU $IWHU VXEVHTXHQWOLWLJDWLRQVDQGD VHULHV RI GLVFXVVLRQV EHWZHHQ WKH 0LQLVWU\ RI +HDOWK WKH 0LQLVWU\ RI ,QIRUPDWLRQ DQG %URDGFDVWLQJ DQG WKH 0LQLVWU\ RI /DZ DQG -XVWLFH D FRPSURPLVH ZDV DUULYHG DW UHTXLULQJ DPHQGPHQW RI WKH UXOHV $PHQGHG UXOHV ZHUH QRWLILHG RQ 6HSWHPEHU DQG ZHQW LQWR HIIHFWEHJLQQLQJRQ2FWREHU 7KHDPHQGHGUXOHVKDYHEHHQFRQVLGHUHGDQH[DPSOHRIJOREDOEHVWSUDFWLFHVLQWREDFFRFRQWURO In Kerala Voluntary Health Services v. Union of India the Hon’ble Kerala High Court GLUHFWHGWKH&HQWUDO*RYHUQPHQWWKURXJKWKH0LQLVWU\RI,QIRUPDWLRQDQG%URDGFDVWLQJWRHQVXUH WKDWQRVFHQHVDUHGHSLFWHGLQILOPVWHOHVHULDOVRURWKHUYLVXDOPHGLDZKLFKZRXOGYLRODWHWKH SURYLVLRQVRI&273$ 288 Smokeless Tobacco and Public Health in India Against Regulation of Point-of-Sale Advertisement of Tobacco Products (Under COTPA, Section 5) 32 33 In Namdeo Kamathe v. Union of India and Sridhar Kulkarni v. Union of India filed before the Hon’ble Bombay High Court, distributors of tobacco products petitioned the FRXUW WR FKDOOHQJH 5XOHV WR QRWLILHG vide *65 1R GDWHG )HEUXDU\ DQG DPHQGHGvide *651RGDWHG0DUFK ZKLFKSURSRVHGWKHUHJXODWLRQRISRLQWRI VDOH 326 DGYHUWLVLQJ7KHSHWLWLRQHUVDOOHJHGWKDWWKHQRWLILHG5XOHVYLRODWHWKHLUIXQGDPHQWDO ULJKWWRIUHHGRPRIVSHHFKDQGH[SUHVVLRQXQGHU$UWLFOH D DQGIXQGDPHQWDOULJKWWRWUDGH XQGHU$UWLFOH J RIWKH&RQVWLWXWLRQDQGWKXVultra vires WKH&RQVWLWXWLRQRI,QGLD,QDQex parte KHDULQJWKH&RXUWVWD\HGLPSOHPHQWDWLRQRIWKHVH5XOHV DQGWKHPDWWHUKDVEHHQsub judice VLQFH $ public interest litigation was also filed before the Hon’ble Kerala High Court seeking LPSOHPHQWDWLRQRIWKH5XOHVSHUWDLQLQJWRSRLQWRIVDOHDGYHUWLVHPHQWV7KH&RXUWLVVXHGQRWLFH 34 WRWKH*RYHUQPHQWVHHNLQJLWVUHVSRQVHRQWKHPDWWHU ,QWKHPHDQZKLOH WKH6XSUHPH&RXUWRI 35 India in Health for Millions v. Union of India and Others VHWDVLGHWKH%RPED\+LJK &RXUW2UGHUWKDWDFWHGDVDQLPSHGLPHQWWRLPSOHPHQWDWLRQRIWKH3RLQWRI6DOH5XOHVQRWLILHG XQGHU &273$ 2QFH DJDLQ DFWLYH OLWLJDWLRQ E\ D FLYLO VRFLHW\ RUJDQLVDWLRQ KDV PDGH SRVVLEOHWKHLPSOHPHQWDWLRQRIDQHVVHQWLDOODZRQWREDFFRFRQWURO In Rajiv Kumar Gupta and Others v. the State of Maharashtra the Hon’ble Bombay +LJK &RXUW XSKHOG WKH )LUVW ,QIRUPDWLRQ 5HSRUW ),5 whiFK LV WKH ILUVW OHYHO RI IRUPDO FRPSODLQWWRSROLFH UHJLVWHUHGDJDLQVWWKHPDQXIDFWXUHURI5DMQLJDQGKD3DQ0DVDODIRUFUHDWLQJ PLVOHDGLQJDGYHUWLVHPHQWVDQGIDLOLQJWRPHQWLRQWKHSUHVHQFHRIPDJQHVLXPFDUERQDWHLQWKHLU products. The Hon’ble Bombay High &RXUWKHOGWKDWWKHSHWLWLRQHUVPLVOHGWKH )RRG +HDOWK $XWKRULWLHVDQGWKHSHWLWLRQZDVGLVPLVVHG Litigation Under Other Acts Litigation Under the Consumer Protection Act, 1986 $ FRQVXPHU RUJDQLVDWLRQ ILOHG D FRPSODLQW DJDLQVW WKH WREDFFR LQGXVWU\ LQ EHIRUH WKH 1DWLRQDO &RQVXPHU 'LVSXWHV 5HGUHVVDO &RPPLVVLRQ 1&'5& LQ WKH PDWWHU RI Consumer Education Research Society and Others v. Dharampal Satyapal and Others 7Ke SHWLWLRQHUVFODLPHGFRPSHQVDWLRQRIPRUHWKDQ5V FURUH 5VPLOOLRQ RQO\IRUDQGRQEHKDOI RI LGHQWLILHG DQG XQLGHQWLILHG YLFWLPV RI