Tobacco use in India: How laws and awareness campaigns are empowering the public

India, where tobacco use is very popular, has required cigarette manufacturers to include graphic warnings on packaging and strengthened protections for minors.

Oral cancer rates are very high in India. In comparison with the U.S. population, where oral cavity cancer represents only about 3% of malignancies, it accounts for over 30% of all cancers in India. (1) This article will highlight the risk factors for oral cancer in the Indian population, as well as what is being done to educate the public and prevent or intervene early in oral cancer.

In India, as reported by Pankaj Chaturvedi at the Global Oral Cancer Forum, the Amended Juvenile Justice (Care and Protection of Children)Act makes tobacco sale to minors punishable by law. (2) The new Act took effect January 15, 2016, and the punishment for those selling tobacco products to minors is seven years in jail and a fine.

READ MORE | Never too late: The newest in tobacco cessation

Paan masala products are also dangerous, as they contain areca nuts, a potential cancer-causing agent. Areca nuts have addictive properties similar to caffeine, tobacco, and alcohol and can lead to a high number of cases of submucous fibrosis, which can become malignant. India has a high incidence of oral cancer due to tobacco use, and as said by the Global Adult Tobacco Survey, the age of initiation of tobacco habits in India is 17 years. (2) According to the report, almost one million people die of oral cancer in India yearly.

In September 2014, the Union Health Ministry in India issued a statement making it mandatory for cigarette manufacturing companies to convey statutory warning against smoking on both sides of a cigarette pack with graphic depiction of throat and mouth cancer, and stating that it must cover at least 85% of the packaging. On March 8, 2016, the Supreme Court of India issued notice to the Health Ministry on a Public Interest Litigation (PIL) seeking the immediate enactment of plain packaging rules for cigarette and other tobacco products. The Supreme Court offered that colorful and attractive covers on tobacco products are more eye-catching and attract more tobacco users. (4)

READ MORE | On 2015 World No Tobacco Day, will we know how many the drug really kills?

All forms of tobacco use and alcohol abuse are known risk factors for oropharyngeal cancer. 57% of all men and 11% of women between 15–49 years of age use some form of tobacco in India. (1) Another problem is the use of betel quid (paan), which is made of pieces of areca nut, processed or unprocessed tobacco, aqueous calcium hydroxide (slaked lime), and some spices wrapped in the leaf of piper betel vine leaf. (1) Gutka, zarda, kharra, mawa, and khainni are also all dry mixtures of lime, areca nut flakes, and powdered tobacco custom mixed together and offered for sale. (1) Bidis, small hand-rolled cigarettes, produce three times more carbon monoxide and five times more tar than tobacco cigarettes. (5) Those who smoke bidis have a three-fold higher risk of oral cancer compared with nonsmokers, and are also at increased risk of lung, stomach and esophageal cancer. (5) Secondhand smoke is also an issue with these other products.

According to Pankaj Chaturvedi, HPV is not a huge risk factor in India. He stated at the Global Oral Cancer Forum that they do not know if they will one day be hit with a “tsunami” of HPV-related cancers. But as of now, tobacco and the other products mentioned are the main risk factors for oral cavity cancer.

So what is being done to slow the incidence of this disease? As mentioned, not selling to minors is one way to slow down use. Also, large graphic warnings are said by some to be of benefit. (6) There are media campaigns to raise awareness of the harm of smoking, smokeless tobacco, and secondhand smoke. The videos are varied and very graphic. (7) Vital Strategies is has joined forces with India to create a campaign called “Smoking Kills,” which features the voice of Anil Kapoor of Slumdog Millionaire fame. (8)

Early detection could improve cure rates, as well as lower the cost and morbidity associated with treatment. It is critical that cost-effective oral cancer screening and awareness initiatives be introduced in high-risk populations, such as in India.

References
1. Kekatpure V, Kuriakose MA. Oral Cancer in India: Learning from Different Populations. Cancer Prevention, Issue 14. 2010.
2. http://indianexpress.com/article/cities/mumbai/amended-juvenile-justice-act-makes-tobacco-sale-to-minors-punishable/.
3. http://www.who.int/tobacco/surveillance/gats_india/en/.
4.https://drive.google.com/file/d/0BzXilfcxe7yuU3FJLUJFOF80aFE/view.
5. WHO report on the global tobacco epidemic, 2008. The MPOWER package. Geneva: World Health Organization; 2008.
6. https://www.vitalstrategies.org/vital-stories/op-ed-large-graphic-warnings-will-benefit-every-indian.
7. https://www.vitalstrategies.org/resource-center/media-campaigns/country/india.
8. https://www.vitalstrategies.org/vital-stories/in-india-smoking-kills-campaign-targets-secondhand-smoke.