Smoking Habit in India

There are evidences suggesting smoking in India has been known since at least 2000 BC, when cannabis was smoked and is first mentioned in the  Atharvaveda. Performing ‘ home’ (fire offerings) and ‘dhupe’ (fumigation) are mentioned in the Ayurveda for medical purposes and have been practiced for at least 3,000 years while dhumrapana (literally “drinking smoke”) , has been mentioned in literature to be practiced for at least for 2,000 years.

In 1566 – Portuguese sailors enter India through Goa. They offer tobacco smoke to Emperor Akbar. Probably fearing its ill effects, hakims of royal darbar advised to pass tobacco smoke through water before inhaling it. In 1609 Emperor Jahangir introduced tax on tobacco.

Prevalence

There are approximately 120 million smokers in India. According to the World Health Organization (WHO), India is home to 12% of the world’s smokers. Approximately 900,000 people die every year in India due to smoking related illnesses, as of a survey in 2009. According to estimation, India is the second largest consumer of tobacco globally, and accounts for approximately one-sixth of the world’s tobacco-related deaths.

Table -1: Global Adult Tobacco Survey ( GATS) 2009-2010*- Indian Data in brief

*(GAT India was conducted by International Institute of Population Sciences, Mumbai on behalf of Government of India)

• Smoking is a global problem. With the increase in awareness, education and

efforts (from Governments, NGOs & medical profession),  it is steadily decreasing in past few decades in many western (developed) countries but increasing in low and middle income countries, especially in Asia.

• Globally 7 million people die each year as a result of diseases related to tobacco smoking and is projected to increase to 8.3 million by 2030, with the largest increase in low- and middle-income countries. As per a recent survey about half the world’s male smokers live in 3 Asian countries e.g. China, India, and Indonesia. Asia is not only the large tobacco consumer but it is also the biggest tobacco producer.
• In India, according to the National Family Health Survey (NFHS)-3 survey, conducted in 2005–06, tobacco use is more prevalent among men, rural population, illiterates, poor and vulnerable section of the society.
• Tobacco problem in India is very complex, using large variety of smoking form and different ways of using smokeless tobacco(chewing, paste, powder). Tobacco is smoked in form of Bidi,  Cigarette, Hukka, Chilam, Chutta, reverse  Chutta and  It is chewed as Pan Masala, Zarda, Gutkha, Khaini and Pan. Some people, especially women inhale it as Naswar (fine powder), also applied as paste or powder on teeth and gums.
• There is a wrong notion that bidi is safer than cigarette. Although it is cheaper but not safe as amount of potentially hazardous component in tobacco smoke e.g. nicotine (bidi -8%, cigarette 1%) & tar ( bidi 45-50mg, cigarette 18-20mg), are higher in bidi than cigarette.
• Data related to tobacco consumption – as whole or in different form, production of tobacco product and tobacco related mortality & morbidity are scares. Most data are based on studies not covering large population. Another problem in data collection is many tobacco users hide their habit of tobacco consumption.
• In India it is difficult to access tobacco production, with a large use of a variety of smoking forms and an array of smokeless tobacco products. Many of these products are manufactured as cottage and small-scale industries using varying mixtures and widely differing processes of manufacturing. Bidis and some of the smokeless tobacco products are mostly manufactured in the unorganized sector while cigarettes are mainly manufactured in large-scale industries.

Composition of tobacco smoke

Tobacco Smoke from cigarette and bidis is an aerosol produced by incomplete combustion of tobacco, paper or leaf. Temperatures in burning cigarettes range from about 400 ℃ between puffs to about 900 ℃ during a puff. During the burning of the cigarette tobacco and paper or leaf in which tobacco is rapped, contains thousands of chemical substances, generated by combustion, distillation and other processes.

Tobacco smoke contains more than 4000 compounds, many of them are potentially harmful to human organs, and some of them are listed below:

Gaseous phase

(About 500)

Carbon dioxide

Carbon monoxide

Ammonia

Hydrogen cyanide

Benzene

Alkaloid

Nicotine

Anabasine

Nornicotine

Anatabine

Particulate phase

(About 3500)

Tar (Includes many   carcinogens)

Polynuclear aromatic hydrocarbons

N-nitrosamines

Aromatic amine

Hazards of smoking

Tobacco, used in any form is potentially dangerous to health. Scientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability.

As per report from  International Agency for Research on Cancer (IARC), there is sufficient evidence in humans that tobacco smoking causes cancer of the lung, oral cavity, nose ,throat and paranasal sinuses, esophagus (food pipe), stomach, pancreas, liver, kidney, ureter, urinary bladder, uterine cervix and bone marrow (myeloid leukemia).

As per reports 90% of all lung cancer deaths in men and 80% in women are caused by smoking.

There are definite evidences suggesting evidences of associations between active smoking and adverse pregnancy outcomes, fetal abnormalities, decrease in reproductive functions, especially in women, many lung diseases, heart and blood vessels disorders.

Most of the middle aged & elderly smokers suffer from Chronic obstructive pulmonary disease (COPD)– a dreaded disease responsible for  about 556,000 deaths per year in India

Association between bidi smoking and tuberculosis is observed to be very high. Forty percent of the tuberculosis burden & deaths in India may be attributed to smoking.