RUDO FDQFHU FDXVHG E\ FKHZLQJ RI WREDFFR SURGXFWV 7KH\DOVRFRQWHQGHGWKDWVHOOLQJJXWNDDKD]DUGRXVSURGXFWZLWKRXWDQ\ZDUQLQJVXLWDEOHIRU SHRSOH ZKR DUH XQDEOH WR UHDG DQG ZLWK RQO\ IHHEOH ZDUQLQJV IRU WKRVH ZKR FDQ UHDG DOVR DPRXQWVWRGHILFLHQF\LQWKHSURGXFWDQGWKXVVKRXOGEHFRPSHQVDWHG7KHOLWLJDWLRQLVFXUUHQWO\ sub judice EHIRUH1&'5& Litigation Under the Drugs and Cosmetics Act, 1940 ,Q WKH PDWWHU RI Kastoori Udyog and Others v. The Union of India and Others WKH Hon’ble Rajasthan High Court upheld the Central Government`s Notification GSR 443(E), dated $SULO SURKLELWLQJ WKH XVH RI WREDFFR LQ WRRWKSDVWHVWRRWKSRZGHUV XQGHU 6HFWLRQ 33(EED) of the Drugs and Cosmetics Act, 1940. The Hon’ble High Court also issued direction to WKH&HQWUDO *RYHUQPHQWWR DSSRLQWDFRPPLWWHHRIH[SHUWVWRVWXG\WKHXVHRIWREDFFRLQ SDQ PDVDOD JXWND DQG RWKHU SURGXFWV DQG LWV HIIHFW RQ SXEOLF KHDOWK ,Q WKH HYHQW WKH FRPPLWWHH 289 Chapter 16. Litigation and Judicial Measures GHWHUPLQHGWKDWVXFKSURGXFWVZHUHLQMXULRXVWRSXEOLFKHDOWKDSSURSULDWHVWHSVVKRXOGEHWDNHQ WRSURKLELWLWVPDQXIDFWXULQJ In Laxmikant v. The Union of India and Others the Hon’ble Supreme Court upheld the DERYH QRWLILFDWLRQ SURKLELWLQJ WKH XVH RI WREDFFR LQ WRRWKSDVWHVWRRWKSRZGHUV WDNLQJ LQWR DFFRXQW WKDW WREDFFR LV DQ LQJUHGLHQW WKDW PD\ FDXVH FDQFHU ZLWK WKH REVHUYDWLRQV WKDW LPSRVLWLRQRIDWRWDOEDQLVLQWKHSXEOLFLQWHUHVW Litigation Under the Prevention of Food Adulteration Act, 1954 (PFA) 7KH3UHYHQWLRQRI)RRG'UXJ$GXOWHUDWLRQ$FW ZDVHQDFWHGWRSURWHFWWKHKHDOWKRIWKH SHRSOHRI,QGLDIURPIRRGWKDWLVDGXOWHUDWHGDQGLQMXULRXVWRKHDOWK7KH3)$GHfines ‘food’ as: ‘Any article that is used as food or drink for human consumption and includes any article that ordinarily enters into or is used in the composition or preparation of human food’. &RXUWVKDYH HODERUDWHGRQWKLVGHILQLWLRQGHFODULQJWKDWFRQVWLWXHQWVVXFKDVDUHFDQXW VXSDUL XVHGLQ6/7 SURGXFWV VXFK DV JXWND ]DUGD NKDLQL DQG RWKHUV DUH IRRG SURGXFWV /LWLJDWLRQV RQ WKLV LVVXH LQFOXGHWKHIROORZLQJ x In P.K. Tejani v. M.R. Dange the Constitutional Bench of the Hon’ble Supreme &Rurt observed that the word ‘food’ under the PFA is a very general term and applies to DOOWKDWLVHDWHQE\KXPDQEHLQJVIRUQRXULVKPHQWDQGLQFOXGHVLQJUHGLHQWVLQIRRGLWHPV $VVXSDULRUDUHFDQXWLVHDWHQIRUWDVWHDQGQRXULVKPHQWLWLVIRRGZLWKLQWKHPHDQLQJ RI6HFWLRQ Y RIWKH$FW x In State of Tamil Nadu v. R. Krishnamurthy WKH6XSUHPH&RXUWKHOGWKDWDOOWKDW LV UHTXLUHG WR FODVVLI\ D SURGXFW DV IRRG LV WKDW LW EH FRPPRQO\ XVHG IRU KXPDQ FRQVXPSWLRQRULQSUHSDULQJKXPDQIRRG x In M/s. Khedal Lal & Sons v. State of U.P) Allahabad High Court, )$& WKH Hon’ble Allahabad High Court held that chewing tobacco (i.e., zarda) is a food article. x In Manohar Lal v. State of Uttar Pradesh, &ULPLQDO 5HYLVLRQ 1R RI WKH Hon’blH $OODKDEDG +LJK &RXUW KHOG WKDW WREDFFR LV VRPHWKLQJ WKDW LV FRQVXPHG E\ KXPDQEHLQJVDQGLVIRRGXQGHU6HFWLRQ Y RIWKH3)$ 42 x In Sri Krishan Gopal Sharma and