Authors: Chaturvedi Pankaj , Sarin Ashima, Seth Sanjay, Gupta PC

On 8th June 2017, results from the second Global Adult Tobacco Survey (GATS 2) of India were released. GATS is a global standard for systematically monitoring adult tobacco use and tracking key tobacco control indicators. India is the world’s largest democracy, and the second largest consumer and third largest producer, of tobacco. Tobacco control results from India take on a global significance in terms of impact on total mortality and disease burden.

For a large and diverse country like India, effective tobacco control has always been a daunting task. In the last five years, the country has witnessed a number of legal battles between the government and the tobacco industry. At one point, a parliamentary committee supported the tobacco industry and sought dilution of certain tobacco control measures. The powerful tobacco lobby tries to delay or derail attempts to reduce tobacco use prevalence. According to media reports, the Health secretary and Health ministers were removed from their posts in part because of their support of tobacco control measures. GATS 2 is can be viewed as a report card of the Government’s action on tobacco control.

GATS 2 was a household survey of 74,037 persons, aged 15 or more, conducted in all 30 states of India and two union territories in 2016-17. The first GATS was conducted in 2009-10. GATS 2 results found a 6% decline in tobacco use prevalence, from 34.6% in GATS 1 to 28.6% in GATS 2. The decline in prevalence was equivalent to a 17% relative decrease, and the number of tobacco users has reduced by about 8.1 million. The GATS 1 data released in October 2010 reported an estimated absolute number of 275 million tobacco users in India. The 2017 National Health Policy of the Government of India had set a target of relative reduction in current tobacco use by 15% by 2020; a target which has now been exceeded. The next target is a 30% reduction by 2025.

This period also witnessed the emergence of new contributors outside the Ministry of Health providing additional powerful tools for tobacco control. The Ministry of Women and Child Development amended the Juvenile Justice Act to make the sale of tobacco to minors as a non bailable offence punishable by 7 years of rigorous imprisonment and a fine of up to 100,000 Indian Rupees (US1550). The Department of Consumer Affairs amended the Legal Metrology Act to prohibit sale of loose cigarettes, which currently accounts for over 70% of the country’s total cigarette sales.

Meanwhile, a regulation under the Food Safety Act (2011) prohibited addition of tobacco and nicotine to any food substance. Through public interest litigation, this regulation enabled the Supreme Court to order a nationwide ban on gutka (a combination of flavored smokeless tobacco and areca nut). In addition, more than a dozen states have independently prohibited flavored smokeless tobacco products – an important step given gutka is a risk factor for oral cancers.

Voice of Tobacco Victims (VoTV), a campaign led by doctors and tobacco victims, played a pivotal role in the getting gutka/smokeless tobacco banned and taxes hiked on various tobacco products in India. The campaign has won awards and recognition from several organizations such as the World Health Organization, British Medical Journal, and the Campaign for Tobacco Free Kid. While most believed that prohibition would not work, VoTV was convinced that it would lead to decreased accessibility and affordability translating into reduced youth initiation. The 360-degree campaign involved advocacy, a legal battle, media, and research. The VoTV network also reached several medical societies and hundreds of individual doctors to increase engagement in tobacco control advocacy.

Despite tremendous resistance and litigation from the tobacco industry, the Ministry of Health imposed an 85% pictorial warning on tobacco packets from 1st April 2016. A significantly higher proportion of adults considered quitting because of the warnings on tobacco products (61.9% current cigarette smokers thinking about quitting smoking GATS 2 versus 38% in GATS 1). The tobacco tax hikes also contributed to reduction in prevalence, with individual expenditure on cigarettes and bidis having tripled since GATS 1.

GATS 2 reported a reduction in smokeless tobacco users from 25.9% to 21.4%. It also affirmed that a smokeless tobacco ban would not lead to switching to smoking. Smoking prevalence between the two GATS survey declined from 14% to 10.7 %, despite the ban on gutka/smokeless tobacco.

Summary of GATS 2 tobacco use

Pattern of tobacco

• 6% of adults aged 15 and above (267 millions) used tobacco in any form
• 199 million use smokeless tobacco, 100 million smoke tobacco and 32 million smoke as well as chew tobacco.
• The most commonly used tobacco products are khaini (a type of smokeless tobacco) 85 million users and bidi (hand rolled cigarette) 67 million users.
• 199 million users live in rural area and 68 million in urban

Significant changes compared to GATS 1

• 17% relative decrease in tobacco prevalence
• Tobacco use among 15-24 year olds showed relative reduction of 33% and for 15-17 year olds there was a 54% reduction.
• The age of initiation of tobacco use increased by 1 year ( 17.9 to 18.9).
• While there was a decrease in second-hand smoke exposure in public places (6%) and at home (13%), there was no decrease in workplaces.
• 9% (83 % to 92%) more believed that second-hand smoke is harmful
• 7% (89% to 96%) more believed that smokeless tobacco is harmful

Areas of concern

• 68% of smokers, 17% of bidi smokers, and 50% of smokeless tobacco users purchase loose tobacco.
• 30% of those who work indoors are exposed to second-hand smoke
• 23% adults are still exposed to SHS at public places.
• Nearly 10% of people still notice some form of tobacco advertisement.
• Despite the gutka ban, 51 million people were still able to buy gutka

We must commend Government of India for their commitment to Tobacco Control. We also recognize the efforts of several national/international NGOs, academic institutions and civil society activists who have contributed to this impressive result. GATS 2 demonstrates that the tobacco control strategies in India are going in the right direction. For continuing improvement, the country needs further strengthening of policies, particularly enforcement of tobacco control laws.