1. Tobacco Epidemic and Best Practices Control Policies-India
Dr. Rana J Singh
MD DPHA IFPM
Dy.Regional Director(Tobacco and NCD Control)
The Union South-East Asia(The Union)
3rd Conference of The Union South-East Asia Region, May 26-28, 2016, Kathmandu, Nepal

2. Tobacco Wild tobacco (Nicotiana rustica)
Cultivated tobacco (Nicotiana tabacum)
Wild tobacco (Nicotiana rustica)
Any of numerous species of Nicotiana or the cured leaves of several of the species that are used after processing in various ways for smoking, snuffing, chewing, and extracting nicotine
Text source: Encyclopedia Britannica. (1999); Image source: Wikimedia Commons. (2007). Permission granted for educational use. 2

3. Burden of Tobacco-Global
Tobacco is the leading cause of preventable death in the world – WHO report 2003.
Tobacco kills:5.4 million people each year
ONE BILLION people will die from tobacco use this century.

4. Global Scenario Tobacco is responsible for 1 in 10 deaths in adults
About 1 billion men and 250 million women are smoker
If the current trend continues , tobacco use would cause 10 million deaths each year by 2020
Half ( 650 million) of the people who smoke today will eventually be killed

5. Global Burden
In poor and developing countries , tobacco use is emerging as an epidemic .
High public health costs for treating tobacco related diseases.
Tobacco kills people at the height of their productivity
In some low income countries , poor spend almost 10% of their income on tobacco

6. Tobacco Is a Risk Factor for 6 of the World’s 8 Leading Causes of Death
Hatched areas indicate proportions of deaths related to tobacco use. 6

7. Nearly Two-Thirds of World’s Smokers Live in Just 10 Countries
More than 40% live in just 2 countries
The tobacco epidemic will cause the most harm to low-income and moderate-income countries with high population
The tobacco industry is expanding its advertising, marketing and promotion to the developing world to capture these growing millions of potential customers
Tobacco use is growing fastest in these countries, fueled by steady population growth. This will create a ‘perfect storm’ of future tobacco-related disease and death
Because developing countries are still in the early stages of the tobacco epidemic, they have yet to experience the full impact of tobacco-related disease and death already evident in wealthier countries where tobacco use has been common for much of the past century
Many of these countries have fewer resources to respond to the health, social and economic problems caused by tobacco use, which will exacerbate the tobacco epidemic’s impacts
Tobacco-related disease and death will hit these countries very hard in the coming decades
Source: MPOWER package. 2008 7 7

8. Tobacco Burden in India Global Adult Tobacco Survey- India(2009-10)
Total
(%)
Males
Females
Tobacco users
34.6
47.9
20.3
Smokers
14.0
24.3
2.9
Chewers
25.9
32.9
18.4

9. Tobacco use in India Tobacco Users (35%)
Only smoke do not use smokeless tobacco (9%)
Smoke as well as use smokeless tobacco (5%)
Use only smokeless tobacco, do not smoke (21%)
84% tobacco users use it every day
Smokers 14%
(112 million)
Smokeless tobacco users 26%
(206 million)

10. Percentage of current tobacco users

11. Prevalence % of Total Users
Rank
Prevalence
% of Total Users
Smoking
Smokeless tobacco 1
Mizoram 40%
Bihar 49% 2
Meghalaya 36%
Jharkhand 48% 3
Nagaland 32%
Chhattisgarh 47% 4
Arunachal Pradesh 29%
Nagaland 45% 5
Tripura 27%
Manipur 45% 6
Sikkim 26%
Odisha 43% 7
Manipur 26%
Tripura, Mizoram 41%
Smoking
Smokeless tobacco
Uttar Pradesh 17%
Uttar Pradesh 15%
West Bengal 12%
Bihar 14%
Andhra Pradesh 10%
Chhattisgarh 10%
Bihar 7%
Maharashtra 10%
Rajasthan 7%
West Bengal 7%
Madhya Pradesh 7%
Odisha 6%
Chhattisgarh 5%
Jharkhand 5%

12. Overview of Tobacco Use
Prevalence of tobacco use is 35%
Among tobacco users 84% are daily users
Among smokers and smokeless tobacco users many use multiple tobacco products
One-fourth of cigarettes smokers and half of the bidi smokers smoke more than 10 cigarettes/bidis per day
Mean age at initiation of tobacco use is 17.8 years
Among tobacco users 60% use tobacco within half an hour of waking up

