Tobacco and Alcohol
Tobacco and Alcohol
Tobacco & Lifestyle
Tobacco is a major cause of death and disease in India.
Globally, tobacco accounts for over 7.2 million deaths every year, including deaths from second-hand smoke exposure, and this number is projected to increase.
India has a unique variety of tobacco use, including smoked forms like cigarettes, bidis, and cigars, as well as smokeless forms, which account for about 35% of total tobacco consumption.
Tobacco & Lifestyle contd.
The Global Youth Tobacco Survey (GYTS), supported by the CDC and WHO, surveys tobacco use among youth.
GYTS tracks tobacco use prevalence among 13-15 year old students.
According to GYTS, 17.5% of 13-15 year old students in India use tobacco in some form.
Many states report alarmingly high prevalence of tobacco use among school-going youth.
North Eastern states like Nagaland (63%), Manipur (46.7%), and Sikkim (46.1%) have the highest prevalence of tobacco use among school students.
Tobacco & Lifestyle contd.
The National Tobacco Control Cell was set up in February 2001 as a result of collaborative efforts of the Ministry of Health and WHO to boost tobacco control efforts and coordinate activities at the national level.
The National Tobacco Control Cell assists in developing comprehensive anti-tobacco public awareness plans, providing health education, building capacity among NGOs, establishing and strengthening tobacco cessation centers, and providing technical inputs on research and policy issues.
The Cell is recognized as an innovative approach towards effective tobacco control that can be replicated by other countries.
Tobacco & Lifestyle contd.
Tobacco use is associated with many serious diseases.
Tobacco use is the most important lifestyle risk factor for diseases.
Globally, tobacco accounts for:
27.8% of all cardiovascular deaths
13.6% of all lung cancer deaths
6.6% of upper aerodigestive cancer deaths
6.6% of other cancer deaths
27.2% of deaths due to COPD
12.8% of other respiratory deaths
Worldwide, tobacco use causes 7.2 million deaths, 59 million DALYs lost, and an estimated economic loss of $200 billion per year.
Medical recommendations are clear: individuals and communities should completely give up tobacco use.
Public health practitioners should educate and motivate individuals and communities regarding the adversities associated with tobacco use and encourage them to quit.
Tobacco & Lifestyle contd. - Tobacco Related Diseases
IHD (RR 1.28 to 1.78)
Stroke (RR 1.17)
Lung cancer (RR 12 to 24)
Oral cancer (RR 6.95 to 7.87)
Liver Cancer (RR 1.40)
Cancers of upper aerodigestive tract
Peptic Ulcer
COPD
Buerger’s Disease
Hypertension
Amblyopia
Tobacco & Lifestyle contd.
In addition to education and motivation, use all possible means to convince community leaders, peers, politicians, and social groups to exert influence to:
Make availability difficult (e.g., banning the sale of tobacco products in major markets, near educational institutions, in hotels/restaurants, etc.).
Make smokers feel that their habit is “undesirable” (e.g., ban smoking in public places, transport systems, auditoria, offices, meetings/gatherings, parties; create separate restricted areas as earmarked smokers' rooms).
Exert influence through influential socio-political groups.
Set personal examples by influential persons such as doctors, sports and theatre personalities, etc.
Enforce relevant laws.
COTPA Act 2003
The Cigarettes and Other Tobacco Products Act (COTPA) of 2003 regulates the production, supply, distribution, and advertisement of tobacco products in India to reduce tobacco use and protect public health.
What does the act prohibit?
Smoking in public places
Selling tobacco products to anyone under 18 years of age
Selling tobacco products within 100 yards of educational institutions
Direct and indirect advertisement, promotion, and sponsorship of tobacco products
What does the act require?
Tobacco product packages to display specified health warnings
What is a public place?
Any place that the public has access to, including auditoriums, hospitals, railway waiting rooms, restaurants, public offices, and educational institutions
Alcohol and Lifestyle
More than half of the 3.3 million annual deaths attributable to alcohol use are from NCDs, including cancer (Globally).
An estimated 62.5 million alcohol users are in India.
Due to its large population, India is identified as a potentially third largest market for alcoholic beverages.
Sale of alcohol has been growing steadily at 6% and is estimated to grow at 8% per year.
About 80% of alcohol consumption is in the form of hard liquor, showing that the majority drink beverages with a high concentration of alcohol.
Branded liquor accounts for about 40% of alcohol consumption, while the rest is in the form of country liquor.
Alcohol and Lifestyle contd.
People start drinking at a younger age than previously.
India has a large proportion of lifetime abstainers (89.6%). The female population is largely abstinent, with 98.4% as lifetime abstainers. This makes India an attractive business proposition for the liquor industry.
Changing social norms, urbanization, increased availability, high-intensity mass marketing, relaxation of overseas trade rules, and poor awareness related to alcohol have contributed to increased alcohol use.
Taxes generated from alcohol production and sale is a major source of revenue in most states and has been cited as a reason for permitting alcohol sale.
