Tobacco Consumption and Legislations Regarding Tobacco Use in India – Is It Time for A Policy Change?

sec-ABSTRACT One of the most consumed and readily available products causing psychological dependence among the population is tobacco and its related products. Though the government of India is undertaking measures to reduce tobacco consumption, factors like easy availability, lack of monitoring of tobacco use among youngsters, low cost and rapid absorption into the central nervous system is prompting people from a young age to the elderly to consume tobacco-related products. Legislative measures to reduce tobacco consumption seldom reach or benefit people as laws differ across States. This increases the prevalence of respiratory diseases like Chronic Obstructive Pulmonary Disease (COPD) and lung cancer. This review article discusses the status of tobacco consumption in India with emphasis on tobacco-related legislation in States and associated health inequities.


INTRODUCTION
Tobacco consumption is one of the best preventable causes of death and disability worldwide. 1 In developing countries like India, the mortality and morbidity due to tobacco consumption are disproportionately high. By the year 2030, it is estimated that tobacco could cause the mortality of tens of millions of people in developing countries. 2 Youth and adults' tobacco consumption can severely affect their health and well-being. Tobacco use comprises the use of both smoked (cigars, bidis, cigarettes, rolled cigarettes, cheroots, hookah, pipes, chillum, chute and tobacco rolled in newspapers) and smokeless (khaini, betel quid with tobacco, tobacco lime mixture, oral tobacco, gutka, snuff and pan masala). Both can lead to many types of cancers, leading to early loss of life in their productive years. 3 According to the World Health Organization (WHO), tobacco leads to more than 7 million deaths yearly. In India, smoking and tobacco consumption is the fourth most crucial risk factor for developing non-communicable diseases such as heart disease and cancer. 4 According to WHO, in India, nearly 9% of the youth population consume tobacco. This is an essential indicator that primordial prevention has failed. All those who consume tobacco are exposed to the ill effects of smoking early in their lives, leading to premature death due to various complications such as ischemic heart disease and Cerebrovascular disease. Those who continue tobacco consumption can develop longterm consequences of tobacco use, such as Chronic Obstructive Pulmonary Disease (COPD) and frequent lower respiratory infections. 4

PASSIVE SMOKING
Passive smoking or Environmental Tobacco Smoke (ETS) is the involuntary inhaling of smoke from another person's cigarettes, beedis, and pipes. Passive smoking is more dangerous and harmful. The fume that burns off the end of a cigarette has more toxic substances than the smoke inhaled by the smoker, as there is no filter through which the smoke passes. Spouses of smokers and those exposed to workplace smoking are at increased risk of getting these illnesses. Children are also more vulnerable. Inhaling sec-ond-hand smoke is a known cause of low birth weight, sudden infant death syndrome (SIDS), pneumonia, bronchitis and asthma. 5 Exposure to environmental tobacco smoke during pregnancy increases risk of having placenta previa, placental abruption, stillbirth, low birth weight, and miscarriage. 6