13. Tobacco Use in India – in real terms
Males (%)
Female (%)
Total (%) (numbers, min)
Country population:
Non-user 52 80
65 (510.5 m)
Total users
48 (197m),
more than Brazil (5)
20 (77.9m),
more than Iran (17)
35 (274.9 m)
More than combined population of Indonesia (237 m) and Canada (34.3 m). By itself would be 4th highest population
Smokers
15 (61.1);
UK (22)
2 (7.8)
9 (68.9 m)
More than UK, France or Thailand (20th biggest country by population)
Chewers
24 (~98.5)
Philippines (12)
17 (~66.2)
21 (~163.7m)
More than Bangladesh, Nigeria or Russia
Dual Use
9 (~37)
1 (~3.3)
5 (~40.3 m)
More than Argentina (32nd most populous country)
High prevalence states (above national prevalence)
Arunachal Pradesh, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Odisha, Sikkim, Tripura, Assam and West Bengal

14. Exposure to SHS

15. Exposure to SHS

19. GYTS India 2009 13-15 years school students 14.6% use tobacco
4.4% smoke
21.9% live in the homes where others smoke in their presence

20. Burden of tobacco in India
Kills 10 lakh persons annually in India (more than TB, HIV/AIDS, malaria combined).
2500 deaths daily.
50% of cancers in men and 25% in women.
Highest incidence of oral cancer in the world.
Majority of cardio-vascular and lung disorders
Most common preventable cause of death worldwide.

21. Burden of tobacco use
Almost 40% of TB deaths are associated with smoking.
Incidence of impotence is 85% higher among smokers.
5500 youth initiate tobacco use every day.
Environmental burden
300 cigarettes – a 2 week supply for a pack a day smoker

22. India’s policy on Tobacco control

23. Two major regulations for tobacco control in India
Cigarette and Other Tobacco Products Act 2003(COTPA 2003)
Food Safety and Standards Act 2006(FSSA 2006)

24. Cigarette and Other Tobacco Products Act(COTPA-2003)
Section 4 – Prohibition of smoking in public places
Section 5 - Ban on advertisements of tobacco products
Section 6 (a) - Prohibition of sale of tobacco products to and by minors
Section 6 (b) - Prohibition on sale of tobacco products within the radius of 100 yards of any educational institutions
Section 7 - Specified health warning labels on all tobacco products

25. Section 4 /Prohibition of Smoking in Public places rules,2008 The Owner, proprietor, manager, supervisor or in charge of the affairs of a public place is responsible to make the public place as …..shall ensure
No person smokes in his jurisdiction
Display of the specified board at each entrance, and conspicuous place inside
Such board at each floor and entrance to lift
No smoking aids are provided in public place
Shall notify and display the name of person to whom complaint be made
Designated smoking area/Smoking rooms : exemptions

26. ● Advertisements allowed at point of sale and in or on package
Section-5
● No person engaged in the production, supply or distribution of tobacco products shall advertise
● No person having control over a medium shall cause to be advertised through that medium
● No person shall take part in any advertisement which directly or indirectly suggests or promotes to use or consumption of tobacco products
● No trade mark or brand name of cigarettes or any tobacco product to be promoted in exchange for sponsorship, gift, prize or scholarship
● No person, under contract or otherwise, promote or agree to promote any tobacco product or its usage
● Advertisements allowed at point of sale and in or on package 26

27. Section 6 (a): Provisions of the law
Prohibits sale of tobacco products to and by persons below the age of 18 years.
The Owner / manager / in-charge where tobacco products are sold shall ensure that:
A board from the two option is at the entrance of the place where tobacco products are sold in a manner as given below :
Minimum size of the board should be 60cm x 30cm with white background.
The board should contain the warning “sale of tobacco products to a person below the age of 18 years is a punishable offence”, in Indian language(s) as applicable and a pictorial depiction of ill effects of tobacco use on health.
The board shall not have any advertisement / promotional messages / pictures / images of cigarette and any other tobacco products.
No tobacco product is handled or sold by minors.
No tobacco product is sold through a vending machine.
No tobacco products are displayed in a manner that enables its easy access to minors.
The seller of tobacco product shall confirm that the buyer of tobacco product is not a minor. In case of doubt the seller may request the buyer to provide appropriate age proof/identity proof.
Cigarette and other tobacco products Amendment Rules, 2011

28. Signages under section 6 (a)
Specifications as given in the Compact Disk : Pictorial image shall occupy 50% of the board (60cm x30cm)
The design and specification of board can be downloaded from

29. Section 6 (b): Provisions of the law
All educational institutions should have a board on their boundary wall or at the entrance. The board should state prominently that “sale of cigarette or any other tobacco products in an area within the radius of 100 yards of the educational institution is strictly prohibited; the offence is punishable with a fine upto Rs. 200”
Measurement of the distance: distance of 100 yards shall be measured radially from the outer limit of boundary wall, fence or as the case may be, of the educational institution, for the location of a tobacco vendor or point of sale