Many workers engaged in tobacco cultivation suffer from an occupational illness known as ‘green tobacco sickness’ (GTS), an acute form of nicotine toxicity resulting from absorption of nicotine through the skin.

Passive smoking

Passive smoking is defined as the involuntary inhalation of smoke ( by person not smoking) from bidi, cigarettes (also cigars, hookah , chillum, marijuana, even e-cigarettes etc) smoked by other people (smoker). In other words, passive smoking means a person breathing in secondhand smoke, or what is commonly referred to as environmental tobacco smoke (ETS). Secondhand smoke can be:

• Mainstream smoke (MSM)– smoke exhaled by a smoker.
• Sidestream smoke (SSM): smoke that is released from the end of a bidi, cigarette, cigar, pipe, hookah pipe etc. SSM can be a greater danger than MSM not only in that it contains greater amounts of cancer-causing substances and toxins, but because it persists for a longer period of time – often lasting even after a cigarette has been extinguished.
• Exposure to both forms of secondhand smoke can be affected by several factors including environmental temperature and humidity; the ventilation of the room , vehicle or other space, and of course, number of smokers and non smokers present in a particular location.
• Thirdhand smoke– Once the cigarette, bidi or any other form of smoking is completely burned (extinguished), the gases, and particles left over may also be inhaled via passive smoking. Toxic chemicals from SHS cling to rugs, curtains, clothes, food, furniture and other materials. These toxins remain even in the presence of windows, fans or air filters, and can recycle back into the air through the filters. They coat the surfaces of rooms, materials and smoker’s belongings. These substances are released back into the air as gasses, although this is likely a minor portion of the secondhand smoke inhaled, but may be harmful to young children who may be crawling around on the surfaces where third hand smoke accumulates.

According to a report second-hand tobacco smoke (SHS) kills 600,000 people each year all around the world. Globally, about one-third adults are regularly exposed to SHS. The GATS-India shows that 52% of the adults (rural-58%, urban-39%) were exposed to SHS at home, work place, buses, trains or personnel vehicles. SHS is three- to four-times more toxic per gram of particulate matter than mainstream tobacco smoke. There is conclusive evidence linking passive smoking to an increased risk of cardiovascular diseases, lung cancer and other cancers, asthma and other respiratory diseases in adults and asthma and other respiratory diseases, ear infection and sudden infant death syndrome in children.

Economic burden

There is limited evidence available regarding the economic cost of tobacco use in India). As per these estimates the current estimated burden of COPD for India is Rs. 350 Billion

According to reports from Ministry of health, Govt. of India-2014, the economic burden of tobacco related diseases in India accounts for 1.16% of total GDP in 2011-12, which was 12% more than the combined public expenditure on health care incurred by state & central governments. On the contrary Govt. earns from excise revenue from all the tobacco products is 17% of economical cost of tobacco attributable diseases.

Impact on Environment

Use of tobacco leads to clearing of forests for cultivation, stripping fuel wood for curing and use of forest resources for packaging are responsible for damaging the environment. Depletion of soil nutrients adversely affects indigenous flora and fauna. Environmental impacts of tobacco cultivation & processing causes direct or indirect loss to agriculture economy.

Why does a person smoke or consume tobacco?

Nicotine, an important constituent of all forms of tobacco, and is highly addictive

Nicotine is also found in electronic cigarettes and the liquid used in ENDS (electronic nicotine delivery systems). Nicotine is highly addictive. When a person uses tobacco, either by smoking cigarettes, using chewing tobacco or by using another form of tobacco, nicotine enters the body and activates nicotine receptors in the brain.

After smoking a cigarette it takes six to ten seconds to reach nicotine to the brain. In brain it binds to receptors on brain cells and induces the release of chemicals (neurotransmitters) that lead to addiction. It imitates the same effects on a person’s mood as amphetamine (brain stimulant) and cocaine.

Nicotine is a stimulant that speeds up person’s reaction time and increases his or her attention and focus. To many smokers nicotine gives feeling of pleasure.

On delay or withdrawal of smoking (or any tobacco product), smokers start to feel a negative mood change, experiences a strong urge to smoke that is difficult to ignore, it is called a craving and develop withdrawal symptoms in form of Irritability, frustration, anger, increased appetite, tremors, depression, lack of sleep, insomnia, anxiety, difficulty in concentrating and, difficulty in feeling pleasure. As soon as they smoke again, use other tobacco products, or nicotine replacement medications, usually experience relief from these unpleasant symptoms.

The Power of Nicotine Addiction is not the same for everyone. Some people may experience mild addiction. Others can rapidly progress to severe addiction

Addiction to the nicotine in tobacco can happen very quickly, even after smoking for a short time or smoking only a few cigarettes. The good news is that you can overcome addiction to nicotine.

Severity of addiction to smoking can be assessed by ‘Fagerstrom Test’, based on simple questionnaire.

Dr M. Sabir,
Senior Consultant Physician & Pulmonologist, KMRI, Bikaner

Former President, Indian Chest Society
Founder Editor, Public Forum, ICS – website,https://icslungforum.in/#
Retd. Prof. and Head, Resp. Div., Dept. of Medicine, ,
S.P. Medical College, Bikaner

Retd. Prof., Dept. of Medicine, MAMC, Agroha
Phone: +91 151 2200663, +91 9414136993