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 WHO Director General award to Professor Reddy who was a key negotiotar for the Indian delegation for outstanding contributions to global tobacco control at the World Health Assembly in May 2003. He is credited with proposing the treaty in conference speech in 1997. The strong stance of India surprised many, particularly NGOs, because they thought that India, as the second biggest tobacco producer in the world, would wish would to watered down regulations. Of note is that the US has not ratified the treaty and since 2003 the smoking prevalence in the US has flatlined.

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 Females 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 70-75 mm 75-85 mm 1424 190 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 Machine produced 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 Income 21/24 16/24 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