EDITORIAL
Tobacco Cessation in India
Tobacco was introduced in India by the
Portuguese 400 years ago. Since then tobacco
consumption continued to rise in India. It has
been estimated that there are 1.1 billion smokers
worldwide and 182 million (16.6%) of them live
in India1-4. It has been predicted by the World
Health Organisation (WHO) that more than 500
million people alive today will be killed by
tobacco by 2030 and tobacco consumption will
become the single leading cause of death 5.
However, it is an irony that the tobacco use is
the major preventable cause of death worldwide
and that the cost-effectiveness of clinical
smoking cessation interventions have been
reported6. The International Classification of
Diseases (ICD-10) has recognised that “tobacco
dependence” is a disease 7. But the medical
profession has not taken a serious view of this
fact and has not made any serious attempt to
treat the disease, “Tobacco dependence”.
However, it is encouraging to note that the
WHO and the Government of India (GOI) have
taken the initiative for effective tobacco
control8,9.
Tobacco is used for smoking as well as in
smokeless forms in India. Among the tobacco
users, bidi smokers constitute 40%, cigarette
smokers 20% and those using smokeless forms
40 percent. The prevalence of tobacco use in
1993-94 was 23.2% in males (any age) and 4% in
females (any age) in urban areas, 33.6% in males
and 8.8% in females in rural areas 10 . The
National Family Health Survey (India) had
revealed that individuals with no education
were 2.69 times more likely to smoke and chew
tobacco than those with postgraduate
education 11 . This study had also shown that
households belonging to the lowest fifth of a
standard living index were 2.54 times more
likely to consume tobacco than those in the
highest fifths11. Thus, illiteracy and poverty were
associated with tobacco consumption in India.
[Indian J Chest Dis Allied Sci 2005; 47: 5-8]
In a survey of Delhi college students, it has been
observed that 83% of male and 87% female
students started smoking for fun and pleasure
and 94 to 98% students were aware of the
harmful effects of smoking, the benefits of
quitting and the ban of smoking in public
places. Majority felt that education of public will
have an impact on tobacco cessation (personal
observation).
Despite increasing awareness to the harmful
effects of tobacco, smoking continues to be a
significant health risk factor. It has been
observed that 70% of smokers indicate that they
want to quit12. Studies have demonstrated that a
brief physician-delivered intervention (as brief
as three minutes) for smoking cessation in
primary care setting significantly increases
patients’ smoking cessation rates 13 . Smoking
cessation benefits men and women at any age
and health benefits are immediate and
substantial. Immediate benefits include a
decline in carbon monoxide levels in the blood,
returning of pulse rate and blood pressure to
normal levels and improvements in the sense of
taste and smell 14 . In individuals who quit
smoking before the age of 50 years, the risk of
dying in the next 15 years is half that of a
smoker. Even in persons who quit at 60 to 64
years of age, the risk of dying is reduced by 10%
compared to regular smokers. Smoking
cessation greatly reduces the risk for developing
cancer. The risk of dying from lung cancer after
10 years in persons who quit smoking is 30 –
35% of that for regular smokers. Smoking
cessation also reduces the risk of acquiring a
second primary cancer. Smokers have twice the
risk of dying from Coronary Heart Disease
(CHD) and stroke compared to non-smokers
and the excess risk of dying from CHD is
reduced by half after one year of cessation. After
15 years, the CHD risk is similar to non-
smokers. The risk of dying from stroke also
6 Tobacco Cessation in India
returns to non-smokers level in 5-15 years. The
risk of recurrent heart attacks and
cardiovascular deaths are markedly reduced
(50% or more) after smoking cessation. The rate
of decline in lung function in COPD among
former smokers returns to that of never smokers
gradually, and smoking cessation decreases the
risk of influenza and pneumonia. The birth
weight of the infant will be the same as non-
smokers, if the mother stops smoking before
becoming pregnant or within 3-4 months of
pregnancy. Even cessation at later stage of
pregnancy (up to 30 weeks) will lead to higher
birth weight than regular smokers. The average
weight gain after smoking cessation is five
pounds. However, the health benefits of
smoking cessation exceed the risks from the
weight gain. Smoking cessation is also
associated with concomitant favourable changes
in lipid profile and body fat deposition.
Smoking cessation reduces or eliminates the risk
of passive smoking induced diseases especially
in children: pneumonia, bronchitis, middle ear
infections and exacerbations of bronchial
asthma 14-17. In addition, personal benefits of
smoking cessation include improved health,
better self-esteem, lower level of perceived
stress, good examples for their children,
healthier babies, money savings and freedom
from addiction. Our aim should, therefore, be to
help people stop smoking and to prevent people
from beginning to smoke.
