Burden of Smokeless Tobacco

India
Dr. Jagdish Kaur
Chief Medical Officer
Directorate General of Health Services
Ministry of Health & Family Welfare
Government of India
jagdish.kaur@nic.in

Smokeless Tobacco
o The term smokeless
tobacco includes a large
variety of commercially or
non-commercially
available products and
mixtures that contain
tobacco as the principal
constituent and are used
either orally (through the
mouth) or nasally (through
the nose) without
combustion.
Global Adult Tobacco Survey- India
2010



Total
(%)

Males
(%)

Females
(%)
Tobacco
users
34.6 47.9 20.3
Smokers 14.0 24.3 2.9
Smokeless
Tobacco
users
25.9 32.9 18.4
GATS India 2010
Smokeless tobacco has emerged as the
most prevalent tobacco product as per
GATS India with 163.7 million users of
only smokeless tobacco. In addition,
42.3 million users of both smoking and
smokeless tobacco products (total 206
million).





Status of smokeless tobacco use by place of
residence and daily use
Smokeless tobacco use
status Overall
Gender
Place of
residence
Male Female Rural Urban
Current users 25.9 32.9 18.4 29.3 17.7
Daily user 21.4 27.4 14.9 24.2 14.7
Occasional user 4.5 5.4 3.5 5.1 3.0
5
Prevalence of Smokeless Tobacco by Age,
education and Occupation
6
16
29
31
34
34
33
25
15
33
35
6
18
33
0 10 20 30 40
15-24
25-44
45-64
65+
NO FORMAL EDUCATION
LESS THAN PRIMARY
PRIMARY BUT LESS THAN
SECONDARY
SECONDARY AND ABOVE
GOVT AND NON-GOVT EMPLOYEE
SELF EMPLOYED
STUDENT
HOMEMAKER
RETIRED AND UNEMPLOYED
International Agency for Research in Cancer (IARC)
Monograph (WHO) - Oral Forms of smokeless tobacco

Tobacco alone (with aroma
and flavourings) e.g
Creamy or dry snuff,
Gudakhu, Gul, Mishri, Red
tooth powder
Tobacco with other
components (lime, sodium
bicarbonate, ash) e.g
Khaini, Zarda, Maras,
Naswar
Betel quid with tobacco
(includes areca nut, slaked
lime, catechu and tobacco
with spices) e.g Betel
quid, Gutkha, Mawa

Smokeless forms of tobacco products















Mawa
Mishri (masheri)
Pan masala (betel quid)
Creamy snuff
Khaini
Qiwam
Gutkha
Smokeless forms of tobacco products
Zarda
Red Tooth
Powder
Snus (snuff))
Other smokeless forms of tobacco products
are:
Gudhaku (tobacco paste)
Tuibur (Tobacco water)
Rank
All Persons Males Females
1 Khaini 11.6%
2 Gutkha 8.2%
3 Betel quid with tobacco
6.2%
4 Tobacco used for oral
application 4.7%
Khaini 18.0%
Gutkha 13.1%
Betel quid with
tobacco 7.5%
Other smokeless
tobacco products
3.5%

Tobacco used for
oral application
6.3%
Other smokeless
tobacco products
5.4%
Betel quid with
tobacco 4.9%
Khaini 4.7%
Most Commonly Used smokeless tobacco Products
10
5
5
5
6
6
7
8
8
11
11
12
15
19
19
22
22
25
26
26
28
28
31
33
36
41
41
43
45
45
47
48
49
0 10 20 30 40 50 60
HIMACHAL PRADESH
GOA
CHANDIGARH
PONDICHERRY
HARYANA
PUNJAB
JAMMU & KASHMIR
TAMIL NADU
DELHI
KERALA
UTTARANCHAL
ANDHRA PRADESH
RAJASTHAN
KARNATAKA
GUJARAT
WEST BENGAL
UTTAR PRADESH
SIKKIM
INDIA
MAHARASHTRA
MEGHALAYA
MADHYA PRADESH
ASSAM
ARUNACHAL PRADESH
MIZORAM
TRIPURA
ORISSA
MANIPUR
NAGALAND
CHHATTISGARH
JHARKHAND
BIHAR
Users of Smokeless Tobacco by
States
11
Most Commonly Used 5 Tobacco Products
States with Prevalence among Males Exceeding 25%
Khaini
Chhattisgarh, Jharkhand,
Bihar, Nagaland, Manipur,
Assam
Tobacco used for oral
application
Chhattisgarh

