1. CGHR.ORG Smoking and Death in India Prabhat Jha On behalf of the RGI-CGHR Investigators Sources of support: ICMR and RGI (India); FIC, NIH (US); IDRC & CIHR (Canada); CTSU, MRC & CR-UK (UK) Centre for Global Health Research (CGHR) Keenan Research Centre at the Li Ka Shing Knowledge Institute St. Michael’s Hospital, University of Toronto prabhat.jha@utoronto.ca World Bank seminar, April 2, 2008, Washington, DC

2. CGHR.ORG Key messages for the individual smoker in India 1. Risk BIGGER than previously thought 2. Smoking kills EARLY: 70% smoking deaths are at ages 30-69, losing decades of good life 3. Even a FEW bidis or cigarettes per day kills 4. STOPPING SMOKING WORKS – but, less than 2% of adults in India have quit

3. CGHR.ORG Nationally representative sample (Sample Registration System) 6,671 of these small areas randomly chosen from all parts of India (each with about 1000 people per area)

4. CGHR.ORG How was the study done? 900 non-medical staff monitored 1.1 M (11 lakh) homes for three years (2001-3) All adult deaths from diseases (74,000 deaths) Obtain smoking history of the dead from living household members 2 physicians assigned underlying fatal disease (eg TB) Compare smoking history of the dead to smoking history of 78,000 living adults

5. CGHR.ORG What’s new about this research? Large size of study Nationally representative study of the causes of deaths in adults: results reflect the whole of India First reliable study of female deaths from smoking in India

6. CGHR.ORG Smoking prevalence in India Cigarette or bidi (less tobacco than a cigarette, wrapped in the leaf of another plant)

7. CGHR.ORG Year% men age 15-29 years who smoke 19989.9 200411.8 200624.6 Increase 2006 vs 1998 17 M Rising prevalence among young men?

8. CGHR.ORG Smoking prevalence by education

9. CGHR.ORG Smoking prevalence by education

10. CGHR.ORG Indian Women aged 30-69 No. of deaths studied and smoker vs nonsmoker death rate ratio (RR) Underlying fatal disease No. deaths studied % who had smoked * Smoker vs nonsmoker RR † Tuberculosis1,363133.0 (2.4-3.9) Respiratory disease2,288143.1 (2.5-3.8) Stroke1,59781.6 (1.2-2.1) Heart disease2,47371.7 (1.3-2.1) Cancers2,15382.1 (1.6-2.6) All diseases16,38692.0 (1.8-2.3) * versus 4.5% of 26,678 living women who had smoked † Risk ratio adjusted for age, alcohol use and education

11. CGHR.ORG Indian Men aged 30-69 No. of deaths studied and smoker vs nonsmoker death rate ratio (RR) Underlying fatal disease No. deaths studied % who had smoked * Smoker vs nonsmoker RR † Tuberculosis3,119662.3 (2.1-2.6) Respiratory disease3,487602.1 (1.9-2.3) Stroke2,200531.6 (1.4-1.8) Heart disease5,409521.6 (1.5-1.8) Cancers2,248592.1 (1.9-2.4) All diseases25,290551.7 (1.6-1.8) * versus 37.0% of 31,661 living men who had smoked † Risk ratio adjusted for age, alcohol use and education

12. CGHR.ORG CategorySmokers (%) Risk Ratio * Residence Rural56.41.6 (1.6-1.8) Urban51.31.9 (1.6-2.1) Education None58.21.6 (1.5-1.7) Primary56.81.7 (1.5-1.8) Secondary47.81.7 (1.6-1.9) Alcohol No44.01.6 (1.5-1.7) Yes75.71.6 (1.5-1.8) Total55.41.7 (1.6-1.8) Smoker vs Nonsmoker Risk Ratio Smoking kills all categories of men results for men aged 30-69 *adjusted for age, alcohol use and education

13. CGHR.ORG Any smoking kills *adjusted for age, alcohol use and education

14. CGHR.ORG Cumulative risk of death, from age 30 smokers vs nonsmokers *adjusted for age, alcohol use and education Women

15. CGHR.ORG *adjusted for age, alcohol use and education Men Cumulative risk of death, from age 30 smokers vs nonsmokers

16. CGHR.ORG *risk in the absence of other causes of death, adjusted for age, alcohol use and education Disease-specific risks of death, ages 30-69 smokers vs nonsmokers * Women

17. CGHR.ORG Men *risk in the absence of other causes of death, adjusted for age, alcohol use and education Disease-specific risks of death, ages 30-69 smokers vs nonsmokers *

18. CGHR.ORG Disease Women Total deaths: 2.0 M Men Total deaths:2.9 M No. (% all deaths) No. (% all deaths) Respiratory disease26,00010109,00031 Tuberculosis14,0009120,00038 Heart disease/stroke13,0003152,00020 Cancer9,000467,00032 TOTAL, all diseases93,0005579,00020 Deaths from smoking in year 2010 in India, ages 30-69, by disease

19. CGHR.ORG Age rangeWomenMenBoth Ages 30-6993,000579,000672,000 All adults 20+128,000807,000935,000 Annual deaths from smoking will rise from 930,000 to 1,000,000 (10 lakh) during 2010s Deaths from smoking in year 2010 in India

20. CGHR.ORG Region Ex-smoking % age 30+ Women Men India0.21.9 Kerala*1.17.1 Delhi + 0.050.8 Low quit rates in India, 2004 *highest and + lowest male quit rates, respectively

21. CGHR.ORG INDIA: 1 million (10 lakh) smoking deaths per year during 2010s Smoking causes 10% of the 10 million (1 crore) deaths per year from all fatal disease 70% of smoking deaths are in middle age (30-69): 700,000 (7 lakh); 600,000 men and 100,000 women 20% of all adult male deaths and 5% of all adult female deaths in middle age Over 50% of smoking deaths are in illiterate adults

22. CGHR.ORG Key messages for the individual smoker in India 1. Risk BIGGER than previously thought 2. Smoking kills EARLY: 70% smoking deaths are at ages 30-69, losing decades of good life 3. Even a FEW bidis or cigarettes per day kills 4. STOPPING SMOKING WORKS – but, less than 2% of adults in India have quit

23. CGHR.ORG Press materials on: www.cghr.org/tobacco 1.NEJM Paper and Supplementary Appendix 2.Press and video releases: English, Hindi and regional languages 3.Frequently-asked questions 4.PowerPoint slides in English 5.Information about CGHR and partners News coverage of paper at : http://youtube.com/watch?v=9COgO6cXwY4 http://youtube.com/watch?v=uH66GQADiEs http://youtube.com/watch?v=9COgO6cXwY4 http://youtube.com/watch?v=uH66GQADiEs