Dr. Prabhat Jha, professor of health and development, and founding director of the Centre for Global Health Research at the University of Toronto, details his extensive findings, published in the New England Journal of Medicine, on the current smoking epidemic in India with host Dr. Mark Nolan Hill. Is India's hospital and healthcare system equipped to deal with the breadth of smoking-related illnesses? Dr. Jha also talks about the efforts of India's tobacco industry to squash his scientific data, and explains how the Indian government can resist the push of tobacco industry lobbyists.
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INDIA’S SOARING SMOKING-RELATED MORTALITY RATES
Change and Challenges in the wind as 2008 comes to an end. The same is true when examining this month's ReachMD XM160 special series - Focus on Global Medicine. We take a look at both the changes and the challenges impacting global medicine.
By the year 2010, experts are predicting that India will suffer nearly 1 million smoking-related deaths per year. How equipped is the hospital and healthcare system in India to deal with the breath of smoking-related illnesses. You are listening to ReachMD, The Channel for Medical Professional. Welcome to The Clinician's Roundtable. I am your host, Dr. Mark Dolan Hill, professor of surgery at Chicago Medical School and our guest today is Dr. Prabhat Jha, Professor of Health and Development and Founding Director of the Center for Global Health Research at the University of Toronto. Dr. Jha is the lead author of impactful research published on the current smoking epidemic in India.
DR. MARK DOLAN HILL:
Welcome Dr. Jha.
DR. PRABHAT JHA:
Thank you for having me Mark.
DR. MARK DOLAN HILL:
Today, we are discussing influences on soaring smoking-related mortality rates in India. Dr. Jha has the research that you have done received significant media attention in India?
DR. PRABHAT JHA:
It has and one of our objectives was to make sure that the key messages from the study, it is a five-year quite intensive study, but it really boils down to just 4 key messages for the individual smoker in India, which we have tried to convey.
DR. MARK DOLAN HILL:
What are those sir?
DR. PRABHAT JHA:
For the first is that the risk is much bigger than previously thought, that by previous estimates smoking was not supposed to account for these many deaths or the proportion of particular diseases as we found in India. The second is that smoking kills, early 70% of the smoking deaths in our study and that are occurring nationally are at ages 30 to 69 meaning they are losing decades of good life versus nonsmokers. The third is that we found even if few bidis or cigarettes per day kills, there is no such thing as safe amount of smoking, and the fourth is that stopping smoking is highly effective. We know that from worldwide evidence, but in India only 2% of adults report themselves as ex-smokers and most of them have quit because they have got disease. They only quit after disease. So, a genuine quitting in India is still very, very uncommon.
DR. MARK DOLAN HILL:
Well, how did you get this information to the media? Specifically, what did you do?
DR. PRABHAT JHA:
What we did is we had obviously along with the press release; we had a major press conference in Delhi. We created a video, which is available on our website, which is www.cghr.org/tobacco and that video was available in regional languages, in fact you can find it on youtube if you just type either my name, Prabhat Jha or CGHR, Center for Global Health Research. It comes up as a video that shows in 5 minutes the key messages from the study and we have that translated into regional languages of India. So, it was broadcast locally. So, it was the combination of those things that we deliberately did to try to make sure people and individual smokers really understood the risks, which was the objective of the study.
DR. MARK DOLAN HILL:
And what about in the schools?
DR. PRABHAT JHA:
Well, interestingly that video that we have released has been turned into a public service announcement and is now already over about a 1000 schools and expanding regularly and certainly that’s going to be a part of the strategy, but I think the important strategy is not just to tell children don’t smoke, but it’s to tell adults if you quit, we will get a lot of benefits. We know that from other studies, there are huge benefits to quitting smoking. So, the strategies have to be both about getting the current 120 million smokers in India to quit along with telling the kids that haven’t started yet, not to start.
DR. MARK DOLAN HILL:
And how do you transmit this information to the rural population?
DR. PRABHAT JHA:
Well, we have put things in the way of media messages that are on radio and so far, but I think the most important way that this information can be translated would be for the Indian government to adopt prominent warning labels on cigarette or bidi packs, just like the Canadian or the UK warning labels. These are the half the pack is composed of a warning label with a pictorial warning and that changes overtime. That’s a very effective way particularly when we find that over half the deaths from smoking in India occur in those that are illiterate. So just writing text that smoking is bad for you isn’t going to be something they understand, but pictorial warning is something that will convey those risks more meaningfully.
DR. MARK DOLAN HILL:
Is the government receptive to that?
DR. PRABHAT JHA:
Well partially, I mean we released this paper in mid February and at the end of February, the government group met to review warning labels. They didn’t go fully along with what we had hoped, but they have moved to at least get pictorial warning labels and not the really scary ones, the graphic ones, but the pictorial warning labels will come in this year and we hope that will eventually transit to the graphic pictorial warnings, which have things like showing people who are dying of lung cancer or showing tuberculosis or impotence or all the other things that have worked very effectively in Canadian warning labels.
DR. MARK DOLAN HILL:
And those are on bidis as well as the cigarettes.
DR. PRABHAT JHA:
That is the plan is to put it on both.
DR. MARK DOLAN HILL:
Dr. Jha, how much of a limiting factor is cost in the population purchasing these tobacco products?
DR. PRABHAT JHA:
Well, cigarettes are cheap and bidis are cheaper in India. That bidis can cost pennies and even for a poor person, they are marketed in a way that you can buy them at any local shop like a local vendor of milk or whatever kind of corner grocery store and you can buy them individually often rather than buying the whole pack.
