Are tobacco control efforts resulting in increased quitting in India?

 

The findings of the Tobacco Control Policy (TCP) third round survey in India revealed some alarming facts about tobacco use and the implementation of tobacco control policies. India is home to approximately 267 million tobacco users (99 million smokers and 199 million smokeless tobacco users). This report is based on a survey of adult tobacco users and tobacco non-users (aged 15 and older) in Maharashtra, Bihar, West Bengal, and Madhya Pradesh conducted by the Healis Sekhsaria Institute for Public Health, India, in collaboration with the University of Waterloo, Canada. The TCP India first round Survey in four states was conducted between August 2010 and October 2011. The second round of the survey was conducted between October 2012 to September 2013 and the most recent, third round of the survey was conducted between July 2018 to July 2019.

Increased Quitting did not changed proportion of Smokeless tobacco use in India

Among tobacco users, the proportion of smokeless tobacco use has increased from 72% (2010- 2011) to 80% (2018- 2019) whereas mixed tobacco use (smoked and smokeless) decreased from 11% to 7%, and smoking decreased from 17% to 14% during the same period.

Among tobacco users, quitting has increased in three states from the reported findings in years 2016-17 to TCP India 2018-19.  

In Maharashtra and West Bengal, intentions to quit smoking, as well as smokeless tobacco, have increased between 2010-11 to 2018-19.  However, in Madhya Pradesh intentions to quit smokeless tobacco have increased, while smoking has decreased during the same period.

Tobacco price are too low to motivate quitting

Personal health, family, and setting a good example for children remained the major reasons for tobacco users to think of quitting between 2010-11 and 2018-19.

The rising cost of tobacco products remained a lower priority reason over other reasons that made tobacco users think about quitting between 2010-11 and 2018-19.

In Maharashtra and West Bengal, about a third of smokers reported they had visited a health professional in the past six months. This was lower in Madhya Pradesh (24%) and Bihar (19%). Among those who had visited a health professional, 49% or more in Madhya Pradesh and West Bengal, 35% in Maharashtra, and about 20% in Bihar were advised to quit. However, very few were referred to another cessation service to get help to quit tobacco.

High awareness of cigarette health warnings, but low awareness of quitline

In all four states, almost everyone (100%) was aware of health warnings on cigarette packages.  However, the percentage of cigarette smokers who noticed warning labels ranged from 46% in Bihar to 88% in Madhya Pradesh.

The survey results showed low awareness of the quitline number on cigarette packs, ranging from only 5% of cigarette smokers in Bihar, to between 24% and 34% of smokers in the other three states.

In Maharashtra and Madhya Pradesh, almost all the bidi smokers were aware that bidi packs have warning labels. In contrast, 64% in West Bengal and only 6% of the bidi smokers in Bihar were aware of bidi pack warnings. Similarly, the percentage of bidi smokers who noticed warning labels when they smoked was highest in Madhya Pradesh (82%) and lowest in Bihar (<52%). Only one in five bidi smokers were aware of the ‘quitline number’ on bidi warnings in Maharashtra. In Madhya Pradesh, West Bengal, and Bihar, awareness of the quitline was very low.

Maharashtra and Madhya Pradesh had the highest (90%) awareness of warning labels on smokeless tobacco packs. Bihar had the lowest awareness (68%).  In Bihar, a quarter (26%) of smokeless tobacco users noticed the warning labels ‘often’ or ‘regularly’, and in other states, it ranged from 39% to 67%. Awareness of the ‘quitline number’ on smokeless packs was very low in Madhya Pradesh and West Bengal (<4%), and in the other two states it was 12% and 18%.

Tobacco advertising and promotion has increased in some states

In Maharashtra, West Bengal, and Bihar, fewer tobacco users reported noticing  advertising or pictures that encouraged tobacco use or made them think about using tobacco ‘often’ or ‘once in a while’ in the last six months in 2018-19 compared to 2010-11. In contrast, noticing tobacco advertising increased among tobacco users and non-users in Madhya Pradesh and non-users in Bihar.

