Tobacco Epidemic and Best Practices Control PoliciesIndia Dr

Tobacco Epidemic and Best Practices Control Policies-India Dr. Rana J Singh MD DPHA IFPM Dy. Regional Director(Tobacco and NCD Control) The Union South-East Asia(The Union) 3 rd Conference of The Union South-East Asia Region, May 26 -28, 2016, Kathmandu, Nepal

Tobacco Wild tobacco (Nicotiana rustica) Cultivated tobacco (Nicotiana tabacum) Any of numerous species of Nicotiana or the cured leaves of several of the species that are used after processing in various ways for smoking, snuffing, chewing, and extracting nicotine Text source: Encyclopedia Britannica. (1999); Image source: Wikimedia Commons. (2007). Permission granted for educational use. 2

Burden of Tobacco-Global 1. Tobacco is the leading cause of preventable death in the world – WHO report 2003. 2. Tobacco kills: 5. 4 million people each year 3. ONE BILLION people will die from tobacco use this century.

Global Scenario • Tobacco is responsible for 1 in 10 deaths in adults • About 1 billion men and 250 million women are smoker • If the current trend continues , tobacco use would cause 10 million deaths each year by 2020 • Half ( 650 million) of the people who smoke today will eventually be killed

Global Burden 1. In poor and developing countries , tobacco use is emerging as an epidemic. 2. High public health costs for treating tobacco related diseases. 3. Tobacco kills people at the height of their productivity 4. In some low income countries , poor spend almost 10% of their income on tobacco

Tobacco Is a Risk Factor for 6 of the World’s 8 Leading Causes of Death Hatched areas indicate proportions of deaths related to tobacco use.

Nearly Two-Thirds of World’s Smokers Live in Just 10 Countries More than 40% live in just 2 countries Source: MPOWER package. 2008 7

Tobacco Burden in India Global Adult Tobacco Survey- India(2009 -10) Total (%) Males (%) Females (%) Tobacco users 34. 6 47. 9 20. 3 Smokers 14. 0 24. 3 2. 9 Chewers 25. 9 32. 9 18. 4

Tobacco use in India Only smoke do not use smokeless tobacco (9%) Tobacco Users (35%) 84% tobacco users use it every day Smoke as well as use smokeless tobacco (5%) Use only smokeless tobacco, do not smoke (21%) Smokers 14% Smokeless tobacco users 26% (112 million) (206 million)

Percentage of current tobacco users

Prevalence Rank Smoking % of Total Users Smokeless tobacco Smoking Smokeless tobacco Uttar Pradesh 15% 1 Mizoram 40% Bihar 49% Uttar Pradesh 17% 2 Meghalaya 36% Jharkhand 48% West Bengal 12% Bihar 14% Chhattisgarh 10% 3 Nagaland 32% Chhattisgarh 47% Andhra Pradesh 10% 4 Arunachal Pradesh 29% Nagaland 45% Bihar 7% Maharashtra 10% 5 Tripura 27% Manipur 45% Rajasthan 7% West Bengal 7% Madhya Pradesh 7% Odisha 6% Chhattisgarh 5% Jharkhand 5% 6 Sikkim 26% Odisha 43% 7 Manipur 26% Tripura, Mizoram 41%

Overview of Tobacco Use • Prevalence of tobacco use is 35% • Among tobacco users 84% are daily users • Among smokers and smokeless tobacco users many use multiple tobacco products • One-fourth of cigarettes smokers and half of the bidi smokers smoke more than 10 cigarettes/bidis per day • Mean age at initiation of tobacco use is 17. 8 years • Among tobacco users 60% use tobacco within half an hour of waking up

Tobacco Use in India – in real terms Nonuser Total users Males (%) Female (%) Total (%) Country population: (numbers, min) http: //en. wikipedia. org/wiki/List_of_countries_by_population 52 80 65 (510. 5 m) 48 (197 m), more than Brazil (5) Smokers 15 (61. 1); UK (22) Chewers 24 (~98. 5) Philippines (12) Dual 9 (~37) Use 20 (77. 9 m), 35 (274. 9 m) more than Iran (17) 2 (7. 8) 9 (68. 9 m) 17 (~66. 2) 21 (~163. 7 m) More than combined population of Indonesia (237 m) and Canada (34. 3 m). By itself would be 4 th highest population More than UK, France or Thailand (20 th biggest country by population) More than Bangladesh, Nigeria or Russia 1 (~3. 3) 5 (~40. 3 m) More than Argentina (32 nd most populous country) High prevalence states (above national prevalence) Arunachal Pradesh, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Odisha, Sikkim, Tripura, Assam and West Bengal