DR. MARK DOLAN HILL:
Are there any taxes on bidis?
DR. PRABHAT JHA:
There are taxes on cigarettes, which are not very high. There is effectively no tax on bidis and that’s hopefully will also change. The Indian government is considering some ideas about introducing bidi taxes, which would be quite important of all the things that can reduce consumption particularly in the illiterate population or those that don’t know about the risks. Taxes are highly effective. We have seen that worldwide, there is pretty good evidence of tobacco taxation would be the thing to do in India if it’s doable.
DR. MARK DOLAN HILL:
Is there a type of lobbing effort by the companies that make these cigarettes and bidis to squash your media?
DR. PRABHAT JHA:
Oh yeah, sure, and I walked into an interview on national TV, which I didn’t know that there was going to be a representative of the tobacco industry and so he was just squashing the signs, but he was doing nothing differently than the US tobacco industry had done a few decades ago in the US, right they were saying this is all junk signs and so forth. So, we had a vigorous exchange and I asked the newsperson that was chairing this debate that we few are talking about malaria why would you ever invite a mosquito to say that they don’t spread malaria, it’s the same with the tobacco industry they did spread smoking and obviously they are going to junk the signs, but that’s been their strategy all along people shouldn’t be fooled, so.
DR. MARK DOLAN HILL:
How influential are these lobbing groups in India as compared to the United States:
DR. PRABHAT JHA:
They are relatively more influential because they have the public demand for tobacco, which is considerable in the US. Now, it is not is present yet in India, but they are relatively more influential. But I would submit that it’s just a matter of time before they are on a downward track as the US industry well. They just will have to adapt to public demand for getting better tobacco control. It’s just a matter of time, but the aim of our research is obviously to try to accelerate that. There is no reason India needs to wait 3 decades to figure out what to do about tobacco and if it did the things that Toronto or Massachusetts or California or other places are doing in 5 years, it could dramatically reduce the tobacco deaths that are projected and particularly if it got current smokers to quit, it could dramatically improve health.
DR. MARK DOLAN HILL:
Final question about cost. I remember when I was a little boy and my parents would buy cigarettes for 25 cents of pack and I don’t know exactly what they cost now in United States, but they certainly are very expensive. The cost of cigarettes or bidis in India, how do you they compare to the amount of money the average person in India makes? Is this considered a luxury? Is it really inexpensive to them?
DR. PRABHAT JHA:
Bidis are really inexpensive. You can get them for pennies and remember Indians, on average have gotten richer. Bidis and cigarettes are much more affordable than they were before because incomes have gone up. They were cheap to start with, but they are becoming even more affordable. So, this of concern, contrast that to place like New York where tobacco taxes have been raised significantly and now to get a pack of cigarettes, it costs about 8 dollars or so, which is significant. In India still they are quite affordable and the tax rates are much, much lower than they are in places like New York or in Canada or in Sweden and other places.
DR. MARK DOLAN HILL:
India certainly is a country of many religious people. Does religion play a role in smoking?
DR. PRABHAT JHA:
No it didn’t. The risks are comparable in Hindus and Muslims and in other religious groups. In fact, it doesn’t matter who smokes, rural or urban or the like, but it does matter what is smoked. We found higher risks for those that smoked cigarettes versus bidis, but clearly bidis also significantly increased risk.
DR. MARK DOLAN HILL:
Finally, considering the alarming statistics that you mentioned in your study, are the hospitals and actually the entire healthcare system in India equipped to deal with this rising rate of smoking-related illnesses and smoking-related mortality?
DR. PRABHAT JHA:
Well that’s a big question is that you know there hospitals are already being flooded with people dying with heart attack and there is a big tuberculosis burden and cancer burdens are also showing up. So that’s bound to happen as the population ages, but here you have a man made epidemic that is basically doubling the risk of death from those conditions in middle age or if it were the case that people were dying in old age than they would have died of something else anyway, then we would perhaps have less crible with it, but this is 70% of the smoking deaths occur in middle age, ages 30 to 69. So this is going to be an enormous drain certainly on families thinking about a million people dying. These aren’t just statistics, these are real people that are dying from preventable causes, but it’s also going to have a big impact on the annual expenditures by governments. Now, they have got to look after the poor. However, they show up in the hospitals.
DR. MARK DOLAN HILL:
Are preparations are being made for this?
DR. PRABHAT JHA:
Not really. You know, the best preparation would be to try to get adult smokers to quit. So, they have less occurrence of disease and therefore, need for clinical treatment, but there is no real preparation in terms of dealing with this at the hospital level.
I want to thank our guest, Dr. Prabhat Jha. We have been discussing influences on soaring smoking-related mortality rates in India.
I am Dr. Mark Nolan Hill and you have been listening to the Clinician's Roundtable on ReachMD, the Channel for Medical Professionals. Be sure to visit our web site at www.reachmd.com now featuring on-demand pod casts of our entire library. For comments and questions, please send your e-mail to xm@reachmd.com and thank you for listening.
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Dr. Prabhat Jha, professor of health and development, and founding director of the Centre for Global Health Research at the University of Toronto, details his extensive findings, published in the New England Journal of Medicine, on the current smoking epidemic in India with host Dr. Mark Nolan Hill. Is India's hospital and healthcare system equipped to deal with the breadth of smoking-related illnesses? Dr. Jha also talks about the efforts of India's tobacco industry to squash his scientific data, and explains how the Indian government can resist the push of tobacco industry lobbyists.
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