India caught in catastrophic smoking epidemic

India is in the midst of a catastrophic epidemic of smoking deaths, which is expected to cause about one million (10 lakh) deaths a year during the 2010s – including one in five of all male deaths and one in 20 of all female deaths at ages 30-69. On average, male bidi smokers lose about six years of life, female bidi smokers lose about eight years and male cigarette smokers lose about ten years.

The findings are from the first nationally representative study of smoking in India as a whole. The research, led by a team from India, Canada and the UK, is published online today (February 13, 2008) in the New England Journal of Medicine.

About 900 field workers surveyed all adult deaths during 2001-2003 in a nationally representative sample of 1.1 million (11 lakh) homes in all parts of India. Researchers compared smoking histories of 74,000 adults who had died with 78,000 living controls.

Among men in the study who died at ages 30-69, smoking caused about:

-- 38% of all deaths from tuberculosis (1,174 out of 3,119 deaths)
-- 31% of all deaths from respiratory disease (1,078 out of 3,487)
-- 20% of all deaths from vascular disease (1,102 out of 5,409)
-- 32% of all deaths from cancer (709 out of 2,248)
-- 23% of all deaths from disease (5,651 out of 25,290)

Lead author Professor Prabhat Jha of the Centre for Global Health Research (CGHR), St. Michael’s Hospital, University of Toronto, Canada, said: “The extreme risks from smoking that we found surprised us, as smokers in India start at a later age than those in Europe or America and smoke less. And, smoking kills not only from diseases like cancer and lung diseases but also from tuberculosis and heart attacks.

In India, there are about 120 million (12 crore) smokers. More than one-third of men and about five per cent of women aged 30-69 smoke either cigarettes or bidis (which contain only about a quarter as much tobacco as a cigarette, wrapped in the leaf of another plant – temburni).

The study found that, among men, about 61% of those who smoke can expect to die at ages 30-69 compared with only 41% of otherwise similar non-smokers. Among women, 62% of those who smoke can expect to die at ages 30-69 compared with only 38% of non-smokers.

I am alarmed by the results of this study,” said India’s Health Minister Dr Abumani Ramadoss. “The government of India is trying to take all steps to control tobacco use - in particular by informing the many poor and illiterate of smoke risks”.

“It is truly remarkable that one single factor, namely smoking, which is entirely preventable, accounts for nearly one in ten of all deaths in India. The study brings out forcefully the need for immediate public action in this much neglected field”, states Professor Amartya Sen, Nobel Laureate in Economics, 2001.

The study found there were no safe levels of smoking, but while the hazards of smoking even a few bidis a day were substantial, the dangers of cigarette smoking were even greater, corresponding to more than a doubling of the risk of death in middle age. This suggests that cigarette smokers lose about 10 years of life compared to non-smokers – risks similar to those seen in the West.

“Smoking kills, but stopping works – about a quarter of all smokers will be killed by tobacco in middle age, unless they stop,” said co-author Professor Sir Richard Peto of Oxford University. “British studies show that stopping smoking is remarkably effective.”

Summary of key findings:

-- This is the first nationally representative study of smoking in India as a whole;
-- During the 2010s there will be about one million (10 lakh) tobacco deaths a year in India;
-- About 70% of these one million deaths will be before old age; meaning 700,000 (7 lakh) per year killed at ages 30-69 (600,000 men and 100,000 women);
-- Tobacco is responsible for 1 in 5 of all male deaths and 1 in 20 of all female deaths in middle age (i.e., at ages 30-69);
-- Men who smoke bidis lose on average six years of expected life, women who smoke bidis lose about eight years and men who smoke cigarette smokers lose ten years;
-- Smoking kills mainly by tuberculosis, respiratory and heart disease, but also by cancer;
-- Even smoking only a few (1-7) bidis a day raised mortality risks by one-third, and smoking only a few (1-7) cigarettes a day nearly doubled the risk;
-- Most of the gap between male and female mortality rates in middle age is due to smoking;
-- Substantial hazards were found both among educated and among illiterate adults and were found both in urban and in rural areas;
-- Stopping smoking works – but, only 2% of adults have quit in India, and often only after falling ill.

Source: Centre for Global Health Research, Toronto University

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