Smokeless tobacco: A major public health problem in the SEA region: A review.

Smokeless tobacco use is on the upswing in some parts of the world, including parts of SEAR. It is therefore important to monitor this problem and understand the possible consequences on public health. Material for this review was obtained from documents and data of the World Health Organization, co-authors, colleagues, and searches on key words in PubMed and on Google. Smokeless tobacco use in SEAR, as betel quid with tobacco, declined with increased marketing of cigarettes from the early twentieth century. Smokeless tobacco use began to increase in the 1970s in South Asia, with the marketing of new products made from areca nut and tobacco and convenient packaging. As a consequence, oral precancerous conditions and cancer incidence in young adults have increased significantly. Thailand's successful policies in reducing betel quid use through school health education from the 1920s and in preventing imports of smokeless tobacco products from 1992 are worth emulating by many SEAR countries. India, the largest manufacturing country of smokeless tobacco in the Region, is considering ways to regulate its production. Best practices require the simultaneous control of smokeless and smoking forms of tobacco. Governments in SEAR would do well to adopt strong measures now to control this problem.

The relationship between tobacco advertisements and smoking status of youth in India.

OBJECTIVE: To examine the relationship between tobacco advertisements, counter-advertisements, and smoking status among Indian youth. MATERIALS AND METHODS: Global Youth Tobacco Survey (GYTS) data was used; the data encompassed a representative two-stage probability sample of 60,001 students aged 13-15 years in 24 states in India. These students were interviewed with an anonymous, self-administered questionnaire. Binary logistic regression analyses were performed with smoking status as the dependent variable, and exposure to cigarette advertisements or counter-advertisements as independent variables. RESULTS: Students watching anti-smoking media messages were less likely to be current smokers, which was true for both boys [OR = 0.89, 95% CI (0.81-0.98)] and girls [OR = 0.79, 95% CI (0.69-.90)]. This relationship was stronger among past smokers for boys [OR = 0.56, 95%CI (0.52-0.60)] and girls [OR = 0.49, 95% CI (0.45-0.53)]. On the other hand, students who were exposed to cigarette brand names during sports events and other televised programs, newspapers or magazines, and being offered free cigarette or cigarette-branded merchandise promotions were significantly more likely to be smokers, with effects ranging from moderate (OR=1.19) to very strong (OR=3.83). CONCLUSIONS: This is the first attempt from India to investigate the relationship between smoking and advertising. When the data were collected, cigarette advertising was legal and highly correlated with smoking behavior. Today, indirect surrogate advertising still exists; future research should examine its effect, as it is likely to have the same impact as direct advertising on smoking behavior. Finally, counter-advertising has a protective effect on youth and may function as a cessation aid.

Tobacco use among students and school personnel in India.

BACKGROUND: Tobacco usage is addictive and causative for several diseases and premature death. Concerted efforts by the individual and society are needed for control and for surveillance. The habit is initiated during early youth and this age group requires constant monitoring and timely appropriate action to curtail usage. The WHO FCTC has recommended actions to monitor and limit the tobacco use in young age groups. One of the actions is to examine the prevalence of tobacco habits in school children 13-15 years of age and of personnel employed in schools. METHODS: WHO & CDC designed the study systems for Global Youth Tobacco Survey (GYTS) and Global School Personnel Survey (GSPS). In 2006 we conducted GYTS and GSPS in several parts of the country. The schools were chosen by strict sampling procedure and a well structured, self-administered questionnaire was used to obtain information on tobacco usage from 13 to 15 year old students of chosen schools and personnel of these schools. RESULTS: Current use of any tobacco product was 14.1% among students (17.3% boys, 9.8% girls) and among school personnel it was 29.2%(35.0% males and 13.7% females). The prevalence was highest among male students in North East (34%) and the lowest was 4.9% among female students of western states. Cigarettes and Bidi smoking were more prevalent among boys. Smokeless tobacco use prevalence rate varied between 20% and 4.5% among boys and between 21.5% and 1.6% among girl students. Among male school personnel, the prevalence varied from 57.9% in NE to 25.7% in South. Among females 26.5% were tobacco users in the NE and in Western region it was 6.6%. CONCLUSION: It is essential to adopt forceful strategies, which are area specific, in order to undo the harm inflicted by tobacco use upon the individuals &society. Periodic surveys for surveillance of trends are essential to evaluate the outcome of programmes among students and school personnels.

Stage at diagnosis and relative differences in breast and prostate cancer incidence in India: comparison with the United States.

