The Journey to Reducing Harms Related to Tobacco Use in India
Author
Table of Contents
- Introduction
- Current Indian Government Characteristics/Demographics
- Tobacco Use in India
- Economic Policies
- Potential Progressive Policies
- Conclusion
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Understanding the political, economic, and cultural challenges specific to India is key to forming actionable policies that will support fundamental changes for Indians who use tobacco products.
Introduction
Globally, nearly 8 million people die of smoking-related diseases each year. Standard approaches, such as those undertaken by organizations like the World Health Organization (WHO), have failed to directly impact these numbers. Typical solutions assume that all smokers are the same, when, in reality, individual smokers have different needs. A community-specific approach must recognize this fact, and policies aimed at mitigating smoking-related diseases must address the particular behavioral needs and challenges of those in the community.
In 2021, we reviewed the state of smoking in India. Because several years have passed since the government of India implemented tobacco control polices and nearly 1 million people die due to smoking-related diseases in the country each year, an updated analysis is critical. In this paper, we therefore review the current political landscape of smoking in India and explore culturally appropriate opportunities that could dramatically improve health outcomes for those who smoke. Understanding the political, economic, and cultural challenges specific to India is key to forming actionable policies that will support fundamental changes for Indians who use tobacco products.
Current Indian Government Characteristics/Demographics
A complex interplay of democratic principles, federalism, and a diverse sociopolitical landscape characterizes India’s government. Prime Minister Narendra Modi’s tenure has been marked by a series of policies aimed at transforming various sectors of the economy and society. His administration has focused on initiatives that promote economic growth, infrastructure development, social welfare, and foreign policy engagement, reflecting a comprehensive and somewhat progressive approach to governance.
India’s Current Progressive Political Environment
Launched in 2014, one of the hallmark initiatives of Modi’s government is the “Make in India” campaign, which aims to encourage domestic and foreign companies to manufacture their products in India. This initiative seeks to boost the manufacturing sector, create jobs, and enhance India’s position in the global supply chain. In addition to economic reforms, Modi’s government has prioritized infrastructure development through various initiatives such as the Smart Cities Mission and the Pradhan Mantri Awas Yojana (PMAY). The Smart Cities Mission aims to promote sustainable urban development by integrating technology into urban planning and governance, thereby improving the quality of life for citizens. The PMAY legislation is meant to provide access to affordable housing for low- and moderate-income residents. Furthermore, the government has implemented various schemes targeting financial inclusion, such as the Pradhan Mantri Jan Dhan Yojana, which aims to provide banking services to the unbanked population, thereby promoting economic empowerment. These initiatives reflect a commitment to enhancing urban infrastructure and ensuring inclusive growth.
Social welfare policies have also been a significant focus under Modi’s administration. The Swachh Bharat Abhiyan (Clean India Mission) aims to improve sanitation and hygiene across the country. This campaign has led to the construction of millions of toilets, significantly reducing open defecation and improving public health outcomes. These initiatives suggest that India’s current leaders are willing to apply modern approaches to public policy, which highlights an opportunity to moderate strict positions on tobacco control, such as banning reduced-risk products while traditional tobacco products remain on the market.
Policies Associated with Tobacco Use
In terms of public health governance, India faces significant challenges. Disparities in healthcare access remain a pressing issue, particularly for marginalized communities. Modi’s government has adopted a multifaceted approach to address the health concerns associated with smoking and tobacco use. This approach encompasses legislative measures, public health campaigns, and community engagement initiatives aimed at reducing tobacco consumption and mitigating its associated health risks.
One of these policies is the enforcement of the Cigarettes and Other Tobacco Products Act (COTPA), which aims to regulate the production, supply, and distribution of tobacco products. This legislation includes provisions for banning smoking in public places, mandating health warnings on tobacco packaging, and restricting tobacco advertising. The Indian government has also emphasized the importance of smoke-free environments as a critical public health strategy to protect non-smokers from secondhand smoke exposure, which is known to cause various health issues, including respiratory diseases and cardiovascular problems.
