The past decade has seen a significant paradigm shift in tobacco-related policies that has led to a significant curtailing of the use of tobacco in many countries. However, nearly all of these advances have occurred in industrialized countries. Unfortunately developing countries' policies have lagged far behind (1), and tobacco consumption in these countries continues to rise (2, 3). The Indian Parliament recently introduced a multifaceted tobacco control bill (the Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Bill of 2001). This paper summarizes tobacco use and its consequences in India, examines the major legislative control measures that preceded this comprehensive legislation, and discusses additional measures required to successfully curb tobacco use in India.
History of tobacco use in India
The Portuguese introduced tobacco to India 400 years ago and established the tradition of tobacco trade in their colony of Goa. Two hundred years later the British introduced commercially produced cigarettes to India and established tobacco production in the country (4). Today, of the 1.1 billion people who smoke worldwide, 182 million (16.6%) live in India.
Tobacco consumption continues to grow in India at 2--3% per annum, and by 2020 it is predicted that it will account for 13% of all deaths in India (5, 6).
Tobacco use in India is more varied than in most countries. Only 20% of total tobacco consumption is in the form of cigarettes (6). A common alternative to traditional cigarettes is the bidi, a hand-rolled, filterless tobacco cigarette. Tobacco is also used in the hookah (a traditional water pipe), as pan masala or guthka (a chewing tobacco containing areca nut), as chutta (a clump of tobacco smoked with the lighted end inside the mouth), and mishri (a powdered tobacco robbed on the gums as toothpaste) (6). Bidis account for the largest proportion of tobacco consumption in India, at about 40% (6, 7).
In India an estimated 65% of all men and 33% of all women use some form of tobacco (6). While the prevalence of smoking among men and women differs substantially--35% of men and 3% of women--both use smokeless tobacco products to approximately the same extent (6).
Health consequences of tobacco consumption in India
In 1990 approximately 1.5% of total deaths in India were tobacco-related, and the nation amassed over 1.7 million disability-adjusted life years (DALYs) due to disease and injury attributable to tobacco use (8). Tobacco-related cancers account for approximately half of all cancers among men and one-fourth among women (6), and it is estimated that 8.3 million cases of coronary artery disease and chronic obstructive airway diseases are also attributable to tobacco each year (9). Treating these three tobacco-related diseases cost approximately US$ 6.5 billion in 1999 (6).
Smokeless tobacco is an important etiological factor in cancers of the mouth, lip, tongue, and pharynx. It is not surprising, therefore, that India has one of the highest rates of oral cancer in the world. These rates are steadily increasing and oral cancers are occurring more frequently among younger individuals (10). Annual oral cancer incidences in the Indian subcontinent have been estimated to be as high as 10 per 100 000 among males (11).
India's tobacco industry and market
India is the world's third largest tobacco-growing country. In 1992 it .produced 7% of the world's total unmanufactured tobacco and 14% of the world's total manufactured tobacco in the form of cigarettes and bidis (6).
The overall contribution of the tobacco industry to India's large agricultural sector--it employs two-thirds of the country's labour force--is small. Approximately 3.5 million people are employed in tobacco cultivation in India, representing less than 0.5% of the agricultural labour force and 0. …