SMOKELESS TOBACCO AND COTPA
SMOKELESS TOBACCO AND Related legislations
Presenter : Dr. WALIED K. BALWAN Moderater: Dr. Abdul Majid
Ganai (Prof and Head) S/R incharge: Dr. FEROZ A. WANI
DEPARTMENT OF COMMUNITY MEDICINE, SKIMS- SRINAGAR
Table of Contents;INTRODUCTION/ BURDENSMOKELESS
TOBACCOCOMPONENTS EFFECTS OF SMOKELESS TOBACCOPREVENTION AND
India has one of the highest rates of oral cancer in the
world.Tobacco is responsible for a significant amount of morbidity
& mortality among middle aged adults.Tobacco-related cancers -
1/2 of all cancers - men & 1/4 th among women.Oral cancer -
1/3rd total cancer ; 90% - tobacco chewers.Men are affected 2-3
times than women due to higher use of alcohol & tobacco .
Tongue & intra-oral cancer - equal in both as chewing tobacco
among women is common. Effects of tobacco use, heavy alcohol
consumption , and poor diet together explain over 90% of head &
According to WHOs Mortality Attributable to Tobacco Report,
globally 12% of all deaths among adults aged 30 years and above
were due to smokeless tobacco in compared with 16% in India,
Pakistan (17%) andBangladesh(31%).According to GATS 33% of adults
use tobacco in some form , and prevalence of smokeless tobacco use
26%According to GYTS 13.6% school going children out of which 9%
were using smokeless tobacco
What Is Smokeless Tobacco?Smokeless tobacco / spit tobacco /
chewing tobacco.Mainly two forms: snuff and chewing tobacco.Snuff -
users "pinch" or "dip" between their lower lip and gum.Chewing
tobacco - users put between their cheek and gum. The tobacco juice
is sucked and chewed - nicotine -absorbed into the bloodstream
through the oral tissues. No need to swallow
Chewed : gutkha, pan, mawa, mainpuri tobacco, khaini,
zardaApplied on gums and teeth : mishri, gudhaku, bajjar, tooth
pasteInhaled : snuff.
gutkhALeads to Oral sub-mucous fibrosis (SMF).Main component -
arecanut along with tobacco.
KHAINI Paste of tobacco + slaked lime & is used with
arecanut. Mixed with the thumb to make the mixture
alkaline-premolar region of mandibular groove
MAINPURI TOBACCOTobacco+ slaked lime + finely cut arecanut +
camphor + cloves.Mainly-Uttar Pradesh.High incidence of oral cancer
MAWAGujarati preparation made from shavings of arecanut, tobacco
and slaked lime. Sold by tobacco vendors in cellophane papers tied
like a small ball.
SNUFFFinely powdered air-cured & fire-cured tobacco
leaves.Used orally/nasally.Carried in a metal container-a twig is
dipped into it-placed in oral vestibule.Causes oral squamous cell
Tobacco leaves + lime+spices boiled in water.Residual tobacco
dried & coloured.
Oral cancer, Oral submucosis fibrosisCracking & bleeding
lips & gums.Receding gums tooth falls out.Increased heart rate,
high B.P, irregular heartbeats - greater risk of heart attacks. Can
lead to nicotine addiction.Can increase risks for early delivery
and stillbirth when used during pregnancy.Can cause nicotine
poisoning in children.
EFFECTS OF SMOKELESS TOBACCO
Why do people Use Tobacco?
This may depend on social class and local factors, some of which
are :Peer influence and pressureAdvertisements/promotions of
tobacco products through films, free distribution, sponsorships,
etcCuriosity and experimentation.Fun and enjoymentA challenge, a
sign of rebellion.Relief of Negative feelings like stress, anxiety,
Prevention and Control
Levels of Prevention Disease prevention in tobacco users always
involves informing users about the health risks the face and
promoting cessation of tobacco use.PRIMORDIAL PREVENTION to prevent
initiation of tobacco use;To be provided in the community and the
clinic.Health education especially at school level.
