SMOKING-RELATED ILLNESSES
International research predicts that in the next decade, India will surpass a frightening landmark, 1 million smoking-related deaths annually. What are the unique challenges of spreading information on the dangers of smoking throughout India, and how is India reducing the scourge of smoking-related illnesses.
You are listening to ReachMD XM-157, the Channel for Medical Professionals. Welcome to the Clinician's Round Table.
I am your host, Dr. Mark Nolan Hill, Professor of Surgery ats Chicago Medical School, and our guest today is Dr. Prabhat Jha, Professor of Health and Development and Founding Director of the Center for Global Health Research at the University of Toronto. Dr. Jha is the legal author of impactful research published on the current smoking epidemic in India.
DR. MARK NOLAN HILL:
Welcome of Dr. Jha.
DR. PRABHAT JHA:
Thank you for having me Mark.
DR. MARK NOLAN HILL:
Today we are discussing strategies to curb India's soaring smoking-related mortality rates. Dr. Jha, how has India found itself in this position of struggling through a smoking epidemic.
DR. PRABHAT JHA:
Well I think India is not dissimilar from any developing countries where smoking has not been taken seriously up until recently that it has been viewed as well, this is something that, smoking is a problem for the west, but it is not a concern for developing countries. That being said, I think there are some good signs. The Indian Health Minister, Dr. Anbumani Ramadoss, is absolutely dedicated to tobacco control. He has been outspoken and spoken out against even Bollywood types that have been smoking on screen. He has been a great supporter of our research and has asked for more of this kind of research to get widespread public understanding.
DR. MARK NOLAN HILL:
For those who are unfamiliar with the term Bollywood, could you define that?
DR. PRABHAT JHA:
Well Bollywood is like Hollywood actors, but with a lot more dancing and theatrics would be the way I will describe it, but the cinema industry in India produces 3 times as many films as come out of Hollywood.
DR. MARK NOLAN HILL:
Really.
DR. PRABHAT JHA:
And all the US, Yeah. Every year there is just a huge number of films and it is very much common cultural icon. People know all the movie stars and they have their favorite movie stars and so forth. So they are a profound influence on cultural practices and certainly on smoking. So getting them engaged to try to understand the risks, I think is part of it. You know, when we brought out our paper, we had supporting quotes from Bollywood figures saying that these risks are really terrible and Indians shouldn’t get caught in this cycle of disease that west has. There is no reason to.
DR. MARK NOLAN HILL:
What do you think are the greatest challenges to communicate this smoking information to the people of India.
DR. PRABHAT JHA:
Well, I think the illiteracy is a major challenge, you know, given that half the tobacco deaths that we found were in the illiterate population, so innovations on how to get these risks understood by people is a real challenge. I think pictorial warning labels are a big part of that and things like higher taxes, while you don’t have to depend on education levels for those taxes, work on everyone, particularly they work on the poor. That's going to be the challenges really of implementation of what these recommendations mean, which is take tobacco control seriously and try to get current smokers to quit, but I am optimistic that I think like other countries if people in India have information, they have got good local leadership and they get some modest support, then they would be able to start to see the end of this large increases in smoking that have been suggested. If you take an example, look what happened in China. China 10 years ago had about the same quitting rate as India, about 2% of Chinese had quit smoking in a 1996 survey, about the same percentage that we are finding now. Then what happened is they had a major paper in the British Medical Journal on smoking risks, which was widely disseminated and they had a world conference on Smoking or Health in 1997. Fast forward 10 years later and by some surveys up to 10% of Chinese adults are reporting to be ex-smokers, perhaps 9% to 10%. So India is basically where China was 10 years ago and in China not much else happened. I think the government didn’t do a lot on the control side, except to keep its ban on advertising in place. That basically prevented kind of like a Virginia Slims female epidemic, but otherwise they didn’t do much more, they didn’t raise prices, or they didn’t do other things, but even with that ex-smoking rates have gone up in China. So India 10 years later, we have got also much, I think much stronger leadership on tobacco with the health minister. We have got now evidence which is locally relevant and there is the world conference on Tobacco or Health will be held in Bombay, so I am hopeful that that combination of all those will spur widespread public attention to tobacco as a risk and mean that, both smokers who quit and the government will do the simple things, which will help more people quit.
DR. MARK NOLAN HILL:
Why do you think there was such a significant difference between China and India.
DR. PRABHAT JHA:
The consequences of smoking are different in those populations, you know. In China a lot more smoking-related deaths from respiratory disease and lung cancer than in India. In India, we see mainly it is tuberculosis and heart disease. In China, it was mainly respiratory disease, lung cancer, and other cancers. So those are just different epidemics in terms of the consequences of smoking, but what has happened in China was the publicity around the risks plus the world conference in my view has spurred people to take tobacco a bit more seriously and quite broadly meaning all parts of society seem to be understanding that and as a result quit rates seem to be going up. In India that hasn’t happened that, but I am hopeful it will. You know, if you put the 2 countries together, even a 10% increase in smoking cessation is something like 40-50 million fewer smokers, which is about the total number of smokers in the United States and that would be significant in terms of how many lives are saved.