Exposure to SHS

Exposure to SHS

GYTS India 2009 • 13 -15 years school students • 14. 6% use tobacco • 4. 4% smoke • 21. 9% live in the homes where others smoke in their presence

Burden of tobacco in India • Kills 10 lakh persons annually in India (more than TB, HIV/AIDS, malaria combined). • 2500 deaths daily. • 50% of cancers in men and 25% in women. • Highest incidence of oral cancer in the world. • Majority of cardio-vascular and lung disorders

Burden of tobacco use • Almost 40% of TB deaths are associated with smoking. • Incidence of impotence is 85% higher among smokers. • 5500 youth initiate tobacco use every day. • Environmental burden

India’s policy on Tobacco control

Two major regulations for tobacco control in India • Cigarette and Other Tobacco Products Act 2003(COTPA 2003) • Food Safety and Standards Act 2006(FSSA 2006)

Cigarette and Other Tobacco Products Act(COTPA-2003) o Section 4 – Prohibition of smoking in public places o Section 5 - Ban on advertisements of tobacco products o Section 6 (a) - Prohibition of sale of tobacco products to and by minors o Section 6 (b) - Prohibition on sale of tobacco products within the radius of 100 yards of any educational institutions o Section 7 - Specified health warning labels on all tobacco products

Section 4 /Prohibition of Smoking in Public places rules, 2008 The Owner, proprietor, manager, supervisor or in charge of the affairs of a public place is responsible to make the public place as …. . shall ensure o No person smokes in his jurisdiction o Display of the specified board at each entrance, and conspicuous place inside o Such board at each floor and entrance to lift o No smoking aids are provided in public place o Shall notify and display the name of person to whom complaint be made Designated smoking area/Smoking rooms : exemptions

Section-5 ● ● ● No person engaged in the production, supply or distribution of tobacco products shall advertise No person having control over a medium shall cause to be advertised through that medium No person shall take part in any advertisement which directly or indirectly suggests or promotes to use or consumption of tobacco products No trade mark or brand name of cigarettes or any tobacco product to be promoted in exchange for sponsorship, gift, prize or scholarship No person, under contract or otherwise, promote or agree to promote any tobacco product or its usage Advertisements allowed at point of sale and in or on package

Section 6 (a): Provisions of the law Prohibits sale of tobacco products to and by persons below the age of 18 years. • The Owner / manager / in-charge where tobacco products are sold shall ensure that: – A board from the two option is at the entrance of the place where tobacco products are sold in a manner as given below : • Minimum size of the board should be 60 cm x 30 cm with white background. • The board should contain the warning “sale of tobacco products to a person below the age of 18 years is a punishable offence”, in Indian language(s) as applicable and a pictorial depiction of ill effects of tobacco use on health. • The board shall not have any advertisement / promotional messages / pictures / images of cigarette and any other tobacco products. – No tobacco product is handled or sold by minors. – No tobacco product is sold through a vending machine. – No tobacco products are displayed in a manner that enables its easy access to minors. – The seller of tobacco product shall confirm that the buyer of tobacco product is not a minor. In case of doubt the seller may request the buyer to provide appropriate age proof/identity proof. Cigarette and other tobacco products Amendment Rules, 2011

Signages under section 6 (a) Specifications as given in the Compact Disk : Pictorial image shall occupy 50% of the board (60 cm x 30 cm) The design and specification of board can be downloaded from http: //mohfw. nic. in/showfile. php? lid=937

Section 6 (b): Provisions of the law • All educational institutions should have a board on their boundary wall or at the entrance. The board should state prominently that “sale of cigarette or any other tobacco products in an area within the radius of 100 yards of the educational institution is strictly prohibited; the offence is punishable with a fine upto Rs. 200” • Measurement of the distance: distance of 100 yards shall be measured radially from the outer limit of boundary wall, fence or as the case may be, of the educational institution, for the location of a tobacco vendor or point of sale

Signage section 6(b)