PURPOSE: To examine and reconcile differences in incidence rates and stage-at-initial-presentation of prostate and breast cancers in India, a country in epidemiologic transition. METHODS: Age-adjusted prostate and female breast cancer incidence rates and proportion of cases by stage-at-diagnosis were compared. Data were derived from the National Cancer Registry Program of India, other Indian registries, the International Agency for Research on Cancer, and the US/ NCI Surveillance, Epidemiology, and End Results (SEER) Program. RESULTS: Average annual cancer incidence rates in India ranged from 5.0 to 9.1 per 100,000/year for prostate and 7.2 to 31.3 per 100,000/year for female breast. Comparative rates in the US for prostate cancer are 110.4 for Whites and 180.9 for Blacks; for female breast, the rates are 86.6 for Blacks and 96.4 for Whites. Notable differences were observed between rural and urban areas in India, while such differences by rurality appear to be much smaller in the US. Overall, about 50-55% of breast cancer cases and about 85% of prostate cancers were detected at late (III and IV) stage; in contrast to the US where 15% of either cancer is diagnosed at late stage. CONCLUSIONS: Differences in stage-at-diagnosis help explain variations in incidence rates among cancer registries in India and rate differences between India and the US. These findings indicate that erroneous inferences will result from incidence-rate comparisons that do not take into account stage-at-diagnosis. Results also point to epidemiologic studies that could be conducted to deepen understanding of the etiology of these cancers. By enhancing data on staging, the Indian cancer registries could widen the scope of collaborative, cross-national research.

Concurrent alcohol and tobacco use among a middle-aged and elderly population in Mumbai.

BACKGROUND: The concurrent use of alcohol and tobacco and its deleterious effects have been reported in the western literature. However, studies on the relationship between concurrent alcohol and tobacco use in India are limited. This study outlines the association between concurrent alcohol and tobacco use among a middle-aged and elderly population in a western Indian cohort after controlling for various sociodemographic factors. METHODS: A total of 35 102 men, 45 years of age and above were interviewed for concurrent alcohol and tobacco use. The sample was part of an earlier cohort drawn from the general population. The data were analysed after controlling for age, education, religion and mother-tongue. RESULTS: Among alcohol users, 51.1% smoked tobacco and 35.6% used smokeless tobacco. The relative risk of alcohol use was highest among those smoking cigarettes or beedis and among those using mishri with betel quid and tobacco. The risk of alcohol use increased with the frequency of tobacco use. The risk also increased with higher amounts of alcohol consumption, but peaked at around 100-150 ml of absolute alcohol use. CONCLUSION: The study highlights the association between concurrent alcohol and tobacco use among the Indian population. This has important public health implications since concurrent use of these is synergistic for increased risk of oropharyngeal cancers.

School policy and tobacco use by students in Bihar, India.

The association between school tobacco policies and tobacco use prevalence among students were examined. A two stage cluster sample design with probability proportional to the enrolment in grades VIII-X was used. Comparison was made between schools with a tobacco policy (Federal schools) and schools without a policy (State schools). Stratified probability samples of 50 schools each were selected. SUDAAN and the C-sample procedure in Epi-Info was used for statistical analysis. Students from State schools (without tobacco policy) reported significantly higher ever and current any tobacco use, current smokeless tobacco use and current smoking compared to Federal schools (with tobacco policy) both in rural and urban areas. Classroom teaching on the harmful effects of tobacco was significantly higher (17-24 times) in Federal schools than State schools both in rural and urban areas. Parental tobacco use was similar for students in Federal and State schools. Students attending state schools were more likely than students attending Federal schools to have friends who smoke or chew tobacco. These findings suggest that the wider introduction of comprehensive school policies may help to reduce adolescent tobacco use.

Tobacco use among school students in Goa, India.

Information about prevalence of tobacco use was assessed among school children in Goa, India. Among 50 sampled schools, the school response rate was 98% and, over 94% students participated in the survey (56% were boys, 44% girls). Ever tobacco use was reported by 13.5% of which over 40% reported initiation at 10 years of age or earlier. The current tobacco use (any product) was reported by 4.5%, without much difference in smokeless tobacco use (2.8%) and smoking (3.0%). Smokeless tobacco was use mainly in the form of applying mishri, tobacco containing toothpaste or toothpowder. Smoking among boys was 3.5% and girls 2.2%. Non-users reported knowledge about the harmful effect of tobacco two to three times more than tobacco users. Over about 50% of students reported having been taught in school about the dangers of tobacco use. Tobacco users (60.5%) as well as non-users (63%) favoured ban smoking in public places equally. Tobacco use by parents and close friends was positively associated with students' current tobacco use.

Tobacco control practices by medical doctors in developing world; a questionnaire study.