TOBACCO LEGISLATION IN INDIA 8
In India, to discourage tobacco use and protect the youth and masses from the harmful effects of tobacco from Second Hand Smoke, the Government of India enacted "Cigarettes and other tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, (COTPA) in 2003. The act imposes a progressive restriction on all tobacco products to reduce their demand and supply.
The specific provisions of COTPA and its problem in the implementation includes,  Ban on smoking in public places -Even though it is implemented in theory, tobacco in the country is still rampant in front of tea shops, inside vehicles and on the roadside, especially in rural areas.
 Regulation of smoking scenes in movies -In typical Indian films, smoking is always glorified with the protagonist or antagonist consuming tobacco.
In some movies, it can be seen that the character's wife is lighting her husband's cigarette. But in all those scenes, if a thorough search is done, a warning sign can be seen that "Smoking is injurious to health", which is of no use to the general public.
 Ban on tobacco product advertisement, including both direct and indirect advertising -This has been effective in the country as we could see no cigarette advertisements.
 Ban on sale of tobacco products within 100 yards of any medical institution -This again is debatable as there are many tea shops selling cigarettes near schools and colleges, which the government does not scrutinize properly.
 Ban on sale of cigarette and tobacco products for people under 18. -This policy mainly failed in India because of improper supervision of the sale of tobacco products by the policymakers, lack of awareness among school students on the harmful effects of tobacco and the influence of parents' smoking habits, and peer pressure among school students.
 Mandatory depiction of statutory warnings (including pictorial warnings on tobacco packs) -This will seldom have an effect unless the person consuming tobacco is aware of the harmful effects at the individual and family level.
 Display of tar and nicotine contents on tobacco packs -This is no use unless the people are sensitized about those terms. Despite various measures taken by our government, smokers continue to smoke until they acquire an illness. So, suppose a person by the age of 20 years becomes a chronic smoker, continues to smoke cigarettes daily in the house and arrives at a disease like COPD by age 50. In that case, his family has been exposed to environmental tobacco smoke (ETS) for 30 years. So, all his family members suffer from the harmful effects of second-hand smoke. In the case of substance misuse, a vital term called individual susceptibility has to be understood. It means that the rate and degree at which smoking affects various systems in our body is different from person to person, which cannot be predicted. 8 Each person's body metabolism, lung capacity, chest expansion, and genetic expression differ. So, a person may smoke 20 packs a day for ten years and be healthy without any health issues. There may be another person who smokes only 2 to 3 cigarettes daily for over ten years and develops COPD, lung cancer or health issues. 9 So, there is no use in comparing a person who smokes tobacco to other chronic smokers and satisfies themselves like, "See this person, he smokes ten packs per day and is healthy. I smoke only five cigarettes daily, and I will be healthy!" This has been the case for most of the Indian population who consume tobacco. These are some reasons why, despite various measures taken by our government, deaths due to smoking in the country are rising. 10

HEALTH INEQUITY RELATED TO TOBACCO CONSUMPTION IN INDIA
One of the significant determinants of health leading to health inequities in India is health-related behaviors, namely tobacco use and smoking. 11 It is observed that those who consume tobacco at a higher rate belong to the lower socioeconomic status and are illiterate. Tobacco use and smoking among young individuals can lead to the development of chronic lung infections like tuberculosis, and in the middleaged can lead to chronic lung diseases and cancer. In many of the studies conducted across India, tobacco consumption is comparatively higher among men when compared to women. 12 Those who belong to the lower socioeconomic status consume smokeless tobacco more than those compared to a higher status. The primary reason for this is the low-cost avail-ability of smokeless tobacco in the local market, which is outside the government's supervision. 13