A profile of clients in addiction treatment centers in 23 states (including states with prohibition) showed that alcohol was the first or second major drug of abuse.
The annual loss due to alcohol was estimated to be Rs.70,000 to 80,000 million.
Habitual alcohol use is a major lifestyle factor associated with ill health and serious diseases.
Alcohol Related Diseases
Hypertension & Stroke (RR 1.4 to 4.1, depending on intake)
IHD (mild consumption may be protective (RR = 0.68); heavy consumption carries risk (RR = 1.33))
Road Accidents
Obesity
Diabetes Mellitus type - 2
Cancers:
Female Breast Cancer (RR 1.14 to 1.62)
Oral Cancer (RR 1.45 to 5.39)
Other cancers (aerodigestive tract, stomach, pancreas, kidneys, bladder) (RR 1.8 to 4.93 depending on intake and site)
Liver disease (RR 1.2 to 13 depending on intake) (cirrhosis, increased susceptibility to liver infections)
Pancreatitis
Degenerative neurological diseases
Social and emotional problems
Psychiatric problems and dependence
Lack of efficiency, productivity, and organizational issues.
Alcohol and Lifestyle contd.
Besides diseases, alcohol has additional social and emotional problems and disrupts family and organizational health.
A WHO report indicates that alcohol use accounts for 3.2% of all global deaths and 4% of all global burden of diseases; it also accounts for 3.5% of all DALYs lost due to all causes.
Lay magazines tend to put across a conveniently distorted version of medical research findings, which tend to indicate that moderate drinking is good for health.
Public health persons need to counter this issue when talking to individuals and communities.
Alcohol and Lifestyle contd.
While “moderate” alcohol intake may be associated with increased HDL-cholesterol levels and lower IHD mortality, continued alcohol intake, even in mild to moderate quantities, is associated with a number of other diseases like road accidents, various cancers, obesity, and hypertension.
It is difficult to maintain “moderation” - many who are initially moderate may become heavy drinkers gradually.
There are other more healthy methods (as brisk, regular physical exercise) rather than drinking to increase the HDL levels.
All these aspects should be emphasized to the clientele.
Alcohol and Lifestyle contd.
The relationship between even mild drinking and obesity is quite logical.
Even two small pegs may raise the blood alcohol level beyond the legally acceptable limit in India (30 mg %), and may interfere with the protective reflexes, causing road accidents.
Alcohol and Lifestyle contd.
Alcohol, even in mild quantities, promotes obesity by:
Providing “blank” calories - each gram gives 7 Kcal;
1 small peg gives 70 Kcal, equal to running 1 Km!
Promotes overeating
Desire to eat rich, fattening food
Reduces desire for physical activity
Alcohol volume by Mass
To convert volume (e.g., ml) by mass (e.g., g) and vice-versa, it is necessary to know the density.
The density of alcohol: . Therefore: a wine of 12.5% vol contains .
Alcohol and Lifestyle contd.
The hazards of alcohol use should be well communicated to our clientele, and they should be motivated to give up alcohol. The recommendations should be:
There is nothing like medically prescribed or medically encouraged drinking to get good health; with all its well documented resultant diseases, alcohol should not be used.
However, if someone still decides to drink, they may do so provided there is no other risk factor (Obesity, Diabetes, hypertension) and provided one drinks only in “moderation”.
Besides restricting to moderation, adhere to the following principles:
Never drive after drinks (even after very mild drinking).
Try not to drink on two consecutive days.
Try not to drink in daytime.
Drink along with food and not on an empty stomach.
Alcohol and Lifestyle contd. Defining “Moderate” Drinking
A “unit” of alcohol is defined as equivalent of 10 grams pure ethanol.
This will be equal to 1 small peg of hard drink or 100 ml of Wine or half a bottle of Beer.
Moderation means a maximum of 3 units in a day for men (and 2 units a day for women).
The Principles of Public Health Approach for Preventing Alcohol and Tobacco Use
Tobacco and alcohol use are major causes of diseases, ill health, reduced quality of life, and lowered productivity worldwide.
It is a priority area for all public health systems and functionaries to develop and implement programs and strategies to combat these major ill-health issues.
Tobacco and alcohol control issues can be considered together from the preventive point of view since both are highly addictive substances, are used by a large proportion of the human population, and are liable to cause a wide variety of serious diseases.
The preventive strategy should focus on two levels: the national/large community level and the individual/family level.
I. Steps at the National / Large Community Level
The approach would include a combination of three strategies: Information, Education and Communication (IEC) steps, Statutory (legal or regulative) steps, and Fiscal steps.
1) IEC Steps:
1a) Developing a nationwide educational strategy and program: A comprehensive policy and program should be developed by nations/states for informing community members about the health hazards due to tobacco and alcohol, the seriousness of these diseases, and the potential methods of prevention.
Educational programs should involve the departments of advertising and audio-visual media and those concerned with information and broadcasting.
Educational messages should be adequately pilot tested and should be presented on various channels of mass media, not only on governmental but also private channels as well.
Steps at the National / Large Community Level contd.