Public health campaigns have been instrumental in raising awareness about the dangers of smoking. The Indian government has launched initiatives that focus on educating the population about the health risks associated with tobacco use, including its links to diseases such as lung cancer, chronic obstructive pulmonary disease (COPD), and heart disease. In addition to awareness campaigns, the Modi administration has supported various smoking cessation programs that provide resources and support for individuals looking to quit. These programs often include counseling services, nicotine replacement therapies, and community-based support groups, suggesting that the administration recognizes that a multidisciplinary approach (including health promotion, education, and clinical training) is necessary for effective tobacco dependence treatment. Moreover, the Modi government has recognized the need for targeted interventions in specific populations, such as prisoners and individuals with mental health conditions, who may be more likely to use tobacco. Tailoring cessation programs to meet the unique needs of these groups is essential for addressing the broader tobacco epidemic in India.
Tobacco Use in India
Currently, India is the second largest tobacco-producing nation in the world, yielding nearly 750 million kilograms of leaf per year. India is also the second largest exporter of tobacco and tobacco products. The Indian tobacco industry employs approximately 46 million people and generates nearly $842 million (USD) in revenue. Sixty-three percent of the tobacco grown in India is used within the country. It is estimated that nearly 27 percent of the Indian population uses traditional tobacco products, and the main consumers of these products are males in rural and lower-income regions. Tobacco products have the highest rate of use in rural areas and among individuals with lower levels of education, who also receive the poorest access to health care services and tobacco-cessation products.
India’s tobacco epidemic is characterized by a high prevalence of both smoking and smokeless tobacco use, with approximately 275 million tobacco users reported in the country. The Global Adult Tobacco Survey indicates that, in India, tobacco use is a leading cause of preventable morbidity and mortality, contributing to over 1 million deaths annually. The preferred tobacco products for men are combustible products such as cigarettes and bidis (thin, hand-rolled cigarettes that contain three to five times as much nicotine as regular cigarettes). Of note, bidis are often either manufactured by small companies or produced in the home and, therefore, tend to be unaffected by typical tobacco control initiatives. Indian women typically use oral tobacco products that include betel leaf and areca nuts, which are known carcinogens.
Economic Policies
The need for effective tobacco control policies in India is underscored by the economic burden of tobacco, which accounts for more than 1 percent of the country’s gross domestic product and significantly strains public health expenditures.
India joined the WHO Framework Convention on Tobacco Control (FCTC) in 2005, implementing tobacco control policies nationwide. The primary tobacco control initiatives included banning smoking in public and work spaces, prohibiting most forms of advertisement, requiring that products include health warnings, and imposing taxes—though excise and value-added taxes have had little impact on the price-per-pack in India. In fact, as legal sales have decreased, the illicit market has increased: India’s is now estimated to be the fourth-largest in the world. Additionally, although cigarettes are taxed, other tobacco-based products such as bidis generally are not, as most unbranded or self-rolled products are not included in the regulatory oversight.
Another complexity of implementing tobacco control mechanisms in India is that the government profits from tobacco sales. ITC is the largest tobacco company in India, with a market value of over $60 billion (U.S.). The Indian government is the second largest shareholder of ITC, with government-run insurance funds owning nearly 25 percent of the company’s shares. The Specified Undertaking of Unit Trust of India, the group that manages the government’s ITC investment, has made some effort to divest from ITC, but the process has been slow. This relationship between the Indian government and tobacco manufacturers has generated significant conflicts of interest within the country and violates the WHO-FCTC treaty.
Potential Progressive Policies
Tobacco Harm Reduction (THR)
Harm reduction is an accepted approach within public health for opioids and other drugs and is a practical approach to reduce smoking risks as well. It is based on the concept that prohibition is not realistic at the population level. Instead, it supports promoting behavioral changes that reduce or eliminate inhalation and exposure to the toxins in any combustible product.
In addition to the challenges associated with tobacco control measures, there are also challenges associated with implementing THR in India. Recently, India banned the sale of reduced-risk products, including electronic nicotine delivery systems (ENDS) and heated tobacco products (HTPs), as well as modern oral products. Although interested consumers can still find such products through online sources, they risk hefty fines and imprisonment if caught purchasing them. In addition, because India’s THR policies are weak and the country only has FCTC-defined tobacco control policies in place, there has been little to no improvement in the rates of smoking-related disease and death over the past 20 years. As a result, harm reduction advocates in India are speaking out, calling for the implementation of evidence-based approaches, including modifying current laws to legalize reduced-risk products.