Noticing tobacco advertisements and promotions in stores, newspapers and public transportation increased in Bihar, West Bengal, and Madhya Pradesh, while it decreased in Maharashtra between 2010-11 and 2018-19. Tobacco advertisements and promotions on TV continues to remain high or increased in all four states between 2010-11 and 2018-19. In contrast, it has decreased in restaurants in all four states during this period.

Anti-tobacco Education could help tobacco users to quit

Tobacco users and non-users continue to report TV, tobacco packages, and public transportation or vehicles or stations as the most common source of anti-tobacco information in all four states between 2010-11 and 2018-19.

In 2018-19, more than one-third of smokers and smokeless tobacco users in Maharashtra reported that anti-tobacco ads made them “more likely to quit”. In contrast, only about 10% of the smokers and smokeless tobacco users in Bihar reported the same.

Tobacco is still affordable despite price increases

Only 9% of cigarette smokers and 3% of bidi or smokeless users reported that money spent on their tobacco resulted in not having enough money for household essentials i.e. over 90% of cigarette smokers and 97% of bidi or smokeless users reported that tobacco continues to be affordable to them even after the increased price of tobacco products over the years. 

The average price of a single cigarette increased from Rs. 3.1 in 2010-11 to Rs.7.8 in 2018-19. Similarly, the average price of single bidi increased from Rs. 0.4 in 2010-11 to Rs.1.0 in 2018-19. Similarly, the average price of any pouch of the smokeless product increased from Rs. 5.2 in 2010-11 to Rs.11.4 in 2018-19.

Dr. Mangesh Pednekar, Director, Healis Sekhsaria Institute for Public Health said that “In India, smokeless tobacco use and bidi smoking continues to be the dominant forms of tobacco use over cigarette smoking. Tobacco use in any form causes not only loss of lives but also huge economic and social costs. Even though the harmful effects of tobacco use are well known, tobacco product promotion and limited availability of cessation support remain a big concern. It is, therefore, necessary that the country should come up with effective enforcement of tobacco control policies and anti-tobacco campaigns to dissuade people, especially the youngsters, from the use of tobacco. There is an urgent need to increase state-specific tobacco cessation infrastructure that will support the increasing calls from users for cessation help on the existing National ‘quitline number’. ” 

Dr. Prakash C. Gupta, Director, Healis Sekhsaria Institute for Public Health said that “The use of tobacco is the major risk factor for many kinds of fatal diseases in India, such as lung-related diseases, stroke, cancer, etc as well as many non-fatal diseases. It is one of the leading causes of death, accounting for 3500 deaths every day in India. The survey reveals many alarming facts that need to be addressed with immediate effect. It is heartening that the number of people who want to quit is increasing as can be seen from the survey results.”

Dr. Geoffrey T. Fong, Founder and Lead Principal Investigator of the International Tobacco Control Policy Evaluation Project at the University of Waterloo, Waterloo, Ontario, Canada said that “The TCP Project findings show that while India has introduced proven tobacco control policies, including large pictorial warnings, anti-tobacco campaigns, tax increases, and restrictions on tobacco advertising and promotion, these policies need to be strengthened so that they will be effective for everyone including cigarette smokers, bidi smokers, and smokeless tobacco users and in all states across India. In particular, it is critically important to raise tobacco taxes to increase prices to decrease the affordability of all tobacco products, increase the effectiveness of the implementation of graphic warnings on bidis and smokeless products, and to create strong media campaigns with access to cessation services to prevent young people from using tobacco and to support tobacco users to quit.”

 

Recommendations

·         Continue to invest in and offer anti-tobacco campaigns focusing more on adverse effects on personal health, family disapproval, and setting good examples for children.

·         Warning labels that include information on how to access cessation services may also motivate tobacco users to make quit attempts, and help them to stay quit.

·         Develop innovative strategies to disseminate information the National quitline number and information about cessation services to a large number of tobacco users.

·         Enhance the prominence of the National quitline number on tobacco packs.

·         Increase state-specific tobacco cessation infrastructure to support the increasing calls from users for cessation help on the existing National ‘quitline number’

·         Develop and implement effective taxation policies to reduce the affordability of tobacco products among low and middle-income groups as they are the highest tobacco consumers in the country.