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
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%)
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
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
Top Related