Betel quid with tobacco
Nagaland, Manipur, Tripura

Gutkha
Madhya Pradesh

12
States with prevalence among Females exceeding 25%
Other smokeless
tobacco products
Bihar

Tobacco used for oral
application
Chhattisgarh
Khaini

Mizoram

Betel quid with tobacco
Tripura
Nagaland, Manipur,
Meghalaya

13
Male Female
States where 90%
+ users are daily
users
Jharkhand,
Maharashtra,
Haryana, Goa and
Delhi
Mizoram Jammu &
Kashmir,
Maharashtra, Tamil
Nadu Chhattisgarh,
Puducherry, and
Odisha
Daily Use of smokeless tobacco by States
14
Cessation efforts by Smokeless
Tobacco users
Quit ratio of smokeless tobacco use among ever daily smokeless
tobacco users
5
5
5
5
6
0 2 4 6 8 10
Overall
Male
Female
Rural
Urban
16
35
39
29
35
37
0
10
20
30
40
50
Overall Male Female Rural Urban
17
Percentage of smokeless tobacco users who made a quit attempt in
past 12 months
*Includes all current users and former users of smokeless tobacco
who have abstained for less than 12 months

Percentage of users of smokeless tobacco who made a quit attempt by state/UT
8
9
13
15
19
19
21
21
22
23
24
25
26
29
30
32
33
34
34
35
35
37
38
38
40
40
41
43
44
49
51
54
0 10 20 30 40 50 60 70 80 90 100
Delhi
Chandigarh
West Bengal
Punjab
Nagaland
Orissa
Jammu & Kashmir
Assam
Sikkim
Arunachal Pradesh
Tripura
Meghalaya
Tamil Nadu
Jharkhand
Mizoram
Chhattisgarh
Haryana
Manipur
Maharashtra
Bihar
India
Kerala
Uttaranchal
Himachal Pradesh
Goa
Gujarat
Rajasthan
Uttar Pradesh
Pondicherry
Karnataka
Andhra Pradesh
Madhya Pradesh
18
0 10 20 30 40 50 60 70 80 90 100
Bihar
Odisha
Jharkhand
Haryana
Manipur
Madhya Pradesh
Punjab
Assam
Sikkim
Delhi
Maharashtra
India
Uttar Pradesh
Meghalaya
West Bengal
Kerala
Rajasthan
Chhattisgarh
Gujarat
Chandigarh
Jammu & Kashmir
Mizoram
Tripura
Uttarakhand
Arunachal Pradesh
Puducherry
Karnataka
Tamil Nadu
Goa
Nagaland
Himachal Pradesh
Andhra Pradesh
15
16
17
19
19
21
21
21
23
24
26
27
27
27
28
28
29
30
32
32
33
34
34
36
37
40
40
42
44
51
52
53
Includes only those users of smokeless tobacco who visited a health care
provider in the past 12 months
19
Percentage of users of smokeless tobacco who were advised to quit by health care
provider* by state/UT
Current users of smokeless tobacco who noticed health
warning and thought of quitting because of warning label
20
63
73
43
34
41
19
0
10
20
30
40
50
60
70
80
90
100
Overall Male Female
%

O
F

C
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T

U
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E
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O
F

