Alternate Forms of Tobacco Use

1. Alternate Forms of Tobacco Use Monika Arora Director HRIDAY-SHAN

2. Tobacco Use Practices • Many kinds of tobacco are grown in the world, with a variety of uses. • In developed countries, cigarette smoking accounts for most of the tobacco use. • In South East Asian countries other forms of smoking and smokeless tobacco is commonly used. • Types of Tobacco Products used in SEAR countries: • Smoked Forms: Regular cigarettes, Kreteks, klobots, cherrots, beedis and cigars, kakkad/chillum/sulfa/hookli (smoking in clay pipes), hukka (hubble- bubble) and hand rolled tobacco. • Smokeless Forms: Pan Masala with tobacco, gutkha, khaini, chewing tobacco with areca nuts.

3. Tobacco Use in India: Practices and Prevalence • India has myriad varieties of tobacco use (smoking, inhaling and chewing forms). • Only about 14% of total tobacco consumption is in the form of cigarettes in India. • Beedis account for the largest proportion of tobacco consumption in India (about 40%).

4. Tobacco Toll in India • 700, 000 deaths per year due to smoking • 800, 000 to 900, 000 per year due to all forms of tobacco use/ exposure • Fastest trajectory of rise in tobacco related deaths forecast for the next 20 years • Many of the deaths (>50%) occur below 70 years of age

5. Types of Tobacco • Smoking Tobacco • Smokeless Tobacco • Oral Use (through the mouth) • Nasal Use (through the nose)

6. Alternative Forms of Smoking Tobacco • CHEROOT • A cheroot is a roll made from tobacco leaves. • KRETEKS • Indigenous cheroots containing tobacco, cloves and cocoa. • They contain a wide range of exotic flavourings which has an anaesthetising effect. • Kreteks are used commonly in Indonesia. • CHUTTAS • Chuttas are coarsely prepared cheroots. • Nearly 9% of the tobacco produced in India is used for making chuttas. • 300 million pieces produced every year in India • Chutta smoking is widespread in the coastal areas of Andhra Pradesh, Tamil Nadu and Orissa. • REVERSE CHUTTA SMOKING • Term describes smoking while keeping the glowing end of the tobacco product inside the mouth. • Practiced extensively by women in rural areas of India like Vishakhapatnam and Srikakulam district of Andhra Pradesh.

7. Alternative Forms of Smoking Tobacco • DHUMTI • Dhumti is a kind of a conical cigar made by rolling tobacco leaf in the leaf of another plant. • It may be occasionally smoked with the lighted end inside the mouth (Reverse Dhumti Smoking). • It is used in parts of India like Goa. • BEEDI • A beedi is an indigenous cigarette in which tobacco is wrapped in a tendu or temburini leaf and tied with cotton thread at one end. • They are potent because they do not have a filter and are wrapped in nonporous leaves. • The tar and carbon monoxide content is higher than a regular cigarette • Popular in Bangladesh, Pakistan, Afghanistan, Sri Lanka, Cambodia and India because of its low price as compared to cigarettes. Beedis are becoming popular outside of South East Asia, where they have been marketed in a variety of flavours (cherry, chocolate etc.) • About 40% of the tobacco produced in India is used for making beedis. • Beedi smokers run the risk of developing oral cancers, lung cancers and other health problems.

8. Smoking Tobacco • HUKKA (Hubble- Bubble) • It is a traditional Middle Eastern or Asian device for smoking and considered smoother and more flavourful as compared to other methods of smoking tobacco . • The tobacco is burnt directly by a piece of charcoal and the smoke passes through the water before being inhaled through a long tube or pipe attached to the bottle. • HOOKLIS • Hooklis are clay pipes commonly used in western India. • CHILLUM • Chillum is a straight, conical pipe traditionally made from fired clay, 10-14 cm long and held vertically. • Chillum smoking is a very social form of smoking and is an exclusively male practice. It is limited to the northern states of India, predominantly in rural areas. • Chillum probably predates the introduction of tobacco to India and was used for smoking opium and other narcotics.

9. Health Effects of Tobacco Smoking • Relative Risk for all-cause mortality for ever-smokers compared to never-smokers was 1.6 in men and 1.3 in women. • Prevalence of Tuberculosis (TB) is about 3 times as great among ever-smokers as among never smokers. Gupta PC, et al. Cohort Studies, Cohort study for tobacco attributable mortality in Mumbai, 2002. • Follow-up of a Mumbai cohort of 55000 people showed that all-cause mortality relative risks for cigarettes use was 1.4 and 1.8 for beedi users. Gupta P.C., World Health Organization Bulletin, 2000

10. Smokeless Tobacco • Smokeless tobacco is used to describe tobacco that is consumed without heating or burning at the time of use. • Smokeless tobacco can be used either orally or nasally. • In South East Asia, smokeless tobacco product are commonly handmade but commercial products are also available and widely marketed. The oral use of smokeless tobacco is widely prevalent in India. • Different methods of consumption include: chewing, sucking and applying tobacco preparations to the teeth and gums.

