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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

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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

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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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Smoking prevalence by education

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Smoking prevalence by education

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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

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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

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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

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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

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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

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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

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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