30. Signage section 6(b)

31. Depiction of Specified Health Warnings
Section 7: There shall be no production, sale and import of cigarettes or any other tobacco product unless every package of cigarettes or any other tobacco product bears on it label, specified warning.
Section 8: Manner in which specified warning shall be made
The specified warning on a package of cigarettes or any other tobacco products shall be-
legible and prominent ;
conspicuous as to size and colour
Section 9: Language in which the specified warning shall be expressed

32. New pictorial warnings w.e.f April 2016
For chewing or smokeless forms of tobacco packages

33. New pictorial warnings
For smoking forms of tobacco packs

34. National Tobacco Control Programme(NTCP)

35. Justification for NTCP-India
Complexity of Tobacco use in India
Complexity of Stakeholders and multi-sector involvement
TC requires multi-sectoral approach involving various stakeholders
Need to identify various strategies for different sectors / stakeholders for effective TC
NTCP acting as Central Programme will:
- help sensitize all sectors and stakeholders
- increase awareness generation among youth and adults
- help raising policy and legislation issues
- help implementation of related public health and legislative
issues of tobacco control at state
Tobacco is a public health problem in India and like other need a national level programme to provide guidance to the states
FCTC obligations

36. Goals of NTCP-India Prevent initiation among youth and adults
Promote quitting among adults and youth
Eliminate exposure to tobacco smoke(SHS)
Reduce demand by IEC campaigns, ban on TAPS, and pack warnings
Reduce Supply by restricting access to minors
And thereby :
Reduce tobacco related morbidity and mortality

37. National Tobacco Control Program
Central Government Level
Set up the National Tobacco Regulatory Authority for effective enforcement and monitoring
State and District Government Level
Launch pilot of the State and District Tobacco Control Program
Establish State and District Tobacco Control Cells (STCC and DTCC). Currently in 21 states, 42 districts
Establish state and district level steering committees to monitor legislation imlementation
Establish tobacco cessation centres
Build capacity through training, sensitization and workshops
All levels
Increase public awareness

38. National Tobacco Control Program
MoH&FW
State Tobacco Control Cell
District Tobacco Control Units
Monitoring tobacco control laws & reporting
IEC
Tobacco Cessation
Training
School based activities

39. Central level Activities(NTCC)
Set up a National Tobacco Regulatory Authority(NTRA)
Establishing labs for testing tar/nicotine content of tobacco products
Capacity building: Development of training material
Public education: National level Mass Media Campaign
Surveillance: Support to conduct GATS/GYTS
Alternate crops and livelihood
To take necessary action, in co-ordination with other Ministries and stakeholders, to fulfil the obligation(s) under the WHO Framework Convention on Tobacco Control

40. State level Activities during 12th FYP (proposed)
State Tobacco Control Cells(STCC) to be established to undertake:
IEC and Advocacy efforts
Training of key stakeholders including enforcement officers, schools teachers etc.
Meetings of the State Level Co-ordination Committee(SLCC) and its follow up
Activities relating to enforcement of COTPA in the state
Overall monitoring and supervision for the implementation of NTCP and Tobacco Control Act (COTPA, 2003) in the districts.
Flexipool has been provided to states to cater to state specific needs and demands

41. Components of District Tobacco Control Programme (Pilot Phase)
Training : Training of School teachers, health workers, health professionals, law enforcers, NGO’s, women SHG’s on tobacco control
IEC : IEC using Cable TV, Street Shows, Exhibitions, Melas, etc in the regional language at grassroot level; Anti tobacco awareness programs by the trained Women SHG/ NGO’s.
School Programs : School Programme in Govt. Schools (50 Schools per district).
Monitoring Enforcement of Tobacco Control Laws
Tobacco Cessation Centres: Setting up of TCC’s in Districts.

42. District Tobacco Control Program
Training : Training of health workers, health professionals, law enforcers, NGO’s, women SHG’s on tobacco control measures

43. District Tobacco Control Program
IEC : Local/Folk media, BCC strategies, in collaboration with NGOs/CBOs/SHGs/PRIs. IEC material being updated/prepared.

44. District Tobacco Control Program
School Level Activities : involving awareness/ education campaigns, training of school teachers, Tobacco Free Schools initiatives.

45. District Tobacco Control Program
Monitoring - Formation of District level committees/District Action Plans for Enforcement of Tobacco Control Laws, evolving district specific monitoring and implementation mechanisms.

46. District Tobacco Control Program
Tobacco Cessation Clinic – To provide help to quit tobacco use at the community level, cessation facilities are being provided and capacity building for cessation at the district and sub district level.

47. Let us all work together to fulfill the dream of a healthy, Tobacco Free India

48. Thank you