TOBACCO LAWS IN INDIVIDUAL STATES IN INDIA
Even among the tobacco laws, some states impose stringent tobacco control laws to reduce tobacco consumption. 14 Some smoke-free cities in India are Kottayam in Kerala, Chandigarh, Shimla and Sikkim. Some of the measures imposed in the cities above to control tobacco consumption are: As per the public notice that the Chandigarh administration issued, smoking at hotels, restaurants, hospitals, railway stations, bus stands, buses and taxis is banned. All public places should paste a poster of 30 cm × 60 cm (minimum dimension) in size stating "No Smoking," and smoking near public places should not be allowed. All the police officers have been given full authority to take action against anybody smoking in public places. Persons throwing the half-burnt cigarettes or beedis shall be held responsible, and they can be penalized on the spot. Hotels and restaurant owners have to make their premises smoke-free. They should paste a minimum of two posters of at least 30 cm × 60 cm in size stating, "Cigarette smoking is an offence here." All educational institutes must put a sign at the boundary of their premises saying, "Cigarette smoking within a radius of 100 meters of this premise is an offence." Tobacco selling outlets must put a poster of at least 30 cm × 60 cm size outside their shop stating, "Sale of tobacco or its products to a person less than 18 years of age is an offence." A Tobacco Control Cell has been established in the city under the leadership of the Health Secretary, with a chief police officer and other stakeholders as members to look over the implementation of the "smoke-free city" campaign. The Government of India is now actively considering making Mumbai and New Delhi smoke-free in the next two years. 15 The latest city to join the list of smoke-free towns in India is Kohima, the capital of Nagaland. 16 Regarding the depiction of smoking scenes by actors in the movies, a ban was imposed by the central government in 2006 that movies must not show actors smoking that it may instil a false sense of security among the younger generation as they look upon the actors as their role models. But in 2006, Delhi high court lifted the ban on smoking scenes in movies that contradicted the rights of expression. 17 The Goa Prohibition of Smoking and Spitting Bill Act, 1997, is among the country's unique acts related to tobacco consumption. This act has banned all forms of smoking or chewing tobacco and spitting in public, which implies "voluntary ejection of saliva from the mouth after chewing or without chewing and ejection of mucus from the nose after inhaling snuff or without inhaling." 18,19 Public policy changes which can be adopted at the National and State level to reduce the tobacco epidemic in India There is a low level of awareness regarding the harmful effects of tobacco consumption among people from the lower socio-economic class and very low awareness regarding passive smoking in rural areas. 20 Scaling up policies to provide health education campaigns at various hotspots in rural areas with a higher prevalence of tobacco consumption can be done throughout the country. 21 Individual State level Geographic Information System (GIS) Mapping can be done to identify the hotspots. 22 Rather than opting for a blanket ban on scenes of tobacco consumption in tv series/ movies, the government can impose laws to ban the glorification of smoking practices by protagonists or antagonists in the films. This can reduce the impact of smoking tobacco on the younger generation. The government of India, though, have not banned the depiction of tobacco use in movies but reduced the tobacco portrayal with proper monitoring and display of messages that need to be monitored and followed up periodically. 23 In the Union Budget 2020, the finance minister proposed increasing the excise duty on cigarettes by increasing the National Calamity Contingent duty on tobacco products. But this can invariably lead to the illegal cigarette trade and affect tobacco farmer earnings in the country. 24 It's a good measure that the government has increased the taxation in the form of GST on cigarettes and bidis to 28%. Data shows that a 10% increase in tobacco prices can reduce tobacco consumption by around 8 to 10% in rural areas while, at the same time, increasing revenue for the country. 25 Limited tobacco cessation facilities at the National and State levels in the country are another primary concern. These facilities provide only counselling for behavioural modification changes. Research data shows that only 12 to 14% of people quit tobacco after utilising these facilities. 26 These facilities offer nicotine replacement therapy under the supervision of health personnel, supplementing with behavioural counselling. 27 Low priority for health education on passive smoking in rural and urban areas is a significant cause of concern as passive smoking is becoming rampant in rural areas with mothers and children suffering from chronic respiratory illnesses. A Community level health programme can be initiated separately by local panchayats and talukas in rural areas to educate people and take community-level measures like smoke-free areas and advocating measures to ban the selling of cigarettes near schools and colleges. 28 Since economically disadvantaged and minority groups are at a higher risk, health education regarding passive smoking practices has to be scaled up in those areas by Information Education and Communication (IEC) Campaigns. Strict laws must be enforced on the prohibition of smoking in vehicles. In the community, awareness has to be created among taxi and auto drivers to avoid smoking while driving as it can passively affect the passengers.
Measures must be made for restaurants and other places to enforce no-smoking policies. The stakeholders must choose smoke-free care facilities for children and the elderly, as passive smoking can seriously affect them. 29 Parents should be good role models to their children by not smoking or practising the use of any other tobacco product. Research has shown that smoking practices among parents have a significant impact on the smoking practices of their children. 30 Mass media campaigns using brief recurring messages to motivate children and adolescent boys and girls to remain tobacco-free must be planned and carried out by district tobacco control units in their respective districts which can positively impact the attitude toward tobacco usage. 31 Schools and Colleges have to play an essential role in creating awareness regarding tobacco consumption among children as primordial prevention begins in school. This is challenging because the schools have a notion that topics related to mental health should not be discussed in school. Meetings have to be conducted among stakeholders of schools to encourage them to run awareness campaigns in school explaining the hazards of tobacco consumption. 32 Community participation and health education among families, especially wives, on the ill effects of passive smoking on them and their children have to be carried out so that they are empowered and can take measures to avoid or minimise the impact of passive smoking in the house. 33 Most businesses, offices and companies have policies that protect non-smokers from second-hand smoke. If the company does not have such a policy, it can be worked with management and labour organisations to create one. Government has to evaluate these firms periodically. If the apartment buildings are not smoke-free, it can be pointed out to the landlord that a non-smoking facility has lower insurance and maintenance costs. These measures will help reduce tobacco usage at workplaces and residential buildings. 34 Strengthening, scaling up and successfully implementing the WHO MPOWER Strategy in all States across the country. The strategy includes, Monitoring tobacco use and prevention policies, protecting people from tobacco smoke, offering help to quit tobacco use, Warning about the dangers of tobacco, enforcing bans on tobacco advertising, promotion and sponsorship and Raising taxes on tobacco products for effective tobacco control. 35 Public Private Partnerships (PPP) can be encouraged to be implemented by individuals so that the burden on the government can be reduced to some extent. Some notable PPPs in India are Tobacco Intervention Initiative (TII), Mumbai Smiles Foundation and Live, Learn and Laugh Programme. 36 The core principle followed in each of the individual programmes can be scaled up, and incentives can be provided to private sectors. The country is witnessing many private hospitals and clinics established across the country. They can be involved in creating new Public Private Partnerships because of the health inequity in the country. People with higher socioeconomic status do not go to government hospitals. This has become a significant problem in dealing with tobacco addiction in the country. Setting up tobacco cessation facilities in private hospitals can help the country handle people addicted to tobacco and bridge the gap between classes. 37 Primary care physicians have to be empowered to identify people on the verge of becoming addicted to smoking or people who are nicotine dependent and be able to deal with them in a holistic approach.
The measures taken by smoke-free cities in India like Chandigarh can be taken into consideration, and they can be implemented in all states. 15 All the Stakeholders in respective states must take initiatives with full support from the Central government. Though Government takes all these measures, it all rests in the hands of the general population to act. The literacy rate has to be increased in the rural areas to empower them and make them understand that tobacco consumption and other substance abuse practices like alcohol can affect their health and well-being. 38