Another v. Government of N.C.T. of Delhi WKH 6XSUHPH&RXUWKHOGWKDWSDQPDVDODDQGPRXWKIUHVKHQHUDUHIRRGXQGHU6HFWLRQ Y RI WKH3)$ Box 16.1: Gutka Banned in Goa Since 2005 ,Q WKH *RYHUQPHQW RI *RD DPHQGHG WKH *RD 3XEOLF +HDOWK $FW WR SURKLELW FRQVXPSWLRQ PDQXIDFWXUHVDOHDQGGLVWULEXWLRQRIDQ\DUWLFOHRIIRRGFRQWDLQLQJWREDFFRZLWKLQWKH6WDWHRI*RD7KH WREDFFRLQGXVWU\FKDOOHQJHGWKLVSURYLVLRQRQWKHJURXQGVRIEHLQJLQYLRODWLRQRI&273$DQG3)$,QSai Traders v. State of Goa and Others %RP&5 WKH%RPED\+LJK &RXUWKHOGWKDW&273$DQG 3)$KDGGLIIHUHQWREMHFWLYHVIURPWKDWRIWKH$PHQGPHQW$FWZKLFKLVWRHQVXUHPDLQWHQDQFHRI SXEOLF KHDOWKDQGXSKHOGWKHDPHQGPHQWWRWKH*RD3XEOLF+HDOWK$FW 8QGHUWKH 3)$WKH&RPPLVVLRQHU)RRGDQG'UXJ$GPLQLVWUDWLRQDQG)RRG +HDOWK $XWKRULW\ IRUWKH6WDWHRI0DKDUDVKWUDLVVXHGDQRWLILFDWLRQGDWHG-XO\EDQQLQJWKHPDQXIDFWXUH VDOH VWRUDJH DQG GLVWULEXWLRQ RI JXWND DQG SDQ PDVDOD FRQWDLQLQJ WREDFFR IRU ILYH \HDUV EHJLQQLQJ$XJXVW,QDhariwal Industries Ltd. and Another v. Union of India and Others 290 Smokeless Tobacco and Public Health in India 43 the Appellants challenged the validity of the ban notification before the Hon’ble Bombay High Court. The Hon’ble Court dismissed the writ petition and upheld the validity of WKH QRWLILFDWLRQ 6HYHUDO RWKHU VWDWHV DOVR SURKLELWHG WKH PDQXIDFWXUH VDOH VWRUDJH DQG GLVWULEXWLRQRISDQPDVDODDQGJXWNDZLWKLQWKHLUERUGHUV XQGHUWKHSURYLVLRQVRIWKH 3)$DWWKDW WLPH +RZHYHU WKH WREDFFR LQGXVWU\ FKDOOHQJHG WKH MXGJPHQW RI WKH Hon’ble Bombay High Court and other such State Orders by moving the matter to the Hon’ble Supreme Court of India. 44 In Godawat Pan Masala Products I.P. Ltd. & Another v. Union of India & Others WKH issue raised before the Hon’ble Supreme Court was the validity of notiILFDWLRQV LVVXHGE\WKH 6WDWH)RRG +HDOWK $XWKRULW\XQGHU6HFWLRQ LY RIWKH3)$E\ZKLFKWKHPDQXIDFWXUHVDOH storage, and distribution of pan masala and gutka were banned in different states. The Hon’ble 45 &RXUWFRQFOXGHGWKDW6HFWLRQ LY RIWKH 3)$ ZDVQRWDQLQGHSHQGHQWVRXUFHRISRZHUIRUWKH VWDWH DXWKRULW\ DQG WKDW WKH 6WDWH )RRG +HDOWK $XWKRULW\ KDV QR SRZHU WR SURKLELW WKH PDQXIDFWXUH VWRUDJH VDOH RU GLVWULEXWLRQ RI DQ\ DUWLFOH QRW XVHG DV IRRG &RQVHTXHQWO\ WKH Hon’ble Court quashed all such notifications issued by state governments, but the Hon’ble Court KHOG WKDW JXWND LV D IRRG SURGXFW DQG WKH SRZHU RI EDQQLQJ DQ DUWLFOH RI IRRG EHFDXVH LW LV LQMXULRXVWRKHDOWKEHORQJHGDSSURSULDWHO\WRWKH&HQWUDO*RYHUQPHQWXQGHU6HFWLRQ $ I RI WKH3)$ 7KHUHIRUHDOOVXFKQRWLILFDWLRQVLVVXHGE\WKHsWDWHJRYHUQPHQWVZHUHTXDVKHG 1RWDEO\ WKH WREDFFR LQGXVWU\ LWVHOI UHIHUUHG WR FKHZLQJ WREDFFR DV DQ HGLEOH FRPPRGLW\ UHJXODWHGXQGHUWKH3)$ZKHQWKHLQGXVWU\FKDOOHQJHGWKH3DFNDJLQJDQG/DEHOOLQJ5XOHVEHIRUH WKH7DPLO1DGX+LJK&RXUW SCIENTIFIC AND TECHNICAL INFORMATION FOR TOBACCO CONTROL LITIGATION Scientific and technical information submitted before the Hon’ble Court plays a vital role in OLWLJDWLRQ RXWFRPHV 7KH WREDFFR LQGXVWry EDVHV LWV