Tobacco Control in India
Christopher Millett
3 month sabbatical
• Welcome Trust Capacity Building grant between Consortia of
UK universities and Public Health Foundation for India (PHFI)
• Based at the South Asia Network for Chronic Disease (July –
Sep 2011)
• ‘Centre of Excellence’ within PHFI
Outline of the talk
- brief overview of the FCTC and tobacco control
policy in India
- limitations of surveillance data for monitoring policy
impacts
- tobacco industry influence (pack warnings and
taxation)
Why tobacco control?
Tobacco use a major risk factor for NCDs
Explains 25-50% of the difference in premature mortality
between SES groups
(Marmot 1991, Jha 2006)
One of the most cost-effective interventions to improve health
(Azaria 2007)
Framework Convention on Tobacco Control (FCTC)
First global public health treaty
Adopted by the World Health Assembly in 2003
Ratified by 174 countries
Ratified by India in Feb 2004 (4th), UK in Dec 2004 , not by US
Call to accelerate implementation of FCTC at UN High Level
meeting on NCDs in September
Cigarettes and Other Tobacco Products Act (COTPA) 2003
Section 4: Smoke-free public places (October 2008)
Section 5: Banning of advertising, sponsorship and promotion
(May 2004)
Section 6: Legal age of purchase = 18 years (February 2004)
Sections 7-9: Pictorial pack warnings (March 2008)
Surveillance / monitoring tobacco use
Beyond cigarettes: bidi, gutkha, khaini, paan masala, hookah,
cigars, chillum, chutta, gul, mawa, misri
Routine surveillance and monitoring of tobacco use
England
India
Health Survey for England (adults
and children, annually)
National Family Health Survey
(adults, 1992, 1998, 2004)
General Household Survey (adults,
annually)
Global Adult Tobacco Survey
(adults, 2009/10)
Smoking, Drinking and Drug Use
(11-15 years, annually)
Global Youth Tobacco Survey (1315 years, 2003, 2006, 2009)
ONS Omnibus
National Sample Survey
(household expenditure, annually)
Primary care data (QOF)
HES data (tobacco related
conditions)
Global Adult Tobacco Survey - 2009/10
GATS India
• > 76,000 HH
interviews
• > 69,000 individual
interviews
• 20 languages &
dialects
• Approximately 1000
fieldworkers trained
• Approx. 180 fieldwork
days
• Use of HH devices
Global Adult Tobacco Survey- 2009-10
Total
(%)
Males
(%)
Females
(%)
Tobacco
users
34.6
47.9
20.3
Smokers
(Bidis)
14.0
(9.0)
24.3
(16.0)
2.9
(2.0)
Chewers
25.9
32.9
18.4
GATS India 2010
275 million tobacco users
197 million males, 78 million females
164 million use only smokeless tobacco
42 million use smoking and smokeless tobacco
Percentage of current tobacco users
Information to Action: key facts from GATS to inform policy
• Smokeless tobacco most commonly used, but high dual use
• Bidis more commonly smoked than cigarettes
• Two-thirds of tobacco users initiate at 18 yrs+
• State level variation – rural / urban divide
• Higher tobacco use among poor, low smoking among women
• Quit rates are tiny (2%)
Tobacco industry influence
• Pack warnings
FCTC Guidelines on Pack Warnings (Article 11)
Fancy a cigarette?
Plain packaging – All eyes are on Australia
Proposed pictorial health warnings
Actual pictorial warnings (March 2008)
• Not market tested
• Fall well short of FCTC guidance
• Cover just 40% of the front panel of the pack
Smoking Forms
Smokeless Forms
Taxing tobacco – recommended practice
Tobacco use is price sensitive
Tax should be progressively increased above RPI
Tax should account for 75-80% of price
Price should be consistent across products to reduce
product substitution
Need to be complemented with anti-smuggling efforts
UK tobacco taxation policy (March 2011 budget)
• Price differential between tobacco products reduced
• General 2% above RPI increase on tobacco
• Additional 10% on hand rolled tobacco (£7.35 for 25 grams)
• 33 pence increase on premium cigarettes (£6.95 pack)
• 50 pence increase on economy cigarettes (£5.63 pack)
Cigarette Taxes in India, 2008-09 (Rs. Per 1000 Sticks)
Tobacco
Product
Unfiltered
Cigarettes
Product
Tiers
(Length)
Basic
Excise Duty
National
Contingency
Calamity Duty
Health
Cess
Total
<=60mm
659
90
70
819
60-70 mm 1068
145
110
1323
<=70 mm
90
70
819
145
110
1323
190
145
1759
235
180
2163
659
Filtered 70-75 mm 1068
Cigarettes
75-85 mm 1424
>85 mm
1748
Bidi Taxes in India, 2008-09
(Rs. Per 1000 Sticks)
Tobacco
Products
Basic Excise
Duty
National
Contingency
Calamity
Duty
Health Cess
Total
Hand
rolled
12
0
0
12
Machine
produced
30
0
0
30
Bidis – why so cheap?
• Low grade tobacco – the good stuff is used for cigarettes
• Low taxes – due to political influence. Inaction by the
national govt has led NGOs to target state governments,
with some success
• Fragmented production and sale – difficult to levy taxes
• Cheap labour – exploitation of rural women and children
The Bidi King
• Today bidi is king in
India because the
country’s bidi king is
Praful Patel.
• His family runs the $5
billion CeeJay Group,
the largest bidi maker in
India’s western
Maharashtra state.
www.iwatchnews.org
And the have nots....!
SES patterning of tobacco use
• Question: is the relationship between SES and tobacco
use consistent across Indian states?
• Data: Annual National Sample Survey (2009/10),
includes HH level data on tobacco expenditure by type
• Sample size: 100,855 households
• Outcomes: use and volume of cigarettes, bidis,
smokeless tobacco
• Predictors: HH level income, education
State level analysis of SES and tobacco use
Cigarettes
Bidis
Smokeless
Use
9/24
22/24
15/24
Volume
8/24
7/24
7/24
Use
21/24
22/24
22/24
Volume
16/24
16/24
9/24
Education
Income
Red font: higher education / income = higher use / volume
Black font: lower education / income = higher use / volume
Summary
• India has led the way legislating for tobacco control
• It has struggled with implementation
• This is due in part to lack of enforcement capacity
and complexity of the tobacco market
• But also due to tactics of tobacco industry
Ongoing India work
Tobacco Control
- Trends in tobacco use, including state level analyses
- SHS exposure (cotinine) in rural Andhra Pradesh
- Documenting smoking in Bollywood movies
- Modelling TC policy impacts on CVD outcomes
Active transport
- Impact of rural-urban migration on physical activity and CVD
risk factors (India Migration Study)
Salt reduction
- RCT examining the impact of a village level intervention on
salt intake
Acknowledgments
Leverhulme Trust (Study Abroad Fellowship)
South Asia Network for Chronic Disease - Public Health
Foundation for India
PCPH