Policy Interventions in Smokeless Tobacco
Control Dr.MonikaArora
Director-HealthPromo5onDivisionPHFI&Execu5veDirector
HRIDAY
Presenta(onatWorkshoponPriori(esinSmokelessTobaccoControlResearchandTrainingNeeds
27-28November2018
• AfiDhoftheworld’stobaccoisconsumedinsmokelessform(Gupta&Subramoney,2004)
• SLT’s 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
Ø 267millionusetobaccoinanyformØ EveryfiDhadultusessmokeless
tobacco(199million)Ø 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).ThelawsuitresultedindeclaringGutkhaasa“foodproduct”.
• 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(onsoftheHon’bleSupremeCourt,MoHFWsubmiieda“comprehensiveanalysisandstudyofthecontentsofgutkha,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 they“quitusinggutkhabecauseoftheban”
• Thecostofpre-packagedgutkhaincreasedfollowingthebans• Nooutletdisplayedpre-packagedgutkha
www.globaltobaccocontrol.org
Ø Mytriwasamul(-component tobaccopreven(onand control interven(on (RCT) conducted in 32Schools of Delhi and Chennai with about 14000adolescents.
Ø Overall, current tobacco use increased by 68% inthe control group and decreased by 17% in theinterven(ongroupoverthestudydura(on
Ø Inten(onstosmokeincreasedby5%inthecontrolgroup whereas inten(ons to smoke decreased ininterven(onschoolsby11%
Ø 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
Ø In our two previous awards from Fogarty’s TOBAC program, our
school-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.
Ø It is important to evaluate the impact of otherwise ‘well-tested’
interven5on strategies in low and middle income countries to
ensuretheytranslateeffec5velyandefficiently.
Ø 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-IØ Implementa(onScienceResearchoneffec(venessofAccesstominors
(Ar(cle16)Ø Assessingcausalassocia(onbetweenexposuretoTAPS(Smokeless
tobaccoandArecanutandPanMasala)andSLTuptakeanduse(Ar(cle13)§ Impactofmisinforma(onthroughsurrogateadver(singofrelated
productsØ ImpactoflargerHealthwarningsinpromo(ngcessa(onamongSLT
users(Ar(cle11)Ø Economicevalua(onofSLTpoliciesandIndustryproduc(on
§ Impactofincreasedtaxesonpriceanddemand,subs(tu(on(Ar(cle6)
§ Sizeofpackaging(loosesaleofproducts)§ Supplychain(organisedVsunorganisedsector)§ Healthcostexpenditure
Ø Reach,recallandimpactofMassmediacampaigns(Ar(cle12)
Ø Cessa(onRatewithNQLandestablishingcosteffec(venessofmcessa(on(Ar(cle14)
Ø 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
Ø SurveillanceofSmokelessTobaccoIndustrymarke(ng(especiallywrtsurrogateadver(sing).
Ø TobaccoIndustryInterference:DevelopingadatabaseØ Systema(cReviewsonSLTpolicyimpactØ ImpactofcomprehensiveSLTbans(Context,mechanismsand
processes)Ø AssesstheimpactofSLTcontrolpoliciesonyouthandyoung
adults. § Effectonlifeyearsgained§ Medicalcostsavertedinadulthood
Ø Mixedmethodsresearchtounderstandtheenablersandbarriersthatcontributetothedifferen(alimpactofSLTpoliciesacrossSES,geographiesandgender
Ø Legisla(veresearchonprocessesfollowedbyPar(estoenforceSLTpoliciesandtotackleindustryopposi(on.
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