DUJXPHQWV RQ WKH WHFKQLFDO DQG VFLHQWLILF FODLP WKDW WREDFFR SURGXFWV DUH QRW DV KDUPIXO DV DVVHUWHG E\ WKH UHJXODWRUV 7KH LQGXVWU\ FKDOOHQJHV GHFLVLRQV WR UHJXODWH WREDFFR RQ WKH JURXQGV WKDW WKH\ ZLOO DGYHUVHO\ DIIHFW WKH HFRQRP\ DQG UHQGHU PLOOLRQV RI SHRSOH XQHPSOR\HG 7KH IDFWs are WKDW WREDFFR XVH LWVHOI DGYHUVHO\ DIIHFWV WKH KHDOWK DQG HFRQRP\ RI D FRXQWU\ DQG WKH MREV JHQHUDWHG E\ WREDFFR FRPSDQLHVDUHWHPSRUDU\DQGVHDVRQDOZLWKOLWWOHRUQRHFRQRPLFVHFXULW\IRUWKRVHHQJDJHGLQ VXFKZRUN 7KH WREDFFR LQGXVWU\ RSSRVHG SURKLELWLQJ WKH VDOH RI 6/7 SURGXFWV XQGHU WKH 3)$ LQ suggesting that all tobacco products must be ‘regulated’ under COTPA (because COTPA only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of ‘coloured pictograms’ aV JUDSKLFKHDOWKZDUQLQJVZRXOGEHFRVWO\IRUWKHPDQXIDFWXUHUVRI 291 Chapter 16. Litigation and Judicial Measures SLT products. However, the Hon’ble Supreme Court’s verdict compelled the smokeless industry WRGLVSOD\WKHZDUQLQJVEHJLQQLQJ0D\ $V WKH WREDFFR LQGXVWU\ UDLVHV VFLHQWLILF DQG WHFKQLFDO DUJXPHQWV WR FKDOOHQJH DQG DYRLG FRPSOLDQFHZLWKODZVOLWLJDWLRQSURYLGHVDQRSSRUWXQLW\IRUWKHJRYHUQPHQWVQRQJRYHUQPHQWDO RUJDQLVDWLRQV 1*2V DQG FLYLO VRFLHW\ WR LQWHUYHQH DQG HVWDEOLVK WKH QHHG IRU HIIHFWLYH PHDVXUHVIRUWREDFFRFRQWUROIt was the expert committee constituted as a result of the Hon’ble Supreme Court’s directive in a PIL that revealed the presence of 3 FKHPLFDOV LQ 6/7 products, 28 of which were found to be carcinogenic. In the same matter, the Hon’ble Supreme &RXUWSURKLELWHGWKHVDOHRIFHUWDLQWREDFFRSURGXFWVLQSODVWLFVDFKHWVEDVHGRQWKHDYDLODEOH VFLHQWLILFDQGWHFKQLFDOLQIRUPDWLRQ LITIGATION INFLUENCING THE CURRENT POLICY ENVIRONMENT FOR REGULATION OF SLT Step I: Prohibition on Sale of Gutka, Pan Masala, and Other SLT Products in Plastic Sachets A local NGO, the Indian Asthma Care Society, filed a PIL before the Hon’ble Rajasthan High &RXUWIRUUHVWULFWLRQRIVDOHDQGLPSRVLWLRQRIILQHVRQWKHPDQXIDFWXUHUVRISDQPDVDODJXWND DQGRWKHUIRUPVRIFKHZLQJ WREDFFREHFDXVHRIWKHHQYLURQPHQWDOKD]DUGVFDXVHGE\OLWWHULQJRI LWVSODVWLFVDFKHWVZKLFKLVDPDMRUWR[LFSROOXWDQW7KH+LJK&RXUWvide LWVRUGHUGDWHG -XO\ DJUHHGZLWKWKHSHWLWLRQHUVDQGJDYHGLUHFWLRQVUHVWUDLQLQJWKHPDQXIDFWXUHUVRIJXWNDDQG pan masala from selling their products in plastic sachets. The Hon’ble Court also ordered H[HPSODU\ILQHVDJDLQVWWKHPDQXIDFWXUHUVRQWKHEDVLVRIWKH‘polluter pays’ principle used for HQIRUFHPHQWRIHQYLURQPHQWDOODZV7KHPDQXIDFWXUHUVZHUH DOVRGLUHFWHGWRFRPSO\ZLWKWKH SURYLVLRQVRI&273$ *XWND PDQXIDFWXUHUV DSSHDOHG Whe 2UGHU RI WKH Hon’ble 5DMDVWKDQ +LJK &RXUW EHIRUH WKH Hon’ble Supreme Court of India in Ankur Gutka v. Indian Asthma Care Society and Others The Hon’ble 6XSUHPH &RXUW vide LWV RUGHU GDWHG 'HFHPEHU GLUHFWHG WKH 0LQLVWU\RI+HDOWKDQG)DPLO\:HOIDUHWRXQGHUWDNHDFRPSUHKHQVLYHDQDO\VLVDQGVWXG\RIWKH FRQWHQWVRI JXWND San Pasala, DQGVLPLODU6/7SURGXFWVPDQXIDFWXUHGLQWKHFRXQWU\DQG WKH