11. Smokeless Tobacco Products ORAL: CHEWING TOBACCO • GUTKHA • Gutkha is a tobacco product industrially manufactured and used mainly in India. • It is used by constantly chewing without letting the juice go in and subsequently spitting the juice and contains sweeteners and flavourings. • PAN (Betel Quid) WITH TOBACCO • It is common and specific to India. • Consists of 4 main ingredients: betel leaf (Piper betle), areca nut (Areca catechu), slaked lime [Ca(OH2)] and catechu (Acacia catechu).

12. Smokeless Tobacco Products • PAN MASALA WITH TOBACCO • Pan masala is a commercial preparation containing areca nut, slaked lime, catechu and condiments with or without powdered tobacco • Pan masala is very popular in urban areas and is fast becoming popular in rural areas • TOBACCO WATER • Tobacco water is used as a beverage and manufactured by passing tobacco smoke through water. • Traditionally, tobacco water was offered to guests/visitors both at family and social level and was considered very rude to omit this greeting.

13. Smokeless Tobacco Products • SUCKING TOBACCO • KHAINI (Tobacco and Slaked Lime) • It is a mixture of sun-dried tobacco and slaked lime and is widespread in Maharashtra and several states of north India. • A small quantity of tobacco is taken in the palm and a little slaked lime is added. The ingredients are mixed vigorously with the thumb and placed in the mouth.

14. Smokeless Tobacco Products TOBACCO PRODUCTS FOR APPLICATION In India, there is a widespread misconception that tobacco has beneficial effect on dental hygiene. • MISHRI • Mishri is a roasted, powdered preparation made by baking tobacco on a hot metal plate until it is uniformly black. • This practice is common in India (prevalent in Goa and Maharastra) • CREAMY SNUFF • Creamy snuff is a tobacco paste, consisting of tobacco, clove oil, glycerin, spearmint, menthol, camphor and sold in a toothpaste tube. • They are advertised as possessing anti-bacterial property. • GUL • Gul is a pyrolysed tobacco product. • It is marketed under different brand names in small tin cans and used as a dentifrice in the eastern part of India. • GUDHAKU • Popularly known as “DantManjan” made of tobacco and molasses. • It is available commercially but can be made by users themselves. • Commonly used in states of India like Bihar, Orissa, Uttar Pradesh and Uttaranchal.

15. Health Consequences of Tobacco Chewing • Relationship between oral cancer and tobacco use (chewing of pan with tobacco) has been reported since the early twentieth century. • Case control studies conducted on tobacco and oral cancer in India have shown that chewing of tobacco tended to have a higher risk for oral cancer than smoking. • In a study in the three centres of Bangalore, Chennai and Thiruvanthapuram • women who chewed pan-tobacco, has a 46 times higher risk than those women who had never chewed it (RR = 45.9) • Men in this study had a 6 fold greater risk of oral cancer if they were pan-tobacco users than never users (risk adjusted for smoking) Balaram P, et al. International Journal of Cancer, 2002

16. Indian Tobacco Industry: Employment & Policy Issues Employment Structure: Indian Tobacco Industry • Production of beedis dominates employment opportunities within the manufacturing sector of the domestic industry. • Vast majority of employment position are available either on a part time or a seasonal basis. • Full time employment: Leaf processing, cigarette manufacturing, distribution and retailing. • Beedi manufacturing employs about 72% of the total tobacco industry employment as compared to cigarettes (1%)and other products (1%).

17. Beedi Sector in India • Beedi making is a highly labour intensive activity, dominated by home workers and involves much less sophisticated manufacturing techniques. • It is predominantly unorganized sector and involves 3 major categories of workers: • forest based tribal workers (who collect tendu leaves) • tobacco growing farmers • beedi rolling home based workers (women and girls) • Beedi Manufacturing: Largest tobacco industry in India. • beedis sold (1998): 858 billion • projection for 2007:1031 billion. http://tobaccofreekids.org/campaign/global/casestudies • Beedi industry engages about 4.4 million workers. (two-thirds home based women and 1 % children).

18. Exploitation in the Beedi Industry India’s 1.5 million private sector beedi workers are among the most exploited workers in India. • They belong to underprivileged sector of society, are illiterate and poor. • The beedi workers work under the control of the contractors. • They are subject to low wages and fraudulent exactions. • Beedi workers across India work in filthy, disease-causing conditions. • It is a health hazardous industry. • Children are introduced when they are 5-8 years of ages.

