The Tobacco Epidemic in India
The complexities and impact of tobacco use in India demand action
India has the second largest tobacco-using population in the world after China. The tobacco ecosystem in India is complex. In this article, we examine the (1) tobacco products, (2) health impacts, (3) economic implications, and we conclude by seeking inputs and ideas for the way forward in India.
First, there are three general groups of tobacco products in India: bidis, smokeless tobacco products, and conventional cigarettes. Bidis are the inexpensive, small, hand-rolled cigarettes that are much more common in India than conventional cigarettes. Bidis comprise tobacco wrapped in a tendu or temburni leaf. We estimate that bidis represented more than 80% of total cigarette stick volume consumption in India during 2017. There is a high prevalence of smokeless tobacco use as well, with dual use contributing a noticeable proportion. Smokeless tobacco products, like gutkha and paan masala, are available in small sachets for as little as half a rupee (less than $0.01 USD). Reported retail sales of smokeless tobacco in India have dropped precipitously during the past several years, because many states banned the sale, manufacture, distribution, and storage of gutkha and its variants. As of May 2013, gutkha was banned in 24 states and 3 union territories. That said, the product and products like it remain widely available.
According to the Global Adults Tobacco Survey (GATS) for India 2016-2017, 28.6% (266.8 million) of all adults (42.4% of men and 14.2% of women) currently use smoking and/or smokeless tobacco products. GATS estimates that 99.5 million adults currently smoke tobacco; and 199.4 million adults use smokeless tobacco. The e-cigarette market in India is underdeveloped, with only an estimated 100,000 to 150,000 vapers as of 2018.
Knowledge gaps and risk misperceptions remain relatively high in the country. For example, India ranked lowest on the perception of the risks of smoking across the 13 countries polled in the Foundation’s Worldwide State of Smoking Survey (see Table 1).
Table 1. Worldwide State of Smoking Survey – Comparison of Selected Results for India Versus Total
|Question||Base||India||Total||India vs. Total|
|Smoking harmful to health?||Smokers||69.3%||86.4%||(17.1%)|
|Smoking cause lung cancer?||All||69.6%||80.8%||(11.2%)|
|Well informed about smoking and impact on health?||Smokers||68.2%||88.2%||(20.0%)|
|Spent money on cigarettes rather than food?||Smokers & Former smokers||60.2%||43.7%||16.5%|
Source: State of Smoking Survey 2018.
Second, as a result of the widespread use of tobacco products in India, the health implications are enormous. According to WHO, tobacco kills more than 1 million people each year in India, accounting for 9.5% of all deaths. The death toll is increasing, as the estimated 1 million tobacco-related deaths in India in 2018 compares to about 930,000 adult deaths in 2010. The most common cause of death associated with tobacco is cardiovascular disease, at 48% of tobacco-related deaths. Tobacco ranked fifth among the risk factors driving the most death and disability in India as of 2017, after malnutrition, dietary risks, air pollution, and high blood pressure.
A review of 37 studies from four of the six WHO regions found that the use of smokeless tobacco products (SLTs) markedly increased the risk of oral cancer. Analyses of different smokeless tobacco products revealed various levels of risk. A key finding was the relatively high odds ratios (ORs) for gutkha (OR 8.67; 95% CI, 3.59 – 20.93) and paan tobacco/betel liquid (OR 7.18; 95% CI, 5.48 – 9.41), indicating that the use of gutkha and paan could increase the risk of oral cancer by approximately seven to eight times relative to nonuse. A separate finding by the systematic global review was that snus (OR 0.86; 95% CI, 0.58 – 1.29), a form of moist smokeless tobacco commonly used in Scandinavia, demonstrated no such increased risk, with an OR of around 1. The implications of the review are that a substantial reduction in the disability and premature death associated with the use of smokeless tobacco products and the risk of oral cancer is conceivable by switching to a potentially less harmful product such as Swedish snus.
