BMJ  2004;328:780 (3 April), doi:10.1136/bmj.328.7443.780

Editorial

Tobacco related harm in South Asia

High mortality but some promising initiatives

To deal with tobacco we must defy a tenet that an influential section of modern society holds dear—that unfettered commerce will deliver us all from want and suffering. South Asia suffers harm from tobacco on a scale that demands a vigorous response. And it provides examples of how to deal creatively with the problem.

Worldwide about 4 million people die annually from tobacco related causes, and by the late 2020s the estimated toll will be about 10 million.¹ South Asia, with about a quarter of the world's population, contributes substantially to these figures. Tobacco is used in numerous forms in South Asia.^2-4 The commonest smoked product is the bidi, which has to be puffed harder to keep it alight, making it an enhanced damage delivery device.³ Cigarette consumption is high in some countries, with average annual use of 1440 cigarettes for every inhabitant in the Maldives, 620 in Nepal, and 560 in Pakistan.³ Smoking increased substantially between 1990 and 1999 in Bangladesh, India, the Maldives, and Pakistan, reflecting a shift in the focus of the tobacco multinationals towards poorer countries, which have less effective regulation.

More than a third of tobacco consumed is smokeless—in chews with areca nut or betel leaf, industrially manufactured paan masala and gutka, and numerous other products, including tooth powders.^{2 5} A prospective cohort study found that smokeless tobacco use was associated with mortality similar to that of cigarette smoking and with increased oral cancers.⁵ India has one of the highest rates.^{2 6 7} Overall, tobacco accounts for about one half of all cancers in men and one quarter in women in India.⁷

A harmful consequence of smoking, not emphasised in other regions, has been well researched in Bangladesh.⁸ This is the damage done to poor families when tobacco gets priority over food and other essentials. A recent study in India (see p 801), shows that those with the lowest standard of living smoke most.

Tobacco production is associated with its own harm, to people and to the environment. Tobacco is cultivated in nearly all countries of the region, with India accounting for about 10%.² Significant tobacco cultivation skews national tobacco control policy. The tobacco trade uses tobacco farmers as a powerful lever in its political machinations.⁹

Some South Asian countries have responded innovatively to control the harm caused by tobacco. The small kingdom of Bhutan is a pioneer. It has a tobacco control law dating from 1729, and is now moving unobtrusively to eradicate smoking and the trade in tobacco altogether. In the Maldives there are islands that have declared themselves completely tobacco free.² The state of Arunachal Pradesh in India has banned the sale, distribution, and manufacture of tobacco products.¹⁰ There are no reports yet of a serious backlash to banning tobacco. Removing tobacco can be a community led enterprise, not a jackboot affair.

An altogether different approach, employed in Bangladesh and India, is the use of public interest litigation. Judicial activism for the common weal is perhaps stronger in India than in any other country. The Indian courts have moved with resolve to protect the public from tobacco. The Supreme Court of India in November 2001, in a landmark ruling, directed all states and centrally ruled territories to issue orders forthwith to ban smoking in public places and in public transport.² A state court has taken similar action.

Sri Lanka in 1996 broke new ground by curtailing the covert promotion of tobacco through the gratuitous inclusion of smoking scenes in films and television soaps.

For those countries where neither government action nor judicial activism is prominent South Asia again provides some answers. Sri Lanka provides examples of how community action can hold back the tobacco tide, despite unhelpful public policies, and reduce prevalence of tobacco use.¹¹

Major shortcomings are still to be addressed in South Asia's response to tobacco. The evidence based policies implemented by several governments in the West have not been widely introduced here. The influence of the medical profession could be better mobilised to help achieve this. Doctors in South Asia can, at least, encourage people to quit tobacco use. To achieve this they need not even venture out of their clinics.

Faculty of Medicine, Colombo, Sri Lanka (diyanath1{at}yahoo.co.uk)

Ceylon Medical Journal, Sri Lanka Medical Association, 6, Wijerama Mawatha, Colombo 7, Sri Lanka (colvin_goonaratna{at}yahoo.com)

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Primary care p 801

Competing interests: DS is a member of WHO's scientific advisory committee on tobacco product regulation. To enhance tobacco prevention work, he holds token shares in Ceylon Tobacco Company, the monopoly tobacco producer in Sri Lanka. CG And DS are members of the committee on tobacco and alcohol of the Sri Lanka Medical Association and were members of the presidential task force set up to draft a policy for tobacco control in Sri Lanka in the late 1990s.

References

1. How do you sleep at night, Mr Blair? Lancet 2003;362: 1865.[Medline]
2. World Health Organization, Regional Office for South East Asia. Country profiles on tobacco or health. New Delhi: WHO, 2002.
3. McKay J, Ericson M. The tobacco atlas. Geneva: WHO, 2002.
4. Shafey O, Dilick S, Guindon GE, eds. Tobacco control country profiles. 2nd ed. Atlanta: American Cancer Society, World Health Organization, International Union Against Cancer, 2003.
5. Gupta PC, Ray CS. Smokeless tobacco and health in India and South Asia. Respirology 2003;8: 419-31.[CrossRef][ISI][Medline]
6. World Health Organization. Tobacco or health: a global status report: country presentations at regional meetings. Geneva: WHO, 1997.
7. Centers for Disease Control and Prevention. Tobacco or health: a global status report. India. www.cdc.gov/tobacco/who/india.htm (accessed 27 Feb 2004).
8. Efroymson D, Saifuddin A. Hungry for tobacco: an analysis of the economic impact of tobacco on the poor in Bangladesh. Ottawa: PATH Canada, 2000.
9. Campaign for Tobacco Free Kids. Golden leaf, golden harvest—the costs of tobacco farming. Washington: CTFK, 2001.
10. International Agency on Tobacco or Health. India: state bans tobacco products. IATH Bulletin 2003;144: 4.
11. World Health Organization. Prevention and cessation of tobacco use. New Delhi: WHO South East Asia Regional Office, 2003.

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