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Policy Interventions in Smokeless Tobacco Control Dr. Monika Arora Director-Health Promo5on Division PHFI & Execu5ve Director HRIDAY Presenta(on at Workshop on Priori(es in Smokeless Tobacco Control Research and Training Needs 27-28 November 2018

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  • Policy Interventions in Smokeless Tobacco

    Control Dr.MonikaArora

    Director-HealthPromo5onDivisionPHFI&Execu5veDirector

    HRIDAY

    Presenta(onatWorkshoponPriori(esinSmokelessTobaccoControlResearchandTrainingNeeds

    27-28November2018

  • AfiDhoftheworldstobaccoisconsumedinsmokelessform(Gupta&Subramoney,2004)

    SLTs carcinogenic propensity and dependency enhances in

    combina(onwitharecanutandcalciumhydroxide (Nair,Bartsch,&Nair,2004;[WHO],2006)

    Since FCTC implementa(on, reduc(on in prevalence of smokingbutSLTcon(nuestoincrease.

    (Myers2013) Lackofknowledgeonhowtheexis(ngpolicyframeworkrelatesto

    SLT.

    SLT has been a neglected policy area and SLT products remaineasilyaccessibleandaffordabletopeople inSouthAsia, includingminors.

    WHYEMPHASISONSLTCONTROLPOLICIES?

  • SLTandotherrelatedproductpoliciesinSEARcountriesCountry TypeofBan OtherpoliciesBhutan Completebanongrowing,

    manufactureandsaleofSLT100%SalesTaxand100%CustomsdutyappliedonTPforpersonalconsump(on

    Bangladesh BanonTAPS

    50%PHW,Awarenesscampaign,prohibitsaccesstominors

    Thailand Banonimport 85%PHW,prohibitsaccesstominors(20yrs)

    India BanatSub-Na(onallevelonproduc(onandsaleofgutkha(SLTinsomestates),banonTAPS

    Massmediacampaigns,85%PHW,28%tax+cess,m-cessa(on,Prohibitsaccesstominors

    Nepal BanonUseofSLTinpublicplaces Dedicatedtax,90%PHW,Prohibitsaccesstominors

    Indonesia BanonSLT 40%PHW,prohibitsaccesstominors

  • SLTandotherrelatedproductpoliciesinSEARcountries

    Country TypeofBan Otherpolicies

    Maldives BanonSLT Textwarning,prohibitsaccesstominors

    Myanmar BanonchewingBetelQuitingovernmentpremises

    75%PHW,prohibitsaccesstominors

    DPRKorea BannedSLTproducts TextWarnings,prohibitsaccesstominors

    SriLanka BanonSLT 80%PHW,prohibitsaccesstominors(21yrs)

    TimorLeste - 50%PHW,prohibitsaccesstominors(17yrs)

  • DALYS(allcause)aOributabletoSLTinSEARcountries(1990-2016)

  • Deaths(allcause)aOributabletoSLTinSEARcountries(1990-2016)

  • RankingofNCDRiskFactorsinGBD,2015(BasedOnDALYs)

    15-49 Yrs. 50-69 Yrs. High systolic BP High systolic BP

    High fasting plasma blood glucose Tobacco smoking

    High BMI High fasting plasma blood glucose

    Tobacco smoking High BMI

    Diet low in whole grains High total cholesterol

    High total cholesterol Diet high in sodium

    Diet low in fruits Diet low in whole grains

    Alcohol use Ambient particulate matter pollution

    Ambient particulate matter pollution Diet low in fruits

    Drug use Household air pollution from solid fuels

  • DALYS(allcause)aOributabletoSLTinIndianStates(1990-2016)

    Tobaccouse(includingsmoking,SHS,andSLT)remainsamajorriskfactorcausing5.9%ofthetotalDALYsin2016.

    TheDALYrateaiributabletotobaccousewashighestinMizoram,Uiarakhand,JammuandKashmir,Haryana,WestBengal,andTripura.