PRIMARY PREVENTION to help tobacco users quitTo be provided at
clinicsTobacco cessation services for tobacco users who havent yet
exhibited any disease. SECONDARY PREVENTION for early diagnosis and
treatment of diseases in tobacco users.( screening for oral cancer
and pre cancerous lesions).
TERTIARY PREVENTION To help heavy users quit, many of whom have
tobacco related symptoms and diseases.Has to be done in special
clinics or hospitals.Treatment for heavy users.
Why Intervene?The intervention by health care professional, can
help motivate patients to change their behavior.;Intervention helps
them to think about the importance of quitting tobacco use because
of the authority and standing the health care professional enjoys
in society.Physicians are viewed not only as clinicians, but also
educator and role models.
Behaviour Counselling for Tobacco cessation (5 As)Ask- Ask the
patient if he/she is a tobacco user, at every visit.Advise- Briefly
advise against continuing tobacco use and link the current
condition/ ailment to continued tobacco use.Asses- Asses readiness
to quit by asking the patient whether he/she is ready to quit (eg.
How recently you have thought of quitting tobacco)
If the patient appears ready to change( quit),Assist; Assist the
tobacco users in making a quit.Arrange; Arrange for follow up by
setting the next contact.
Approach for a current tobacco users who is not quitting tobacco
use (5 Rs)Relevance- Explain the relevance of quitting to the
client and harmful effects of tobacco use.Risks- Highlight the
health hazards that are more relevant to the individual tobacco
user.Rewards- Benefits of quitting all forms of tobacco use should
be explained ( Health ,financial, approval of family etc.)
4. Roadblocks- Barriers that the client may face in his/her quit
attempt should be identified. Withdrawal symptoms, fears and
concern associated with quitting, depression, lack of social
support, enjoyment of tobacco are some of barriers that the client
may face in attempt.
5. Repetition- The physician should assure the client that
because of chronic nature of tobacco dependence, relapses are
common in the initial phases and multiple attempts may have to be
made before he/she is able to quit tobacco.
WHO-FCTCThe World Health Organization Framework Convention on
Tobacco Control (WHO FCTC) is a treaty adopted by the 56th World
Health Assembly on 21 May 2003. It became the first World Health
Organization treaty adopted under article 19 of the WHO
constitution. The treaty came into force on 27 February 2005.It had
been signed by 168 countries and is legally binding in 180
ratifying countries.It is an evidence based treaty that reaffirms
the right of all people to the highest standard of health.
MPOWER PACKAGEMPOWER is a policy package intended to assist in
the country-level implementation of effective interventions to
reduce the demand for tobacco, as ratified by the World Health
Organization (WHO) Framework Convention on Tobacco Control .The six
evidence-based components of MPOWER are:Monitor tobacco use and
prevention policiesProtect people from tobacco smokeOffer help to
quit tobacco useWarn about the dangers of tobaccoEnforce bans on
tobacco advertising, promotion and sponsorshipRaise taxes on
tobaccoReduce the size of cigarette
TOBACCO CONTROL IN INDIA
In order to discourage tobacco use and protect the youth and
masses from harmful effect of tobacco use and SHS , GOI
enactedCOTPA Cigarettes and Other tobacco products (Prohibition of
Advertisement and Regulation of Trade and Commerce, Production,
Supply and Distribution) Act, 2003 SCOPE OF ACT:The Act is
applicable to all products containing tobacco in any form i.e.
cigarettes, cigars, cheroots, bidis, gutka, pan masala (containing
tobacco) khaini, mawa, mishri, snuff etc. as detailed in the
schedule to the Act.
The Act extends to whole of India.
MAIN PROVISIONS OF THE ACT
Enforcement agencies and mechanisms
Any police officer, not below the rank of Sub-Inspector Any
officer of State Food or Drug Administration
Any other officer, holding the equivalent rank being not below
the rank of Sub-Inspector of PoliceAny other Official as authorized
by the Central/State Governments.