DR. MARK NOLAN HILL:
If you have just joined us, you are listening to the Clinician's Round Table on ReachMD XM-157. I am your host, Dr. Mark Nolan Hill and with me today is Dr. Prabhat Jha, Professor of Health and Development and Founding Director of the Center for Global Health Research at the University of Toronto. We are discussing strategies to reduce India's soaring smoking-related mortality rates.
Dr. Jha 1 of the conclusions of your study stated that if you quit smoking, you certainly improve your situation. What about if someone says well instead of smoking 10 cigarettes a day, I will cut down to 5.
DR. PRABHAT JHA:
What we found is if you look let's just say at beedi smoking, which is the most common. The risks are significant even at low levels of smoking and this has been the popular understanding that, well in India if you do surveys of smokes, actually among the smokers they smoke less cigarettes or beedis per day than would a western smoker. So one of the things that people have been thinking, is okay well that means smoking is not as harmful, but we found, in fact, there is no such thing as safe levels of smoking. If you smoke 1 to 7 beedis a day, then the average in that group is 4, then the risks increase by 30% of death in middle-aged men. If you smoke 8 to 14 cigarettes, it goes up to 50%. If you smoke 15 or more, it goes up more than twofold. So there is certainly no such thing as safe levels of smoking. There is risk even with the modest amount of smoking that is recorded in India.
DR. MARK NOLAN HILL:
If you take a beedi and compare it to an American cigarette in terms of toxic substances, how do they compare?
DR. PRABHAT JHA:
The beedis contain about a quarter of the tobacco as cigarettes and we find, in fact, that the risks for cigarettes are substantially greater than those for beedies. I mean both are toxic for you and even modest amounts of smoking are toxic for you. But cigarettes particularly larger number of cigarettes per day are particularly hazardous. In terms of the toxic constituents, there has been some work to see if something else goes on in beedis and that evidence isn't quite clearly, but clearly they will have other toxic substances which may increase particular diseases, you know, perhaps they have an impact on specific types of cancers and so forth. That is not well researched.
DR. MARK NOLAN HILL:
Are there movements in India to ban smoking from public places?
DR. PRABHAT JHA:
There are and there have been some attempts for example to do things around the 2010 Commonwealth Games, which will be held in Delhi and certainly banning around hospitals and schools and so forth, but my view is that those bans won't be effective unless there is widespread public understanding of the risks in a way that encourages people if you will to self regulate on smoking, meaning there is more of a social norm pressure, that you know someone will actually say do you mind not smoking. This is a smoke-free place. So that self enforcement is key and awareness of the risks that individual smokers' face is part of that.
DR. MARK NOLAN HILL:
Will this be enforced by the establishment, the hotels, the restaurants.
DR. PRABHAT JHA:
The enforcement capacity is limited, right. I mean how many government inspectors can you reasonably think of sending around to check all the restaurants when there is millions of restaurants in India. So that's going to be part of it and prominent fines and making sure that those that are flagrant violators are identified and punished that is going to be part it, but I think the more important part will be self enforcement, just enabling people to understand that nonsmoking is the better norm and indeed that is what has happened in most parts of the US.
DR. MARK NOLAN HILL:
Is there any indication that you have how people in India are reacting to this research and education.
DR. PRABHAT JHA:
Well it is very early. Our paper just came out in mid February, but certainly the widespread coverage of it has been encouraging. This was on all of the major broadcast channels and all of the major newspapers, the main video release of it is playing on YouTube and it has been translated into regional languages. It is showing in some schools as part of their curriculum, so the word is getting out, but clearly one study won't be enough, I think, a sustained effort should try to get information in a way that people really understand, so this isn't just dry academic research. It is really trying to get good information that people really understand and making it understandable is part of the challenge.
DR. MARK NOLAN HILL:
And what about in 2009 when India is hosting the world's largest symposium on Smoking and Health. How do you expect that conference to impact smoking in India.
DR. PRABHAT JHA:
I think it will be like the China conference in 1997. It will shine a light on the epidemic in India and more broadly within South Asia, meaning in Bangladesh and Pakistan and the like, and so hopefully that will put attention on the need for tobacco control and will spur the government to adopt the things we know work. The starting point is governments have to take tobacco seriously and they do that when societies take it seriously and there is popular demand for tobacco control. I think that is going to happen in India. It has already started and it is going to accelerate.
DR. MARK NOLAN HILL:
I want to thank our guest, Dr. Prabhat Jha. We have been discussing strategies to curb India's soaring smoking-related mortality rates.
I am Dr. Mark Nolan Hill and you have been listening to the Clinician's Round Table on ReachMD XM-157, the Channel for Medical Professionals. Be sure to visit our web site at reachmd.com now featuring on-demand podcasts of our entire library. For comments and questions, please send your e-mail to (xm@reachmd.com )and thank you for listening.
I am Dr. David Hillman with Johns Hopkins Bayview in Baltimore and you are listening to the First National Radio Channel created specifically for Medical Professionals, ReachMD XM-157.