S
M
O
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E
L
E
S
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T
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A
C
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Noticed health warning on smokeless tobacco product package
Thought of quitting because of the warning label
Chemical composition
There are 3095 chemical
components in smokeless tobacco
products (including gutkha), among
them 28 are proven carcinogen. The
major and most abundant group of
carcinogens is the tobacco-specific
N-nitrosamines (TSNA) and no safe
level of this chemical has been
ascribed so far.
Other carcinogens reportedly
present in smokeless tobacco
include volatile N-nitrosamines,
certain volatile aldehydes,
polynuclear aromatic hydrocarbons,
certain lactones, urethane, metals,
and radioactive polonium.
o Various studies have found high levels of
Nitrosamines in the branded Indian smokeless
tobacco products available in the market .
o Studies also demonstrated presence of high levels
of heavy metals (Lead, Cadmium, Chromium,
Arsenic and Nickel) in these products, with one
study reporting almost 30% of gutkha brand
samples exceeding the permissible levels of heavy
metals Lead and Copper, when compared to the
provisional tolerable intake limits determined by the
FAO/WHO
Harmful effects of smokeless tobacco
CANCERS - The risk has been found to increase with the duration
and frequency of smokeless tobacco use.
Oral pre-malignant lesions/conditions like leukoplakia,
erythroplakia, submucous fibrosis or lichen planus
(either alone or in combination).
Oral cancer - Highest in India
Oesophageal cancer
Stomach cancer
Pancreatic cancer
Throat (pharynx and larynx)
cancer
Renal cancer
MORTALITY
Studies indicate an
increased risk of all-cause
mortality or all-cancer
mortality in smokeless
tobacco users compared to
non-users, and the
increased risk was seen
predominantly in female
users. Evidence also of
increased risk of dying
from cardiovascular
disease among the users.
NON-CANCEROUS
DISEASES/CONDITIONS
Oro-dental health - Different types of periodontal
diseases (inflammation, gingival recession and
bleeding, staining, tooth loss) and/or caries.
Hypertension & Cardiovascular diseases - Fatal
myocardial infarction.
Nervous system diseases- Fatal cerebrovascular
stroke
Metabolic abnormalities - Abdominal obesity, high
cholesterol level, high triglycerides level,
hypertension, diabetes or hyperglycemia.
Gastro-intestinal and Respiratory
o Increased prevalence
of benign
gastrointestinal
diseases
(oesophagitis, sub-
mucous fibrosis).
o It has been associated
with chronic bronchitis
and impaired lung
function with chronic
use.
Economics of Smokeless Tobacco Products
Production characterized by small-scale informal sector
producers, both handmade and machine made products, and
a wide range of products/prices.

Taxes are either ad valorem or levy schemes based on pouch
producing capability of packing machines.

Overall market knowledge is poor and monitoring &
regulation mechanisms are weak.

A smokeless tobacco manufacturing unit can be set up very
easily and at low cost.
Economics of Smokeless Tobacco Products
Smokeless tobacco products like gutkha pouches are available
at very low prices (1-7 Rupees) making it very affordable to the
poor and vulnerable groups like women and children.

As per GATS India, 54.7% buy from store; 10.4% from street
vendor; 31.9% from kiosks; 3% from other sources.

There is no licensing for sale of these products and these are
sold freely in all kinds of kiosks, tea shops, road side stalls etc.
This distribution network and easy availability also promotes
usage.





ECONOMIC COSTS
Using healthcare expenditure data from
the National Sample Survey of India, a
study found direct medical costs for
treating smokeless tobacco associated
cancers and diseases as USD 285
million.
Indirect morbidity costs (including
costs of caregivers and work loss due
to illness) amounted to USD 104 million.
The total economic cost of tobacco use
was reported as USD 1.7 billion which
was many times more than the annual
government expenditure on tobacco
control and about 16% more than the
total tax revenue generated from
tobacco.
Environmental Costs
o Besides harmful effects on environment
e.g. deforestation, depleting soil of
nutrients at a faster rate etc., the plastic
packaging of smokeless tobacco products
is a major threat to environment.
o Solid waste management not able to
handle the amount of waste generated by
such packs especially in high prevalence
states.
Provisions under COTPA
o Ban on all direct and indirect
advertisements of all tobacco products.
o Ban on sale to minors
o Ban on sale within 100 yards of
educational institutions
o Health warnings including pictorial, on all
tobacco products
Mass Media Awareness Campaign
Public Awareness Campaigns on ill effects of tobacco
use is main component of the National Tobacco
Control Programme (NTCP) both at national & sub
national level.

A mass media campaign was launched by MoHFW in
2009 in collaboration with WLF to raise awareness,
increase knowledge and build risk perceptions of
health consequences of smokeless tobacco.

There are low levels of awareness about ill-effects of
smokeless tobacco use

Limited knowledge about presence of tobacco in many
of the products like pan masala, toothpaste etc.


Violations reported related to prohibition on
Direct/Indirect advertising
Misuse of the point-of-sale boards by the
tobacco industry by depicting back-lit and
illuminated advertisements on the same.

Pan masala companies are violating the
tobacco advertising ban by advertising non-
tobacco pan masala products which share
their brand names with popular Gutkha
(pan masala containing tobacco) products.

Aggressive advertising strategies, using
film/tv stars


Content Regulation
Nicotine and tar contents not to exceed maximum permissible
limits as per the Tobacco Control Act. This provision is not yet
notified.

Regional laboratories for testing tobacco product contents and
Apex lab for research and validation identified. These labs are
mandated to test nicotine levels of the smokeless tobacco products
(as per law).

Challenge Standardized and validated methods required, large no.
and variety of smokeless tobacco products