  • GATSIndia2017

    267millionusetobaccoinanyform EveryfiDhadultusessmokeless

    tobacco(199million) 32milliondualusersoftobacco

    PrevalenceofSmokelessTobaccoinIndia

  • GATSIndia2017

  • GATSIndia2017

    4.8

    8.78

    PanMasalawithouttobacco Betelquidwithouttobacco ArecaNut

    Percentageofadultsusingdifferentnon-tobaccoproducts

    GATS2

  • PercentageofSmokelessTobaccoUsers

    GATSIndia2017

    21.4

    18.2

    5.8

    25.9

    21.4

    4.8

    0

    5

    10

    15

    20

    25

    30

    Currentsmokelesstobaccousers Dailysmokelesstobaccousers Formerdailysmokelesstobaccousers(amongeverdailysmokelesstobaccousers)

    GATS2

    GATS1

  • 33.2

    49.6

    31.735.4

    45.2

    26.7

    0

    10

    20

    30

    40

    50

    60

    Smokelesstobaccouserswhomadeaquitaiemptinpast12months

    Currentsmokelesstobaccouserswhoplannedtoorwerethinkingabout

    quinng

    Smokelesstobaccousersadvisedtoquitbyahealthcareproviderinpast12

    months

    GATS2GATS1

    GATSIndia2017

    Cessa5onamongSLTusers

  • ImpactofPoliciesonSLTuse

  • GutkhaBaninIndia EarlierpolicyaOempts: FivestatesbannedGutkhaduring2000-2004butSupremeCourtof

    India reverseddecisionsby stateson technical grounds (GodawatPanmasalaVs.UnionofIndia,2004).ThelawsuitresultedindeclaringGutkhaasafoodproduct.

    Statelaws:GoaamendedthePublicHealthActin2005toimplementthegutkhaban. Turning Point: Plas(cWaste (Management and Handling) Rules (2011): Supreme Court of

    India prohibits use of plas(c materials in sachets for storing, packaging or selling gutkha,tobaccoandpaanmasalafromMarch2011(AnkurGutkhaVsIndianAsthmaCareSociety&Ors).

    EvidencetoPolicy:Asperthedirec(onsoftheHonbleSupremeCourt,MoHFWsubmiiedacomprehensiveanalysisandstudyofthecontentsofgutkha,paanmasalaandothersimilarproductsandharmfuleffectsofconsump(onofsuchar(cles(2011).

    Expert group consulta5ons and consensus recommenda5on: In April, 2011 Na(onalConsulta(on on Smokeless tobaccowas organized to give recommenda(ons on adop(ng aprogressivebanforsmokelesstobaccoproductsinIndia.

    33Indianstates(covering122millionpeople)andUTshavebannedgutkhawhilesomehavealsobannedothersmokelesstobaccoproductslikezardaandpaanmasala

  • No5fica5onandimplementa5onofFSSRegula5ons,2011,Rule2.3.4,bystates

    GuptaPC,AroraM,SinhaDN,AsmaS,ParascandolaM(eds.);SmokelessTobaccoandPublicHealthinIndia.2016.

  • Adver5singofPaanMasalainIndia

  • ImpactofGutkhaBaninIndia About50%reportedconsuminglessgutkhasincethebans Post-bans,most gutkhausers report purchasing ingredients separately

    andcombining/mixingtheirowngutkha. 15%con(nuetopurchasepre-packagedgutkha Abouthalfofrespondentsreportedaiemp(ngtostopusinggutkha in

    thelastyear. Oftherespondentsthatquitsincethebans,asubstan(alpropor(onin

    eachstate (41-88%) reported that theyquitusinggutkhabecauseoftheban

    Thecostofpre-packagedgutkhaincreasedfollowingthebans Nooutletdisplayedpre-packagedgutkha

    www.globaltobaccocontrol.org

  • Mytriwasamul(-component tobaccopreven(onand control interven(on (RCT) conducted in 32Schools of Delhi and Chennai with about 14000adolescents.

