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CGHR.ORG
Smoking and Death in India
Prabhat JhaOn behalf of the RGI-CGHR Investigators
Sources of support:ICMR and RGI (India); FIC, NIH (US); IDRC & CIHR (Canada); CTSU, MRC & CR-UK (UK)
Centre for Global Health Research (CGHR)Keenan Research Centre at the Li Ka Shing Knowledge Institute
St. Michael’s Hospital, University of Toronto
prabhat.jha@utoronto.ca
World Bank seminar, April 2, 2008, Washington, DC
CGHR.ORG
Key messages for the individual smoker in India
1. Risk BIGGER than previously thought
2. Smoking kills EARLY: 70% smoking deaths are at ages 30-69, losing decades of good life
3. Even a FEW bidis or cigarettes per day kills
4. STOPPING SMOKING WORKS – but, less than 2% of adults in India have quit
CGHR.ORG
Nationally representative sample(Sample Registration System)
• 6,671 of these small areas randomly chosen from all parts of India (each with about 1000 people per area)
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How was the study done?900 non-medical staff monitored 1.1 M (11
lakh) homes for three years (2001-3)All adult deaths from
diseases (74,000 deaths)
Obtain smoking history of the dead from living household members
2 physicians assigned
underlying fatal disease
(eg TB)
Compare smoking history of the dead to smoking history of 78,000 living adults
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What’s new about this research?
• Large size of study
• Nationally representative study of the causes of deaths in adults: results reflect the whole of India
• First reliable study of female deaths from smoking in India
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Smoking prevalence in IndiaCigarette or bidi (less tobacco than a cigarette, wrapped in the leaf of another plant)
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Year % men age 15-29 years who
smoke
1998 9.9
2004 11.8
2006 24.6Increase
2006 vs 1998 17 M
Rising prevalence among young men?
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Indian Women aged 30-69 No. of deaths studied and smoker vs
nonsmoker death rate ratio (RR)
Underlying fatal disease
No. deaths studied
% who had smoked *
Smoker vs nonsmoker RR†
Tuberculosis 1,363 13 3.0 (2.4-3.9)
Respiratory disease 2,288 14 3.1 (2.5-3.8)
Stroke 1,597 8 1.6 (1.2-2.1)
Heart disease 2,473 7 1.7 (1.3-2.1)
Cancers 2,153 8 2.1 (1.6-2.6)
All diseases 16,386 9 2.0 (1.8-2.3)
* versus 4.5% of 26,678 living women who had smoked† Risk ratio adjusted for age, alcohol use and education
CGHR.ORG
Indian Men aged 30-69 No. of deaths studied and smoker vs
nonsmoker death rate ratio (RR)
Underlying fatal disease
No. deaths studied
% who had smoked *
Smoker vs nonsmoker RR†
Tuberculosis 3,119 66 2.3 (2.1-2.6)
Respiratory disease 3,487 60 2.1 (1.9-2.3)
Stroke 2,200 53 1.6 (1.4-1.8)
Heart disease 5,409 52 1.6 (1.5-1.8)
Cancers 2,248 59 2.1 (1.9-2.4)
All diseases 25,290 55 1.7 (1.6-1.8)
* versus 37.0% of 31,661 living men who had smoked† Risk ratio adjusted for age, alcohol use and education
CGHR.ORG
Category Smokers (%)
Risk Ratio *
Residence
Rural 56.4 1.6 (1.6-1.8)
Urban 51.3 1.9 (1.6-2.1)
Education
None 58.2 1.6 (1.5-1.7)
Primary 56.8 1.7 (1.5-1.8)
Secondary 47.8 1.7 (1.6-1.9)
Alcohol
No 44.0 1.6 (1.5-1.7)
Yes 75.7 1.6 (1.5-1.8)
Total 55.4 1.7 (1.6-1.8)
Smoker vs NonsmokerRisk Ratio
Smoking kills all categories of menresults for men aged 30-69
*adjusted for age, alcohol use and education
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Any smoking kills
2.9
1.8
2.2
1.5
1.3
8+
1-7
15+
8-14
1-7
0 1 2 3
Not causedby smoking
Excess riskfrom smoking
Bidi (no./day)
Cigarette (no./day)
Ratio
Risk of death by amount and type, men aged 30-69:smoker vs. nonsmoker risk ratio
*adjusted for age, alcohol use and education
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Cumulative risk of death, from age 30 smokers vs nonsmokers
*adjusted for age, alcohol use and education
Women
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*adjusted for age, alcohol use and education
Men
Cumulative risk of death, from age 30 smokers vs nonsmokers
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*risk in the absence of other causes of death, adjusted for age, alcohol use and education
Disease-specific risks of death, ages 30-69smokers vs nonsmokers *
Women
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Men
*risk in the absence of other causes of death, adjusted for age, alcohol use and education
Disease-specific risks of death, ages 30-69 smokers vs nonsmokers *
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Disease
WomenTotal deaths: 2.0 M
MenTotal deaths:2.9 M
No.
(% all deaths)
No.
(% all deaths)
Respiratory disease 26,000 10 109,000 31
Tuberculosis 14,000 9 120,000 38
Heart disease/stroke 13,000 3 152,000 20
Cancer 9,000 4 67,000 32
TOTAL, all diseases 93,000 5 579,000 20
Deaths from smoking in year 2010 in India, ages 30-69, by disease
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Age range Women Men Both
Ages 30-69 93,000 579,000 672,000
All adults 20+ 128,000 807,000 935,000
Annual deaths from smoking will rise from 930,000 to 1,000,000 (10 lakh) during 2010s
Deaths from smoking in year 2010 in India
CGHR.ORG
Region Ex-smoking % age 30+
Women MenIndia 0.2 1.9
Kerala* 1.1 7.1
Delhi+ 0.05 0.8
Low quit rates in India, 2004
*highest and + lowest male quit rates, respectively
CGHR.ORG
INDIA: 1 million (10 lakh) smoking deaths per year during 2010s
• Smoking causes 10% of the 10 million (1 crore) deaths per year from all fatal disease
• 70% of smoking deaths are in middle age (30-69): 700,000 (7 lakh); 600,000 men and 100,000 women
• 20% of all adult male deaths and 5% of all adult female deaths in middle age
• Over 50% of smoking deaths are in illiterate adults
CGHR.ORG
Key messages for the individual smoker in India
1. Risk BIGGER than previously thought
2. Smoking kills EARLY: 70% smoking deaths are at ages 30-69, losing decades of good life
3. Even a FEW bidis or cigarettes per day kills
4. STOPPING SMOKING WORKS – but, less than 2% of adults in India have quit
CGHR.ORG
Press materials on:www.cghr.org/tobacco
1. NEJM Paper and Supplementary Appendix2. Press and video releases: English, Hindi and
regional languages3. Frequently-asked questions4. PowerPoint slides in English5. Information about CGHR and partners
News coverage of paper at: http://youtube.com/watch?v=9COgO6cXwY4 http://youtube.com/watch?v=uH66GQADiEs
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