Curbing tobacco: K'taka success story

Recently, the deputy speaker of Karnataka Assembly released the findings for the second round of the Global Adult Tobacco Survey (GATS) for the state conducted in 2016-17. The first round of GATS was conducted in 2009-10.

These surveys, anchored by the Union Ministry of Health and Family Welfare, are part of the global tobacco surveillance system and provide robust, standardised and comparable data on tobacco use across countries and states. The survey revealed that 22.8% of adults in Karnataka (about 1.2 crores), nearly one in three men and one in 10 women, are currently using tobacco in some form.

However, Karnataka is among the 24 Indian states that show varying degrees of decline in tobacco use. In the last seven years, the prevalence of tobacco use among adults reduced by 5.4 percentage points. This means that Karnataka has about nine lakh fewer tobacco users compared to 2009-10.

The state registered a relative reduction of 19.1% in tobacco use prevalence between 2009-10 and 2016-17. This is impressive considering that the National Health Policy (2017) has set a target of the relative reduction in tobacco use prevalence of 15% by 2020, and of 30% by 2025.

Both, smoking and smokeless tobacco use declined by 3.1 percentage points in the state. While the reduction in tobacco use among youth (15-17 years) is moderate (3.1 percentage points), the average age of initiation into tobacco use has increased from 17.7 to 19.8 years. There is a substantial reduction in people's exposure to tobacco advertisements/promotion while tobacco control messages have reached more people.

The proportion of people who thought about quitting tobacco because of the warning labels on tobacco packs increased significantly from 28.2% to 47.4%. This suggests that the decision of the Centre to enlarge the pictorial health warnings from covering 40% of pack surface area to 85% seems to have served its purpose.

These changes are promising given that tobacco-related diseases account for about a million deaths a year and impose a huge economic cost. In Karnataka, the economic cost of tobacco-related diseases was estimated to be Rs 983 crores in 2011. Hence, reducing tobacco use remains a proven and cost-effective public health strategy.

For now, if we are to arrange Indian states based on the prevalence of tobacco use, Karnataka would stand 11th, with Goa having the lowest tobacco use prevalence of 9.7%. Among southern states, Karnataka follows Kerala (12.7%), Telangana (17.8%), Andhra Pradesh (20%) and Tamil Nadu (20%). Kerala registered the highest rate of decline in tobacco use, followed by Andhra Pradesh and Karnataka. Tamil Nadu registered an increase of four percentage points in the last seven years.

Focus on urban areas

GATS findings highlight some of the challenges that Karnataka needs to address in future. The reduction in tobacco use in the state came entirely from the rural areas, while the trend remained unchanged in urban spaces. Similarly, the decline in smoking is largely due to the reduction in bidi use while the cigarette use has remained unchanged for the last seven years.

So, there needs to be a distinct focus on urban geographies and the use of cigarettes, including better enforcement of the ban on sale of loose cigarettes in the state while continuing with earlier efforts in rural Karnataka.

Though the overall use of smokeless tobacco has come down, the betel quid with tobacco, gutka, and khaini remain three of the five most commonly used tobacco products in the state. Their use has either increased (khaini) or remained unchanged (gutka) since 2009-10. This is a bit perplexing given the state had banned the manufacture, storage and sale of gutka in May 2013.

Tobacco companies soon came out with twin sachets, one containing tobacco and the other pan-masala, to be sold together leading to a gutka-like product when mixed by users. While the state had issued a further order in September 2016 curbing such practices and banning all forms of chewing tobacco, it was soon reversed, narrowing its scope to gutka.

Tobacco affects not only the users but also the non-users through their exposure to second-hand smoke, often called passive smoking. Such exposure has came down in the last seven years - thanks to smokefree policies - but it remains unacceptably high. One in every four persons in the state is getting exposed to passive smoke at workplace or public places. So, while Karnataka deserves applause for setting a public health example, there is room to do more.

(The writer is faculty, the Institute of Public Health, and consultant, Indian Institute for Human Settlements, Bangalore)