    Overall, current tobacco use increased by 68% inthe control group and decreased by 17% in theinterven(ongroupoverthestudydura(on

    Inten(onstosmokeincreasedby5%inthecontrolgroup whereas inten(ons to smoke decreased ininterven(onschoolsby11%

    Inten(ons to chew tobacco decreased by 12% inthe control groupwhile decreased by 28% in theinterven(ongroup

    Perryetal.,2009

    3.42

    2.83

    1.38

    2.32

    0

    0.5

    1

    1.5

    2

    2.5

    3

    3.5

    4

    Baseline Endline

    Toba

    cco

    use

    prev

    alen

    ce

    Trend in current tobacco use prevalence over time (n=14063)

    Intervention

    Control

    ProjectMYTRI(MobilisingYouthforTobaccoRelatedIni5a5vesinIndia):Differen5alimpactacrossproducts

  • HarrellMBetal2016

    ProjectACTIVITY:Ineffec5veforSLTuse

  • ImpactofcomprehensiveTCinterven5onsonSLTuseamongyouthinIndia

    In our two previous awards from Fogartys TOBAC program, ourschool-basedprogram(ProjectMYTRI:2002-07)andcommunity-wide

    ini(a(ve( Project ACTIVITY: 2007-2012) successfully reduced

    cigareie and bidi smoking, but both were ineffec(ve at cunng

    smokelesstobaccouse.

    It is important to evaluate the impact of otherwise well-tested

    interven5on strategies in low and middle income countries to

    ensuretheytranslateeffec5velyandefficiently.

    Limited studies on the impact of TC policies outside of HICs oDen

    underes(matetheireffectsonyouthandyoungadults.

  • KhanAetal2014

  • 22

    hip://untobaccocontrol.org/kh/smokeless-tobacco/

    NumberandPercentageofPar(esimplemen(ngSLTspecificFCTCprovisions

  • Researchpriori(esfromPolicyPerspec(ve-I Implementa(onScienceResearchoneffec(venessofAccesstominors

    (Ar(cle16) Assessingcausalassocia(onbetweenexposuretoTAPS(Smokeless

    tobaccoandArecanutandPanMasala)andSLTuptakeanduse(Ar(cle13) Impactofmisinforma(onthroughsurrogateadver(singofrelated

    products ImpactoflargerHealthwarningsinpromo(ngcessa(onamongSLT

    users(Ar(cle11) Economicevalua(onofSLTpoliciesandIndustryproduc(on

    Impactofincreasedtaxesonpriceanddemand,subs(tu(on(Ar(cle6)

    Sizeofpackaging(loosesaleofproducts) Supplychain(organisedVsunorganisedsector) Healthcostexpenditure

    Reach,recallandimpactofMassmediacampaigns(Ar(cle12)

  • Cessa(onRatewithNQLandestablishingcosteffec(venessofmcessa(on(Ar(cle14)

    Tes(ngofSLTproducts(Ar(cle9&10) Iden(fyingingredientsacrossproducts FixingStandardsandvalida(onmethodstotestthecontentsof

    differentsmokelesstobaccoproducts Legisla(vemeasurestoregulate Methodsofmanufacturingthesame Es(ma(ngthehealthimpact Characterizingtheproper(esofdifferentcons(tuentsof

    carcinogenic,culturally-acceptable,nontobaccosmokelessproductsthatarefrequentlyusedinconjunc(onwithtobaccoproducts,suchasarecanut(betelnut)andrelatedproductssuchassupariandpanmasala.

    Researchpriori(esfromPolicyPerspec(ve-II

  • Research,SurveillanceandExchangeofinforma5on

    SurveillanceofSmokelessTobaccoIndustrymarke(ng(especiallywrtsurrogateadver(sing).

    TobaccoIndustryInterference:Developingadatabase Systema(cReviewsonSLTpolicyimpact ImpactofcomprehensiveSLTbans(Context,mechanismsand

    processes) AssesstheimpactofSLTcontrolpoliciesonyouthandyoung

    adults. Effectonlifeyearsgained Medicalcostsavertedinadulthood

    Mixedmethodsresearchtounderstandtheenablersandbarriersthatcontributetothedifferen(alimpactofSLTpoliciesacrossSES,geographiesandgender

    Legisla(veresearchonprocessesfollowedbyPar(estoenforceSLTpoliciesandtotackleindustryopposi(on.

  • THANK YOU

    [email protected]