Depiction of Specified Health Warnings Section 7: There shall be no production, sale and import of cigarettes or any other tobacco product unless every package of cigarettes or any other tobacco product bears on it label, specified warning. Section 8: Manner in which specified warning shall be made The specified warning on a package of cigarettes or any other tobacco products shall bea) legible and prominent ; b) conspicuous as to size and colour Section 9: Language in which the specified warning shall be expressed

New pictorial warnings w. e. f April 2016 For chewing or smokeless forms of tobacco packages

New pictorial warnings • For smoking forms of tobacco packs

National Tobacco Control Programme(NTCP)

Justification for NTCP-India Complexity of Tobacco use in India Complexity of Stakeholders and multi-sector involvement TC requires multi-sectoral approach involving various stakeholders Need to identify various strategies for different sectors / stakeholders for effective TC • NTCP acting as Central Programme will: - help sensitize all sectors and stakeholders - increase awareness generation among youth and adults - help raising policy and legislation issues - help implementation of related public health and legislative issues of tobacco control at state • Tobacco is a public health problem in India and like other need a national level programme to provide guidance to the states • FCTC obligations • •

Goals of NTCP-India Prevent initiation among youth and adults Promote quitting among adults and youth Eliminate exposure to tobacco smoke(SHS) Reduce demand by IEC campaigns, ban on TAPS, and pack warnings • Reduce Supply by restricting access to minors And thereby : Reduce tobacco related morbidity and mortality • •

National Tobacco Control Program Central Government Level • Set up the National Tobacco Regulatory Authority for effective enforcement and monitoring State and District Government Level • Launch pilot of the State and District Tobacco Control Program – Establish State and District Tobacco Control Cells (STCC and DTCC). Currently in 21 states, 42 districts – Establish state and district level steering committees to monitor legislation imlementation – Establish tobacco cessation centres – Build capacity through training, sensitization and workshops All levels • Increase public awareness

National Tobacco Control Program Mo. H&FW State Tobacco Control Cell District Tobacco Control Units Monitoring tobacco control laws & reporting Training IEC School based activities Tobacco Cessation

Central level Activities(NTCC) • Set up a National Tobacco Regulatory Authority(NTRA) • Establishing labs for testing tar/nicotine content of tobacco products • Capacity building: Development of training material • Public education: National level Mass Media Campaign • Surveillance: Support to conduct GATS/GYTS • Alternate crops and livelihood • To take necessary action, in co-ordination with other Ministries and stakeholders, to fulfil the obligation(s) under the WHO Framework Convention on Tobacco Control

State level Activities during 12 th FYP (proposed) • State Tobacco Control Cells(STCC) to be established to undertake: v. IEC and Advocacy efforts v. Training of key stakeholders including enforcement officers, schools teachers etc. v. Meetings of the State Level Co-ordination Committee(SLCC) and its follow up v. Activities relating to enforcement of COTPA in the state v. Overall monitoring and supervision for the implementation of NTCP and Tobacco Control Act (COTPA, 2003) in the districts. v. Flexipool has been provided to states to cater to state specific needs and demands

Components of District Tobacco Control Programme (Pilot Phase) § Training : Training of School teachers, health workers, health professionals, law enforcers, NGO’s, women SHG’s on tobacco control § IEC : IEC using Cable TV, Street Shows, Exhibitions, Melas, etc in the regional language at grassroot level; Anti tobacco awareness programs by the trained Women SHG/ NGO’s. § School Programs : School Programme in Govt. Schools (50 Schools per district). § Monitoring Enforcement of Tobacco Control Laws § Tobacco Cessation Centres: Setting up of TCC’s in Districts.

District Tobacco Control Program Training : Training of health workers, health professionals, law enforcers, NGO’s, women SHG’s on tobacco control measures

District Tobacco Control Program q IEC : Local/Folk media, BCC strategies, in collaboration with NGOs/CBOs/SHGs/PRIs. IEC material being updated/prepared.

District Tobacco Control Program School Level Activities : involving awareness/ education campaigns, training of school teachers, Tobacco Free Schools initiatives.

District Tobacco Control Program q Monitoring - Formation of District level committees/District Action Plans for Enforcement of Tobacco Control Laws, evolving district specific monitoring and implementation mechanisms.

District Tobacco Control Program q Tobacco Cessation Clinic – To provide help to quit tobacco use at the community level, cessation facilities are being provided and capacity building for cessation at the district and sub district level.

Let us all work together to fulfill the dream of a healthy, Tobacco Free India

Thank you