KDUPIXOHIIHFWVRIWKHLU FRQVXPSWLRQ 7KH0LQLVWU\RI(QYLURQPHQWZDVDOVRGLUHFWHGWRILQDOLVH QRWLI\ DQG HQIRUFH WKH 3ODVWLFV 0DQXIDFWXUH 8VDJH DQG :DVWH 0DQDJHPHQW 5XOHV ZKLFKinter alia EDQQHGWKHVDOHRIJXWND and San PDVDODLQSODVWLFVDFKHWV,QFRPSOLDQFHZLWK the Hon’ble 6XSUHPHCourt’s direction, the Plastic Waste (Management and Handling) Rules, ZHUHQRWLILHGRQ)HEUXDU\ ZLWK 5XOH G EDQQLQJWKHVWRULQJSDFNLQJRUVHOOLQJ RIJXWNDWREDFFRDQGSDQPDVDODLQSODVWLFVDFKHWV7KHPDQXIDFWXUHUVRIJXWNDWREDFFRand SDQ PDVDODZHUHUHVWUDLQHGIURPXVLQJSODVWLFVDFKHWVEHJLQQLQJRQ0DUFK 6XEVHTXHQWO\ ZKHQWKH0LQLVWU\DPHQGed WKHDERYH5XOHVH[HPSWLQJSODVWLFSRXFKes RUVDFKHWVPHDQW exclusively for export, the Hon’ble 6XSUHPH &RXUW RQFH DJDLQ LQWHUYHQHG WR HQVXUH WKDW WKLV FRQFHVVLRQ was ZLWKGUDZQ 6XEVHTXHQWO\ WKH 0LQLVWU\ vide *65 1R ( GDWHG -XO\ LQWURGXFHG 5XOH J ZKLFK SURKLELWHG WKH XVH RI SODVWLF LQ DQ\ IRUP IRU SDFNLQJ RI JXWNDWREDFFRDQGSDQPDVDOD Step II: Complete Prohibition on Sale of Gutka 6XEVHTXHQWWRWKHMXGJPHQWLQWKHGodawat Pan Masala Products I.P. Ltd. & Another v. Union 52 of India & Others WKDW KHOGJXWNDWREHDIRRGSURGXFWZKLFKWKH&HQWUDO*RYHUQPHQW 292 Smokeless Tobacco and Public Health in India KDV WKH ULJKW WR EDQ EHFDXVH LW LV LQMXULRXV WR KHDOWK WKH 3)$ 5XOHV ZHUH DPHQGHG WR LQFRUSRUDWH5XOH-RI ZKLFKSURKLELWHGWKHXVHRIWREDFFRDQGQLFRWLQHDVLQJUHGLHQWVLQ any food products. However, the manufacturers challenged this Rule in various Hon’ble High &RXUWVDQGWKH&RXUWVKDYHVWD\HGWKHLPSOHPHQWDWLRQRIWKLVSURYLVLRQ WKHPDWWHULVsub judice EHIRUHWKH6XSUHPH&RXUWRI,QGLDvide WKH7UDQVIHU3HWLWLRQUnion of India v. Central Arecanut 53 Marketing Co-Operative and Others ,Q WKH PHDQWLPH WKH *RYHUQPHQW HQDFWHG WKH )RRG6DIHW\DQG6WDQGDUGV$FW )66$ WRUHSODFHWKH3)$7KHREMHFWLYHRI)66$LVWR HVWDEOLVK IRRG VWDQGDUGV DQG UHJXODWHPRQLWRU WKH PDQXIDFWXULQJ LPSRUW SURFHVVLQJ GLVWULEXWLRQDQGVDOHRIIRRGWRHQVXUHWKHVDIHW\RIIRRGLQWHQGHGIRUKXPDQFRQVXPSWLRQ7KH )66$RYHUULGHVDOOIRRGrelated laws and defines the word ‘food’ more broadly than PFA did ,Q DQRWKHUGHYHORSPHQWWKH0LQLVWU\RI+HDOWKDQG)DPLO\:HOIDUH*RYHUQPHQW RI ,QGLDLQ SDUWQHUVKLS ZLWK WKH 3XEOLF +HDOWK )RXQGDWLRQ RI ,QGLD 3+), DQG WKH :RUOG +HDOWK 2UJDQL]DWLRQ :+2 RUJDQLVHGD1DWLRQDO&RQVXOWDWLRQRQ6/7LQ$SULOWRKLJKOLJKWWKH PDJQLWXGHRIWKHSUREOHPRI6/7XVHDQGSRVVLEOHSROLFLHVWRUHJXODWHDQGFRQWURO 6/7 XVHLQ ,QGLD$IWHUGHOLEHUDWLRQVWKH&RQVXOWDWLRQinter alia UHFRPPHQGHG x ,PSRVLQJDFRPSOHWHEDQRQ6/7SURGXFWV x &RQVLGHULQJDOOIRUPVRIFKHZLQJWREDFFRSURGXFWVDVIRRGLWHPV x 5HYLYLQJ DQG LPSOHPHQWLQJ 5XOH - ZKLFK SURKLELWV XVH RI WREDFFR DQG QLFRWLQH DV LQJUHGLHQWVLQDQ\IRRGSURGXFWV )RXU PRQWKV ODWHU LQ $XJXVW , the PFA Act 1954 was repealed by the Food Safety and Standards Act, 2006, DQG 5XOH - RI WKH 3)$ $FW ZDV UHQRWLILHG DV WKH )RRG 6DIHW\ DQG 6WDQGDUGV 3URKLELWLRQ DQG5HVWULFWLRQVRQ6DOHV 5HJXODWLRQ XQGHUWKH )RRG6DIHW\ DQG 6WDQGDUGV$FW )66$ ZKLFKZHQWLQWRIRUFHEHJLQQLQJ$XJXVW 7KHVWDWHPHQWLQ 5HJXODWLRQ WKDW ‘tobacco and nicotine shall not be used as ingredients in any food products’ LVWDNHQYHUEDWLPIURPDQGLQpari materia ZLWK 5XOH-RIWKH3)$ Based on FSS Regulation 2.3.4 and the fact that Hon’ble Courts have held that gutka, zarda, FKHZLQJ WREDFFR DQG SDQ PDVDOD DUH D IRRG SURGXFWV sWDWHV DQG 8QLRQ 7HUULWRULHV KDYH EDQQHGWKHPDQXIDFWXUHDQGVDOHRIJXWNDDQGSDQPDVDODFRQWDLQLQJWREDFFRDQGQLFRWLQHDQGD IHZ VWDWHV KDYH DOVR H[WHQGHG WKH EDQ WR ]DUGD DQG SDQ PDVDOD 6HH $SSHQGL[ IRU D WDEOH VXPPDUL]LQJWKHVWDWXVRIWKHVWDWHVUHODWLYHWRWKH)66$ 6LQFH 5HJXODWLRQ ZDV LPSOHPHQWHG E\ WKH VWDWHV DQG 8QLRQ 7HUULWRULHV WKH WREDFFR LQGXVWU\ KDV FKDOOHQJHG WKH UHJXODWLRQ LQ YDULRXV +LJK &RXUWV LQFOXGLQJ LQ 'HOKL .HUDOD -DEDOSXU *ZDOLRU $OODKDEDG 3DWQD 5DMDVWKDQ %RPED\ DQG .DUQDWDND $OO WKH &RXUWV KDYH UHIXVHGDQ\UHOLHIWRWKHWREDFFRLQGXVWU\LQWKHPDWWHUDQGKDYHXSKHOGWKHODZ/LWLJDWLRQVIRU LPSOHPHQWDWLRQ RI WKLV SURYLVLRQ RI )66$ KDYH DOVR EHHQ ILOHG DQG WKH +LJK &RXUWV RI $OODKDEDG-DPPXDQG.DVKPLU'HOKL DQG$QGKUD3UDGHVKKDYHGLUHFWHGWKHVWDWHJRYHUQPHQWV WRFRQVLGHUHQIRUFHPHQWRIWKH5HJXODWLRQEDQQLQJJXWND Litigations Under the Food Safety and Standards Act, 2006 (FSSA) 7KHILUVWEDQXQGHUWKH)66$UHJXODWLRQZDVLPSRVHGE\WKHVWDWHRI0DGK\D3UDGHVKDQGDWWKH 54 YHU\ ILUVW LQVWDQFH Ghoi Foods Private Limited ZHQW WR WKH *ZDOLRU %HQFK RI WKH 0DGK\D3UDGHVK+LJK&RXUW FKDOOHQJLQJWKHVWDWHQRWLILFDWLRQ6LPLODUO\WKHQRWLILFDWLRQRIWKH 55 *RYHUQPHQWRI.HUDODZDVFKDOOHQJHGE\WKHAll Kerala Tobacco Dealers’ Association The notification of the Government of Bihar was challenged before the Hon’ble Patna High 293 Chapter 16. Litigation and Judicial Measures &RXUWE\Lal Babu Yadav LQWKHVDPH\HDUWKHQRWLILFDWLRQVRIWKH'HOKL5DMDVWKDQ %RPED\ DQG.DUQDWDNDJRYHUQPHQWVZHUHDOVRFKDOOHQJHGDQGPDQ\RWKHUVLPLODUFDVHVZHUH ILOHG RQH DIWHU DQRWKHU DFURVV WKH FRXQWU\ FKDOOHQJLQJ WKH GHFLVLRQV RI WKH JRYHUQPHQWV +RZHYHU all the Hon’ble High Courts rejected the gutka manufacturers’ pleas for a stay of the state governments’ notifications imposing the ban. 7KH ,QGLDQ'HQWDO$VVRFLDWLRQRIWKHVWDWHRI8WWDU3UDGHVKILOHGLQWKH$OODKDEDG+LJK &RXUWIRU LVVXDQFHRIDQRUGHUVLPLODUWRWKDWLPSRVHGE\WKHVWDWHJRYHUQPHQWRI0DGK\D3UDGHVKFDOOLQJ IRULPSOHPHQWDWLRQRIWKH)66$5HJXODWLRQEDQQLQJJXWND The Hon’ble High Court of $OODKDEDGGLUHFWHGWKHVWDWHJRYHUQPHQWVWRWDNHVWHSVWRHQIRUFHWKH5HJXODWLRQEDQQLQJJXWND Similar orders were passed by the Hon’ble High Court of Delhi, the Hon’ble High Court of Jammu and Kashmir, and the Hon’ble High Court of Andhra Pradesh. Though the matters are sub judiceWKHJRYHUQPHQWVRI'HOKL8WWDU3UDGHVK-DPPXDQG.DVKPLUDQG$QGKUD3UDGHVK KDYHDOUHDG\HQIRUFHGWKHEDQLQWKHLUVWDWHV &RQVLGHULQJ WKH YROXPH RI OLWLJDWLRQV UHJDUGLQJ WKis 5HJXODWLRQ WKH *RYHUQPHQW RI ,QGLD WKURXJKWKH0LQLVWU\RI+HDOWKDQG)DPLO\:HOIDUHILOHGDWUDQVIHUSHWLWLRQ—Union of India & Another v. Dharampal Satyapal Ltd. and Others and Food & Safety Authority of India Etc. v. M/s Kaipan Panmasala Pvt. Ltd. and