SUCCESSFUL IMPLEMENTATION OF TOBACCO LAWS IN BRAZIL
Brazil is one of the countries with the highest prevalence of tobacco consumption globally. In recent years, Brazil has been at the forefront of tobacco control initiatives. It has reduced the adult prevalence of 38% of tobacco consumption to 15% in the last two years. It is one of the countries successfully implementing WHO MPOWER measures at the highest level possible. Regarding tobacco cessation policies, Brazil advocates nicotine replacement therapies for tobacco consumers to quit the practice. The endorsed nicotine replacement drugs are part of Brazil's Essential Medicine List (EML). All the cessation centres in Brazil offer psychological counselling supplemented with nicotine replacement therapy if warranted. 39,40 CONCLUSION High time for policy change in the country regarding tobacco consumption The world is facing a Global Coronavirus (COVID -19) Pandemic. It is known that those with lower immunity and co-morbid conditions like diabetes, hypertension and COPD are more at risk of severe complications due to the disease. Tobacco consumption is an essential determinant of these health conditions. It can reduce lung capacity and cause COPD, leading to significant mortality and morbidity when affected by Coronavirus.
The health inequities which were discussed also need to be addressed. There is a famous saying in the country "The rich become richer, and the poor be-come poorer". The recent political advancements and political reforms indicate the same. Though the government is taking measures by implementing various government schemes and policies, they cannot penetrate and reach the needy in the country. Rather than going in for a blanket ban on tobacco and related products, measures have to be targeted at primordial prevention, health promotion and strengthening of preventive and curative measures in all States in the country so that mortality and morbidity from tobacco consumption be reduced.