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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

Smokeless tobacco and cotpa

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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




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 & neck cancers.

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 & leukoplakia.

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 carcinoma. ZARDA

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.


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, boredom.

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


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.


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.

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 level.

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 level.

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 functions

Joint Sec/Director and technical support is provided by DGHS( i.e. DDG/CMO.

Organizations (NTCC)

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, RCH etc.