Others —requesting the Hon’ble Supreme &RXUWWRWUDQVIHUDOOWKHFDVHVDQGKHDUWKHPDWWHULWVHOIWRDYRLGWKHSDVVLQJRILQFRQVLVWHQWDQG FRQIOLFWLQJ GHFLVLRQV E\ GLIIHUHQW +LJK &RXUWV DQG WR DYRLG DGYHUVH RUGHUV DJDLQVW WKH enforcement of the Regulation. The Hon’ble Supreme Court, vide DQRUGHUGDWHG0DUFK KDV DOORZHG WKH WUDQVIHU SHWLWLRQ Union of India & Another v. Dharampal Satyapal Ltd. and Others ZKLFKZLOOEH KHDUGDORQJZLWKWKHHDUOLHUWUDQVIHUSHWLWLRQVLQWKHPDWWHURIUnion of India v. Central Arecanut Marketing Co-Operative and Others 7KH %RPED\ +LJK &RXUW vide DQ RUGHU GDWHG -DQXDU\ GLVPLVVHG D SHWLWLRQ VHHNLQJ H[HPSWLRQIURPWKHEDQRQJXWNDPDQXIDFWXUHGIRUH[SRUW+HDULQJDVSHFLDOOHDYHDJDLQVWWKLV RUGHUWKHWKUHHjudge bench of the Hon’ble Supreme Court dismissed the SHWLWLRQ 2Q $SULO Whe Hon’ble Supreme Court GLUHFWHG WKH +HDOWK 6HFUHWDULHV RI WKH VWDWH JRYHUQPHQWVWKDWKDGEDQQHGJXWNDDQGSDQPDVDOD ZLWK WREDFFRXQGHU)66$5HJXODWLRQ WRILOHDFRPSOLDQFHUHSRUWRQWKHVWDWXVRIWKHLPSOHPHQWDWLRQRI WKLVEDQ7KH+HDOWK6HFUHWDULHV RIWKHVWDWHVWKDWKDYHQRWLVVXHGRUGHUVWREDQJXWNDDQGSDQPDVDOD ZLWKWREDFFRDUHUHTXLUHGWR ILOHDQDIILGDYLWJLYLQJWKHLUUHDVRQVIRUQRWLPSOHPHQWLQJWKHEDQ CHALLENGES AND OPPORTUNITIES /DFNRIFRPSUHKHQVLYHWREDFFRFRQWUROOHJLVODWLRQEHIRUH&273$DQGWKHDGRSWLRQRIWKH:+2 )&7&ZDVDFKDOOHQJHIRUWREDFFRFRQWUROOLWLJDWLRQV+RZHYHUHQDFWPHQWRI&273$LQ DQGLWVSURWUDFWHGLPSOHPHQWDWLRQLQVXEVHTXHQW\HDUVUHVXOWHGLQLQFUHDVHGOLWLJDWLRQERWK LQWKH SXEOLFLQWHUHVW DQGE\WKHWREDFFRLQGXVWU\7KHSXEOLFLQWHUHVWOLWLJDWLRQVRXJKWWRHQVXUHHDUO\ DQGHIIHFWLYHLPSOHPHQWDWLRQRIWKHODZZKLOVWWKHWREDFFRLQGXVWU\OLWLJDWHGWRGHOD\DQGGLOXWH WKHODZ7KHWREDFFRLQGXVWU\KDVFKDOOHQJHGPRVWWREDFFR FRQWUROOHJLVODWLRQEHIRUHWKH&RXUWV DWDOOOHYHOVDQGUHPDLQVWKHJUHDWHVWFKDOOHQJHWRHIIHFWLYHWREDFFRFRQWURO 2QHLQGXVWU\WDFWLFKDVEHHQWRFKDOOHQJHWREDFFRFRQWUROODZVLQPXOWLSOH+LJK&RXUWVRQO\WR LQFUHDVHWKHEXUGHQRQWKHUHVSRQGLQJDJHQFLHV,QPDWWHUVZKHUHPRUHWKDQRQHGHSDUWPHQWLV LPSOHDGHG DV UHVSRQGHQW ODFN RI FRRUGLQDWLRQ DPRQJ WKH UHVSRQGHQWV ZHDNHQV WKH WREDFFR 294 Smokeless Tobacco and Public Health in India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measures. The Hon’ble Supreme Court has yet to WDNHDILQDOGHFLVLRQLQWKHPDWWHURIUnion of India v. 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Indian Asthma Care Society and Others KDVEHHQ KHOSIXO LQ UHVWULFWLQJ WKH VDOH RI 6/7 SURGXFWV LQ SODVWLF VDFKHWV 7KH &RXUW DOVR GLUHFWHG FRPPLVVLRQLQJ RI D UHSRUW ZKLFK KHOSHG WR UHYHDO WKH KD]DUGRXV FDUFLQRJHQLF QDWXUH RI WKH FKHPLFDOFRPSRQHQWVLQ6/7SURGXFWV The findings of the Hon’ble Supreme Court in Godawat Pan Masala Products I.P. Ltd. & Another v. 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Litigation and Judicial Measures REFERENCES Vishaka and Others v. 