Oral cancer accounts for 30% to 40% of cancer cases reported in India. Through the gender lens, smokeless tobacco use is proportionately more impactful on women. Smoking by women in India is still socially unacceptable but SLT use is more common. According to GATS in 2016-2017, 12.8% of women were current users of smokeless tobacco, compared with 2.0% of women who currently smoke tobacco and 14.2% of women who currently use one and/or the other product. Adding to the complexity, tobacco use greatly increases the risk of tuberculosis (TB) disease and death. In 2017, 87% of new TB cases occurred in the 30 high TB burden countries, including India.
Third, the economics of tobacco are complex. Bidis have traditionally been taxed at a much lower rate than conventional cigarettes or have evaded taxation altogether. As a result, bidis are inexpensive and widely available. Bidis are commonly produced in a decentralized manner in the homes of rural women. Research indicates that cigarette smoking is slowly displacing bidi smoking in India. For example, during the period from 1998 to 2015, cigarette smoking prevalence doubled in men between the ages of 15 to 69 years. That said, bidis remain the predominant product. The large pictorial warnings comprising 85% of cigarette packaging was considered a win for tobacco control in the country, but the sale and use of single cigarettes and the high volume of illicit trade limit the impact. On the other hand, the ban on the sale of loose cigarettes, which now applies in some Indian states, is pushing the category toward organized retail sales. Regarding the bans on gutkha and loose cigarette sales, laws on the books do not necessarily translate into laws on the streets in countries with weak regulatory enforcement capacity or where global norms are not seriously adapted into national laws.
A summary of several aspects of the economics associated with tobacco use in India is reflected in Table 2. The Ministry of Health & Family Welfare in India estimates that the total direct and indirect costs of diseases attributable to tobacco use was INR 1,045 billion in 2011 (USD $14.6 billion at current exchange rates), of which 84% were indirect mortality costs. The Ministry estimates that the costs attributable to smoking tobacco (78% of total) were much higher than the costs incurred due to smokeless tobacco use (22% of total). The costs attributable to bidis versus factory-made cigarettes (FMCs) were not projected, although we estimate on a volume or stick basis that the ratio of bidis to FMCs consumed is more than 4:1.
A separate study finds that the total annual economic costs of bidi smoking for 2017 amounted to approximately 0.5% of India’s gross domestic product (GDP), while the excise tax revenue from bidis was only 0.5% of its economic costs. The socioeconomic reality of smoking behavior in India is that people with poor socioeconomic status tend to be bidi smokers, thus the poor bear a disproportionately large share of the related economic costs. Due to the tax structure, research finds that FMCs, despite relatively low prevalence, generated most of the estimated tobacco tax receipts in 2017-2018, while bidis remain the low-cost option.
Table 2. Summary of Selected Tobacco Use Economic Statistics for India
|Current users (millions)1||99.5||199.4||266.8|
|Est. volume - sticks (billions)2||500||81||581|
|Health costs (INR billions)3||811||234||1,045|
|Health costs ($USD billions)4||11.4||3.3||6.9|
|Est. tax receipts FY 2017-18 (INR billions)5||34||383||416||79||495|
|Est. tax receipts FY 2017-18 ($USD billions)4||0.5||5.4||5.8||1.1||6.9|
|Total tax burden (%)5||22.0%||52.8%||60%|
- Global Adults Tobacco Survey (GATS).
- Global Trends in Nicotine report.
- Economic Burden of Tobacco Related Diseases in India.
- Foreign exchange rate 0.014 USD to Indian rupee as of May 1, 2019.
- Estimated impact of the GST on tobacco products in India.
The Foundation recognizes that taxation is an important lever, as emphasized by the Task Force on Fiscal Policy for Health in its recent report. However, we believe the record shows that simple exhortations for governments to increase excise taxes across various product types are not enough to achieve a smoke-free world. We believe real change is unlikely until the wide array of stakeholders with material interests in maintaining the status quo are motivated to act.
Time for greater urgency and action
Given the human and economic impact of tobacco use in India, along with the complexity outlined in this article, the Foundation is committed to working with others to accelerate an end to smoking in this generation. For the next few months, we will be listening, studying, and discussing the optimal role for the Foundation that complements the considerable work that has been underway for decades. We invite leaders to study our strategic plan and propose areas of potential impact and interest.