19. Federal Excise Revenue in India • Excise is imposed on the basis of a fixed amount per 1000 sticks for each of the six categories with highest rate of excise applied to the longest high quality filter tip cigarettes. • Excise structure for other tobacco products varies from zero excise on cigars to a 50% excise duty on snuff and chewing tobacco through to a 300% excise duty on smoking tobacco. • Unorganized tobacco sector (beedis and chewing tobacco) receives a preferential treatment through the imposition of lower excise. • Beedi manufacturing units producing less than 20 lakh beedis per annum are relieved from paying taxes.

20. Legislations related to beedi in India The government of India has enacted a number of legislative measures to regulate the working and living conditions of workers and their families involved in the beedi industry. The legislative measures related to beedis can be categorized as: • Policies related to protection of consumer • Policies related to welfare of labour • Policies related to fiscal aspects

21. Policies Related to Protection of Consumers • The Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003. • Advertising restrictions on beedis: Indian Tobacco Control Act, 2003 • Consumer Protection Act, 1986. • The Standards of Weights and Measures ACT, 1976 and The Standards of Weights and Measures (Packaged Commodities) Rules, 1977.

22. Indian Law- At a Glance Key Provision of cigarettes and other tobacco product Act, 2003 • Ban on smoking in public places • Ban on direct and indirect advertising of tobacco products • Point-of-sale advertising is permitted • Ban on sales to minors • Tobacco products cannot be sold to children <18 years • Tobacco products cannot be sold within a radius of 100 yards of educational institutions • Pictorial health warnings • English and one or more other Indian languages to be used for health warnings on tobacco packs • Testing and Regulation: Ingredients to be declared on tobacco product packages (Tar and Nicotine)

23. Proposed Indian Health Warning on Beedi Pack

24. Policies Related to Protection of Labour Several legislations have been enacted to protect the beedi workers as they belong to the vulnerable section of society and work in adverse work and health conditions • Bonded labour system (Abolition) Act, 1976: aims to abolish the bonded labour system to protect children and other workers to become forced labour in case of inability to repay a loan. • The child labour (Prohibition and Regulation) Act, 1986: aims to stop the exploitation of children involved in beedi rolling. • Minimum Wages Act, 1948: aims to fix minimum rates of wages in industry and trade where labour organizations are non-existent or ineffective. • The beedi and cigar workers (Condition of Employment) Act, 1966: aims to regulate the conditions of service of the beedi workers. • Beedi workers welfare fund Act, 1976: aims to provide for welfare schemes for the beedi workers and their families, related to health, education, maternity benefits, group insurance, recreation, housing assistance etc. • The beedi workers welfare cess (Amendment) Act, 1976: aims to improve living conditions and provide welfare measures to beedi workers. This cess collected by way of excise duty on manufactured beedis contributes to BWWF.

25. Policies Related to Fiscal Measures • Recently cess is levied on cigarettes, pan masala and tobacco products to fund the health sector. • It increased the specific rate on cigarettes by 10% and imposed a surcharge of 10% on ad valorem duties on other tobacco products including gutkha, chewing tobacco, snuff and pan masala. • Beedis have been exempted from this levy.

26. Implementation : Barriers to be Overcome • Untrained and uncoordinated enforcement machinery • Inadequately educated community • Lack of awareness of rules among relevant group (e.g., restaurant managers) • Tobacco industry tactics

27. Other Measures that need to be Taken to Strengthen Tobacco Control • Tax Net to be Uniform • Current financial budget (2005-06) increased rate of excise tax on cigarettes by about 10% and a surcharge of 10% ad valorem duties on oral tobacco products (gutkha, chewing tobacco, snuff and pan masala). • Beedis need to be brought under similar tax regime to avoid cost influenced product choice by youth and poor. • Ban on Gutkha by Centre • State governments requested the Centre to impose such a ban (as per Supreme Court judgement). Under consideration of the Centre.

28. FCTC Implementation in India • The Indian Act enactment preceded the adoption and enforcement of the FCTC • Indian Legislation needs to be upscaled to comply with the provisions of FCTC • Tax and price measures to be implemented to reduce tobacco consumption • Duty free sales to be tackled by Ministry of Finance • Prohibiting use of misleading terms to label tobacco products • Mobilize stakeholders, engage civil society to promote and strengthen education, communication, training and public awareness on tobacco control issues • Promote effective measure for tobacco use cessation • Elimination of all forms of illicit trade in tobacco products including smuggling, illicit manufacturing and counterfeiting • Sale to and by minors • Curb cross-border advertising • Promote economically viable alternatives for tobacco workers, growers and individual sellers (as appropriate)