NATIONAL TOBACCO CONTROL PROGRAMME The GOI launched NTCP in the
11th five year plan (2007-12) to implement Tobacco control Laws and
bring about greater awareness about ill effects of tobacco,
institute a regulatory mechanism including laboratory facility for
effective monitoring and implementation of Anti tobacco initiatives
at State/ District level.
Main ComponentsNational Level:Public awareness/ mass media
campaigns for awareness building and for behavioural
change.Establishment of tobacco products testing labs, to build
regulatory capacity, as required under COTPA,2003.Mainstreaming
researchs and programme components as a part of health delivery
mechanism under NHM.
Monitoring and evaluation including surveillance
(GATS/GYTS).Dedicate tobacco control cell for effective
implementation and monitoring of Tobacco control initiatives at
STATE LEVEL Dedicated tobacco control cell for effective
implementation of Tobacco Control initiatives at state level.
DISTRICT LEVEL Dedicated tobacco control cell for effective
implementation of Tobacco Control initiatives at District
Training; Training of school teachers, health workers, health
professionals, law enforces, NGOs, Women SHGs on tobacco control in
the districts.IEC: Using local media, Nukkad/street corner shows,
Exhibition, Melas, etc in regional languages at the grass root
School Programme: As part of school health programme of the
state govt. or with the help of NGOs to train school teachers and
sensitize children on harmful effects of tobacco, SHS and
provisions under the law, 50 schools are covered in each
district.Tobacco Cessation Centres (TCC): Setting up of Tobacco
Cessation facilities at the District Hospital level.
National Tobacco Control CellThe NTCC is responsible for overall
policy formulation, planning, monitoring and evaluation of the
different activities envisaged under the programme. National cell
Joint Sec/Director and technical support is provided by DGHS(
Training: STCC should train multiple stake holders of tobacco
control level advocacy workshops/senitization programmes. Efforts
should be made to involve all state government department for
tobacco control. Specific tailors made trainings should be
organised for academicians, Health medical/professionals, students,
police, food and drug safety authorities, judiciary, Media etc.
NTCP at District LevelEvery identified district should have
District Tobacco Control Cell (DTCC) in the District Hospital.The
DTCC is headed by DNO preferably CMO/CS on full time basis.It is
desirable that the DNO under NTCP is also given the responsibility
to look after the NCD programmes like NPCDCS, NMHP, NPHCE.Other
team members of this cell include Psychologist/Counsellor, Social
worker and Data Entry Operator on contractual basis under NTCP.
Target Trainees:Doctors, Nurses, Community Health Workers,
ASHAs, Civil society Organisations, NCC, IMA, IDA, Teachers,
Officials from Enforcement deptt. Like Police, Food Authorities,
Municipal Officers etc.
Block Level Interventions:Block level coordination committee;
Block chairperson, members of block panchayat and gram pradhans
(village Heads), prominenet NGOs, CBOs ,local MLAs,MPs, Incharge MO
of the Block PHC as convener.Block level activities; orientation
and senitization of representatives, working towards tobacco free
schools and offices in block.
Village level interventions:
Village Level committee; village Pradhan, ASHA,ANM, Anganwadi
worker , the meetings need to be conevened by the ASHA
worker.Village level activities; senitization of village level
officials, Gram Panchayat, CBOs like Farmers clubs, Mothers froups,
SHGs, Youth/ Adolescent club etc . Special IEC compaign involving
school children on World No Tobacco Day, and special days.
What Further?Integration of NTCP with other health
interventions/programmes.As we are very well aware that tobacco is
a risk factor for cancer of various organs,CVS and Pulmonary
diseases, and is strongly assoiciated with it. Moreover also strong
association with pregnacy n consequences.
ConclusionsThere are numbers of programme for diseases control
,all efforts must be made to integrate NTCP activities into the
ongoing National Health programmes like RNTCP, NMHP. NPCB, NPDCS,