Considering the social and economic impact
of tobacco consumption, smoking cessation
interventions are among the most cost effective
of all medical interventions 6 . A supportive
environment for tobacco cessation can be
created by changing the community norms,
banning smoking in workplaces, mass media
campaign and increasing the cost of cigarettes to
promote tobacco cessation, in addition to clinic-
based smoking cessation programmes. The
importance of public health approach to tobacco
control at a minimal cost should be emphasized.
The treatment of tobacco dependence and
smoking cessation methods include behavioural
and pharmacological therapies for smoking
cessation. Behavioural interventions such as
physician advice, self-help materials especially
V.K. Vijayan and Raj Kumar,
individually tailored materials and proactive
telephone calls from a Counsellor, behavioural
and psychological interventions, mass media
communication campaigns, telephone quit
lines/Internet-based services, quit and win
competitions and smoke-free places are helpful6.
Treatment of nicotine dependence has to
address the problem of tobacco-withdrawal
symptoms. The pharmacologic agents that are
used for smoking cessation include nicotine
replacement medications and non-nicotine
medications. The nicotine replacement
medications are transdermal patches, nicotine
gums, nicotine lozenges, nicotine sub-lingual
tablets, nicotine oral inhaler and nicotine nasal
spray6, 18. The non-nicotine medications that are
described include bupropion hydrochloride,
clonidine and nortriptyline. Population-based
interventions to complement individual-based
behavioural or pharmacological interventions
are also essential 19, 20. There is also a need to
prioritize cessation strategies according to our
national circumstances and resources available.
It is also to be emphasized that there is a need
for capacity building for smoking cessation and
treatment of tobacco dependence. Social
support for quitting, training of health
professionals and integration of smoking
cessation in other health programmes are
essential for successful implementation of
tobacco cessation programmes6, 19. The adoption
of a “WHO Framework Convention on Tobacco
Control” (WHO FCTC) by the World Health
Assembly on 24th May 1999 is an important
landmark to achieve comprehensive tobacco
control worldwide21. India is the 7th country
that has ratified the WHO FCTC on 5th
February 200422. In addition, the WHO Tobacco
Free Initiative encourages countries to develop
and strengthen strategies for tobacco control
measures. Though, on a small scale in a country
like India, the Ministry of Health and Family
welfare, Government of India has taken a
positive stand and has opened 13 Tobacco
Cessation Clinics all over India. In order to
strengthen the tobacco control measures, the
Government of India has passed an anti-tobacco
legislation, “The Cigarettes and Other Tobacco
Products (Prohibition of Advertisement and
2005; Vol. 47 The Indian Journal of Chest Diseases & Allied Sciences
Regulation of Trade and Commerce, Production,
Supply and Distribution) Act 2003”, which has
come into force on 1st May 2004, and this Act
replaces the Cigarettes (Regulation of
Production, Supply and Distribution) Act of
19759. Salient features of this new Act include
prohibition of the advertisement of all tobacco
products and provision for its regulation in
trade and commerce, prohibition of smoking in
public places, prohibition of selling tobacco
products to persons below the age of 18 years,
identification of nicotine and tar contents on the
packets, indication of warning on the package in
English as well as in Indian languages and total
ban on sponsoring any sport/cultural events by
cigarettes and other tobacco products com-
panies. Smoking in public places is made
punishable with a fine of up to Rs.200 while
advertisement of tobacco products will attract
imprisonment of up to two years or a fine of
Rs.1000 or both in case of first conviction. In the
case of second or subsequent conviction, the
imprisonment would be up to five years and a
fine of Rs.50009.
In our country, the tobacco cessation
programmes will have to address the issues of
bidi smoking and smokeless forms of tobacco.
Bidi manufacturing is a cottage industry in India
with many children and women actively
engaged in its production23. In addition, India is
the world’s third largest tobacco growing
industry with a great impact on the economy3.
More than 400,000 hectares of land are
harvested for tobacco and nearly 3.5 million
people are estimated to be engaged in full-time
tobacco manufacturing24. While implementing
tobacco control measures in India and other
developing countries, we will have to take these
factors into account.
V.K. Vijayan1 and Raj Kumar2
Director1 and Senior Lecturer2
Vallabhbhai Patel Chest Institute
University of Delhi, Delhi 110 007, India
E-mail: vijayanvk@hotmail.com
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