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2IILFHIRU6RXWK(DVW$VLD >XQSXEOLVKHG@ $JUDZDO665DMDJRSDO.1LFRWLQHFRQWHQWVLQYDULRXVWRRWKSRZGHUV GDQWPDQMDQV PHDVXUHPHQWDQGVDIHW\ HYDOXDWLRQ)RRG&KHP7R[LFRO 395 396 Smokeless Tobacco and Public Health in India TUIBUR (TOBACCO WATER) Figure: 7REDFFRZDWHUVROGLQWKHPDUNHWSODFH Source: 6LQKD'1 *XSWD3&3HGQHNDU07REDFFRZDWHU DVSHFLDOIRUPRIWREDFFRXVHLQ WKH0L]RUDPDQG0DQLSXUVWDWHVRI,QGLD1DWO0HG-,QGLD Common Name 7XLEXU LQ0L]RUDPKLGDNSKX LQ0DQLSXU Brands 1RQH0DGHORFDOO\LQYHU\VPDOOXQLWV About the Product/Ingredients 7REDFFRZDWHULVWREDFFRVPRNHLQIXVHGZDWHU,Wis a XQLTXHVPRNHOHVVSURGXFWWKDWLVOLTXLG Processing/Manufacturing 7REDFFRZDWHULVPDGHE\SDVVLQJVPRNHJHQHUDWHGE\EXUQLQJWREDFFRWKURXJKZDWHUXQWLOWKH SUHSDUDWLRQWXUQVFRJQDFLQFRORXUDQGKDVDSXQJHQWVPHOO7KHSUHSDUDWLRQLVVWRUHGDQGVROGLQ ERWWOHV DW PDQ\ SODFHV VXFK DV VWDWLRQHU\ VKRSV and daily RU ZHHNO\ PDUNHWV see WKH ILJXUH DERYH 7REDFFR ZDWHU ZDV WUDGLWLRQDOO\ SURGXFHG DW KRPH LQ VPDOO TXDQWLWLHV IRU KRXVHKROG FRQVXPSWLRQ:RPHQ ZRXOG VPRNe DVSHFLDOO\ GHVLJQHGSLSHZLWKa UHFHSWDFOHIRUZDWHUWKURXJK ZKLFKWREDFFRVPRNHwaVSDVVHG /DWHUVPDOOVFDOHPDQXIDFWXULQJXQLWVZHUHVHWXS XVXDOO\ QHDU D ZDWHU sRXUFH OLNH a ULYXOHW ZDWHUIDOO RU IRXQWDLQ IRU FRPPHUFLDO SURGXFWLRQ LQ ODUJHU TXDQWLWLHV 2QH LURQ RYHQ ZLWK D IHZ SLSHV DQG FRQWDLQHUV LV DOO WKDW LV UHTXLUHG DW D FRVW RI DURXQG5V LQ $VSDFHRIƍ [ƍLVVXIILFLHQWIRU DVPDOOSURGXFWLRQXQLWXVXDOO\LQ EDPERRWKDWFKHG VWUXFWXUHV LQ 0L]RUDP $ W\SLFDO IDFWRU\ PD\ SURGXFH OLWHUV RI WREDFFR ZDWHULQRQHPRQWK 3URGXFWLRQLVODUJHO\XQUHJXODWHG DQGWKHUHDUHQRKHDOWKZDUQLQJVRQWKH WXLEXU ERWWOHVVROG 7KHTXDOLW\RIWREDFFRZDWHULVJUDGHGDFFRUGLQJWRWKHFRQFHQWUDWLRQRIWREDFFRVPRNHLQWKH ZDWHUZKLFK LVEDVHGRQWKHTXDQWLW\RIWREDFFRXVHGDQGWKHWLPHWDNHQIRUSURGXFWLRQ—WKH KLJKHUWKHFRQFHQWUDWLRQWKH EHWWHUWKHTXDOLW\ sHHWDEOH$ 397 Appendix 1: Factsheets on Smokeless Tobacco Products in India Table A2: Grades of tobacco water Amount of Amount of Grade of Processing Amount of Price in Rs/L tobacco tobacco water tobacco water time (hrs) water used (L) 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6LQKD'1*XSWD3&3HGQHNDU07REDFFRZDWHU DVSHFLDOIRUPRIWREDFFRXVHLQWKH0L]RUDPDQG0DQLSXU VWDWHVRI,QGLD1DWO0HG-,QGLD 0DKDQWD-&KHWLD0+D]DULND11DUDLQ.6KDUPD67R[LFLW\RIWXLEXUDXQLTXHIRUPRIWREDFFRVPRNH H[WUDFWXVHGLQ0L]RUDP,QGLD&XUUHQW6FLHQFH 5HGG\.6*XSWD3&HGLWRUV5HSRUWRQWREDFFRFRQWUROLQ,QGLD1HZ'HOKL *RYHUQPHQWRI,QGLD0LQLVWU\RI +HDOWKDQG)DPLO\:HOIDUH >FLWHG0DU@$YDLODEOHIURP KWWS PRKIZQLFLQ:ULWH5HDG'DWDO V 7REDFFRFRQWURLQ,QGLDB'HFSGI 399 400 Smokeless Tobacco and Public Health in India ZARDA Figure: =DUGDVROGLQWLQDQGVDFKHWVSource: 'U'KLUHQGUD16LQKD:+26($52 Figure: =DIUDQL=DUGDSource: 'U*DXUDY.XPDU3+), Common Name Zarda 401 Appendix 1: Factsheets on Smokeless Tobacco Products in India Brands 0DQXIDFWXUHGE\VRPHELJQDWLRQDOEUDQGV About the Product/Ingredients Zarda LV IODYRXUHG FKHZLQJ WREDFFR IODNHV PL[HG ZLWK DURPDWLF VSLFHV PHQWKRO KHUEV IUDJUDQFHV VDIIURQ UDZ NLPDP, VLOYHU IODNHV DQG VDQGDOZRRG RLO LQ FRPELQDWLRQV XQLTXH WR 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