AIM: To know about the tobacco control practices by medical doctors in Bihar, India. SETTINGS & DESIGN: All medical doctors in Bihar, India. Two stage sampling with probability propotional to the number of doctors in the districts was used. METHOD: Anonymous survey was conducted on structured questionnaire. STATISTICAL ANALYSIS: SUDAAN and Epi-Info. RESULTS: Most of the doctors were government doctors. Most doctors (>75%) reported either for no policy or partial policy in health settings however over 2/3rd of medical doctors felt need for their training on tobacco cessation. Most of the doctors did not take tobacco history (60-80%). CONCLUSION: Medical doctors in Bihar need to be trained for tobacco cessation. Smoking needs to be enforced vigorously in health sector to protect patients and doctors.

Tobacco use among teachers [corrected] in Uttar Pradesh & Uttaranchal, India.

Information about tobacco use prevalence, knowledge and attitude was assessed among school personnel in Uttar Pradesh. A single cluster sample design with probability proportional to the enrolment in grades 8-10 was used. Statistical analysis was done using SUDAAN and the C-sample procedure in Epi-Info. The school response rate was 100%. School personnel response rate ranged from 72-80%, the proportion of men being 84-92%. Current cigarette smoking and smokeless tobacco use reported by all teachers was 21.9% and 75.6% respectively. The prevalence of daily cigarette smoking was ranged by 12.6-15.1%; bidi and other smoking 4.8-13.4%; smokeless tobacco use 16.3-19.8%. Existing school policy on four measures were reported poor however over 72% school personnel felt need for policy prohibiting tobacco use among students and school personnel. Tobacco prevention instruction by teachers did not fare much better on six different measures (4.9-30.9%). However over 2/3rd school personnel were very supportive on tobacco control issues. There was no training among school personnel on tobacco use prevention skills (3.7%). However most of the school personnel (67.1%) were curious about getting such trainings. A positive environment for tobacco use prevention needs to be created by adopting comprehensive tobacco control policies for schools. First step towards this may be training of school personnel on tobacco use prevention skill and supply of teaching materials.

Tobacco use among students in Bihar (India).

Determination of the prevalence and attitudes toward tobacco use was assessed among 13-15 years school students in Bihar (India). Settings and design: Schools having grade 8-10 in Bihar. A two stage cluster sample design was used. SUDAAN and the C-sample procedure in Epi-Info was used for statistical analysis. Of the 2636 respondents, 71.8% (76.5% boys, 57.2% girls) were ever tobacco users; of them 48.9% had used tobacco before 10 years of age. Current use was reported by 58.9% (Boys 61.4%, Girls 51.2%); smokeless tobacco by 55.6% (Boys 57.6%, Girls 49.2%); and smoking by 19.4% (23.0% boys, 7.8% girls). Nearly one third (29%) students were exposed to ETS inside their homes and nearly half (48%) outside their homes. Almost all students reported watching cigarette and gutka advertisements in almost all kinds of media and events. Tobacco use by parents and friends, knowledge on harmful effects of chewing tobacco, smoking and environmental smoke, and attitudes on tobacco use by others were strongly associated with student tobacco use. Current tobacco use was reported significantly more by students who received pocket money/or were earning than by students who did not receive any pocket money/or did not earn (p value for trend <0.0001). Over half of current users (56%) bought their tobacco products from stores; of these, over 3/4th (77.2%) of them despite their age, had no difficulty in procuring these products. Teaching in schools regarding harmful effects of tobacco use was non-existent (3%). This urgently requires a comprehensive prevention program in schools and the community especially targeted towards girls.

Tobacco use among school personnel in Orissa.

Tobacco use prevalence, knowledge and attitude was assessed among school personnel in Orissa. A single cluster sample design with probability proportional to the enrolment in grades VIII-X was used. Statistical analysis was clone using SUDAAN and the C-sample procedure in Epi-Info. The school response rate was 100%. Over 72% of school personals participated in the survey, the proportion of men being 84%. Current cigarette smoking, bidi smoking and smokeless tobacco use was reported by 26.8%, 30.1% and 38.8% school personnel respectively. Current daily cigarette smoking, bidi smoking and smokeless tobacco use reported by 18.3%, 16.6% and 24.2% school personnel respectively. Men reported significantly more all kinds of daily tobacco use as compared to women. School tobacco control policy on three scales was reported poor (25-39%). However most of the school personnel felt need for such policies (88-98%). Teaching and training on tobacco was reported low (22.7%-35.9%). Most of the school personnel (87-95%) were supportive on different measures on tobacco control issues. Introduction of comprehensive school policies and enforcement on tobacco use may help to reduce adolescent and school personnel tobacco use.