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 (13-15 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(%)

Female

s(%)

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

Product Tiers (Length)

Basic Excise Duty

National Contingency Calamity Duty

Health Cess

Total

Unfiltered Cigarettes

<=60mm 659 90 70 819

60-70 mm 1068 145 110 1323

Filtered Cigarettes

<=70 mm 659 90 70 819

70-75 mm 1068 145 110 1323

75-85 mm 1424 190 145 1759

>85 mm 1748 235 180 2163

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

Education

Use 9/24 22/24 15/24

Volume 8/24 7/24 7/24

Income

Use 21/24 22/24 22/24

Volume 16/24 16/24 9/24

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