Many scientifically peer-reviewed studies highlight the effectiveness of reduced-risk products in helping individuals switch from more harmful alternatives. ENDS products have been shown to help those who smoke significantly reduce the use of more harmful combustible products and carry significantly fewer harmful or potentially harmful constituents. Oral nicotine products such as snus or nicotine pouches have data that also support their utility as well, especially if an individual prefers oral products or if oral use is their primary method of tobacco exposure.
The difficulty in India resides in many of the same issues other countries have struggled with: namely, how to balance the benefits of less harmful products with limiting access to the same products for non-users, including youth. The societal differences and intertwined nature of the tobacco growers and government involvement in the tobacco industry further complicate the promotion of better health through THR approaches.
Age Restriction and Youth Use
COTPA, enacted in 2003, sets the minimum legal age for purchasing tobacco products at 18 years. However, stakeholders have discussed the potential benefits of raising this age limit to 21 years, as evidence suggests that a significant proportion of Indian tobacco users initiate their habits during adolescence. More specifically, research indicates that a high percentage of the country’s tobacco users begin using those products before age 18, with many starting as young as 15 years of age. This early initiation is concerning, as it is associated with a higher likelihood of developing long-term dependence on tobacco and experiencing adverse health outcomes. That said, it appears that there has been a decrease in tobacco use among youth in India: The Global Adult Tobacco Survey reported that in 2009, tobacco use in ages 15-24 was around 18.4 percent, and by 2016, that ratio had fallen to 12.4 percent.
Establishing enforceable youth protection policies is key to creating an environment for behavioral change for all who smoke. For example, since 2019, the United States has prohibited the sale of tobacco and nicotine products to those under the age of 21. Since the establishment of this law, rates of cigarette and other nicotine product use, such as ENDS and oral nicotine products, have plummeted. The combination of age-gating policies and enforcement actions that monitor retailers of tobacco and nicotine products punish those who violate the policy and create an environment in which alternative nicotine products are available to those for whom they are designed. Thus, resolving concerns around youth use, which tend to distract from the more significant problems related to disease and death, creates an opportunity to greatly impact the adult tobacco use population.
Use of Inhaled, Reduced-Risk Products in India
In 2019, the Indian government imposed a ban on ENDS, which included e-cigarettes and HTPs, citing health risks and the need to protect youth from nicotine addiction. This decision was influenced by growing evidence regarding the adverse health effects associated with vaping and the potential for increased tobacco use among young people. However, the enforcement of this ban has faced challenges, particularly in terms of compliance and the availability of e-cigarettes on the illicit market. It has been estimated that the illicit trade of these products has increased from 14.6 percent in 2008 to 25.7 percent in 2022.
In addition, without accessible and legal ENDS products, combustion rates remain high in India. As is the case in many countries, there continues to be tension when the policies in place do not align with the community’s needs. For example, the continued growth of the illicit nicotine product marketplace, even with significant penalties in place, suggests that the Indian population sees ENDS and HTPs as acceptable substitutes for traditional tobacco products.
Policymakers should carefully review tobacco-reduction approaches in places where smoking patterns have been effectively disrupted. In England and New Zealand, for example, where public health officials have seen the potential for reducing the harms of smoking with ENDS products, the application of THR principles—along with the education of both the general public and the physicians who treat those who smoke—has led to reduced smoking rates within the population and improved health.
Modern Oral Product Use in India
An additional challenge in India is the prevalence of oral tobacco product use among women. These products, which combine tobacco with carcinogenic betel leaf and areca nuts, present a greater risk than traditional oral products because of how they are prepared for use.
This specific use pattern requires a community-oriented approach. For example, in Sweden, which once had extremely high smoking rates, public health officials used a historically relevant oral product (snus) to rapidly migrate smokers to the lower-risk snus products. Because snus products were a ubiquitous part of the culture, it was a less challenging construct to implement for Swedish communities.
The same construct could easily be applied to the smoking culture of India. Allowing access to snus or nicotine pouch products, along with proper education and support for those who use traditional oral tobacco products, could help shift individuals to a less harmful product.
Conclusion
There are significant challenges to improving health outcomes for all who use tobacco products within India. The current administration could drive change through policy and help realize the potential for health benefits throughout the Indian population. The only currently known fact is that the existing tobacco policies fall far short of meeting the goal of a smoke-free society. Without novel policies that provide options for those who use tobacco products to switch to reduced-risk products, it is unlikely that India will reduce the health consequences of tobacco use at the population level.