1b) Counter - Advertising (Counter - Marketing) Campaigns: Proactively conducted educational and advertising campaigns to highlight the seriousness of consequences of tobacco and alcohol can increase the proportion of the population who would give up their use and reduce the proportion of persons who take up smoking.
The strategy is to counter the advertising/marketing campaigns carried out by various liquor/tobacco companies, under the influence of which a large number of young people actually initiate their smoking habit.
Taking the help of prominent public personalities as cine stars and sports-persons may be helpful in this direction.
1c) School and Youth based IEC programs: Teenagers are most at risk of initiating tobacco and alcohol habits. Educational programs should be developed targeting adolescents in schools as well as at other youth forums such as youth festivals, sports functions, etc.
Steps at the National / Large Community Level contd.
1d) Quitlines / Helplines: Developing telephonic helplines may be helpful in reducing the prevalence of smokers and increasing the duration of cessation.
These helplines/quitlines may be part of governmental or NGO efforts and are designed to provide total assistance to smokers/alcoholics who desire to quit smoking, maintain a state of cessation, and for persons who want education and assistance for not initiating the tobacco use habit.
I. Steps at the National / Large Community Level contd.
2. Fiscal Measures:
Increasing the prices of tobacco and alcoholic products reduces the proportion of persons who use these substances; particularly, fewer adolescents are able to initiate these habits.
This has been shown in a number of countries and has been (privately) acknowledged by tobacco companies.
Public Health policymakers should suggest that governments consider an increase in excise on raw materials and increased taxation on the finished product.
I. Steps at the National / Large Community Level contd.
3. Legislative and Regulatory Measures: To back up the educational and fiscal steps, governments and communities need to develop legal provisions to make the availability of tobacco and alcohol difficult to consumers and to ensure that users of these substances do not harm other members of their family/community due to this habit. In general, the legislative measures focus on the following provisions:
Printing of statutory warnings regarding the fact that alcohol/tobacco is bad for health on the packets of tobacco/alcoholic products.
Clean indoor air laws and smoke-free zone policies, including prohibition of the use of these substances in public places, such as railways, airlines, and other transportation systems, offices, common rooms, restaurants, and such other public places.
Prohibition of the sale of these substances to vulnerable groups, especially children and adolescents.
Ban on advertisements on the promotion of tobacco products.
I. Steps at the National / Large Community Level contd. - 3. Legislative and Regulatory Measures:
In our country, an extensive law has been promulgated starting with the Cigarettes (Regulation of production, supply and distribution) Act of 1975, which specified the printing of statutory warnings on all cigarette packets. Subsequently, the statutory provisions were enlarged with the promulgation of “The cigarettes and other tobacco products (prohibition of advertisement, regulation of trade and commerce, production, supply and distribution) Act 2003. The act declares that it is expedient in public interest that the Union should take control of the tobacco industry.
The act prohibits smoking in public places and provision of a separate smoker’s room in restaurants having a seating capacity of 30 or more and in airports (From 02 Oct, 2008, i.e. the birthday of the father of the nation, the Govt has extended the promulgation by imposing a blanket ban on all public places). The act also lays down a total prohibition on advertisements of cigarettes and other tobacco products.
The act prohibits the sale of tobacco products to any person aged less than 18 years and lays down restrictions on trade and commerce in and on production, supply, and distribution of cigarettes and tobacco products including printing of statutory warnings on the packets of these products, the letter size, language, and other specifications of these warnings, and also the powers of searching the premises and confiscation under this act, as well as the punishment and appeal under this act. The detailed rules (2004) for the implementation of the act have been published vide Govt of India Gazette No. 200 dated 25 Feb 2004.
I. Steps at the National / Large Community Level contd. - 3. Legislative and Regulatory Measures:
As regards alcohol, we do not have such well-formulated legislative regulations as we have for tobacco, but the effort of the Government has been, in recent years, to develop a comprehensive policy as well as legislation to reduce alcohol intake among communities. The available statutory provisions include the following:
Printing of statutory warnings on bottles of alcoholic drinks
Promulgation of “dry state” order by certain states wherein consumption of alcohol is totally banned, except for those having a permit to drink
Testing of motor vehicle drivers for a breath test and alcohol level in the blood. The upper limit for safety in driving, as far as statutory limits in our country are concerned, is 30 mg per 100 ml of blood.
II. Steps at the Family and Individual Level:
These are directed to educating, motivating, and supporting the individuals and families for, firstly, not initiating the tobacco and alcohol habit and, secondly, to give up the habit. The following steps are documented to be beneficial:
Educating and motivating the family members, especially the spouse and parents.
Enrolling “peer groups” as religious teachers, school teachers, etc., in motivating and playing a role model for the community.
Developing support groups as “alcoholics anonymous” groups and informing the community members about their location, ways to contact them, and the help that they can provide.
Pharmaceutical measures as disulfiram for alcohol cessation and nicotine patches/tablets or bupropion for tobacco cessation. However, these measures should be used under medical supervision.