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Recent trends of tobacco use in India

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DOI: 10.1007/s10389-019-01091-3

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Journal of Public Health: From Theory to Practice
https://doi.org/10.1007/s10389-019-01091-3

REVIEW ARTICLE

Recent trends of tobacco use in India

Akshita Chhabra 1 & Showket Hussain 2 & Shazia Rashid 1

Received: 25 January 2019 / Accepted: 23 May 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Introduction Tobacco use is associated with adverse health effects and is the prime cause of deaths globally, accounting for more
than 7 million deaths annually. India is home to a substantial number of tobacco users, frequently characterized by people who are
consuming smoke and smokeless tobacco, the synergistic effect of which accounts for a significant number.
Aim This study aims to highlight and compare the recent trends in tobacco use in India and other countries based on the impact of
parameters such as age, sex, occupation, level of exposure to tobacco, and tobacco taxation laws. It also intends to indicate the
health hazards of tobacco use among men and women, explicitly highlighting its consequences on the reproductive health of
women.
Methods An organized literature review was executed using subject-specific research/review articles from the PubMed and NIH
databases. Complete information on tobacco use prevalence was obtained using the Global Adult Tobacco Survey (GATS) and
the Global Youth Tobacco Survey (GYTS) reports.
Results In recent years, tobacco users have been significantly reduced in response to modest tobacco control efforts in India, but
its use is still widespread among middle-aged adults, less educated individuals and people living in rural and tobacco-cultivating
areas of India.
Conclusions Lack of awareness among people belonging to poor socioeconomic strata of the society, societal influence, and poor
implementation of anti-tobacco laws could be the possible reasons for its widespread incidence. Hence, more rigorous anti-
tobacco campaigns and widespread implementation of anti-tobacco regulations are the need of the hour.

Keywords Tobacco . Smoking . Tobacco taxation . Health hazard . Socioeconomic status . Reproductive health

Introduction
Prevalence and practice of tobacco use have contributed to
severe health complications such as cancers, chronic obstruc-
tive pulmonary diseases (COPD), cardiovascular diseases,
poor reproductive outcomes, and many other health implica-
tions. The tobacco epidemic has engendered a colossal burden
* Shazia Rashid
shaziarashid123@gmail.com; srashid@amity.edu
Akshita Chhabra
akshitachhabra34@gmail.com
Showket Hussain
hussainshowket@gmail.com; shussain@icmr.org
1
Amity Institute of Biotechnology, Amity University Uttar Pradesh
(AUUP), Sector-125, Noida, Uttar Pradesh 201303, India
2
National Institute of Cancer Prevention and Research (NICPR), I-7,
Sec 39, Noida 20130, India
of illness and premature death across the globe. It is among the
most significant public health threat the world has ever faced,
killing more than 7 million individuals annually. More than 6
million lives have been attributed to direct tobacco use, while
around 0.89 million are the result of non-smokers being im-
perilled by second-hand smoke (SHS) (WHO 2018). Over the
ages, tobacco has established a firm hold in India, and its
prevalence is varied and disparate throughout the country.
Of the estimated 28.6% tobacco use in India, only 10.7% of
the total tobacco consumption is in the form of cigarettes and
bidis (tobacco enclosed in parched leaves of particular trees)
which are traditional alternatives to cigarettes, whereas 21.4%
is used in the form of smokeless tobacco products such as pan
(a blend of lime, bits of areca nut, and spices enclosed in betel
leaf), gutka/ pan masala (blend of pulverized lime and areca
nut) and mishri (used as toothpaste for scouring gums) (GATS
2017). Tobacco consumption patterns are influenced by the
demographic area, socioeconomic status, sociocultural, and
religious influences. India accounts for 12% of the tobacco
smokers in the world (267 million) and of the estimated 1

million tobacco-attributable deaths annually, smoking and ex-
posure to second-hand smoke kill about 0.93 million people
each year (IHMT 2016), while smokeless tobacco use kills an
additional 0.02 million individuals in India annually, account-
ing for 74% of the global burden of smokeless tobacco
(Siddiqi et al. 2015).
The catastrophic effects of tobacco consumption menacing
human lives cannot be ignored. Consequently, an urgent need
to curb the devastating repercussions of tobacco use and ad-
diction accentuates the need to review the recent trends in
tobacco use and the challenges faced by India to curb the
menace of tobacco use. Prevalence studies of tobacco use in
India have shown varied disparities between urban and rural
areas, age, gender, education, and other socio-demographic
variables across the country. The present investigation aims
to synthesize the accessible scientific knowledge on the prev-
alence of tobacco use in India, with the aim of assessing the
magnitude of this problem based on the impact of parameters
such as age, sex, occupation/work of the users, as well as on
the consumption levels/level of exposure to tobacco, smoke-
free laws, tobacco taxation, etc.; ascertaining the gaps in
knowledge, and reviewing various health hazards caused
due to tobacco use among men and women, highlighting its
consequences on the reproductive health of women.
The scheme used for the literature review included ascer-
taining all subject-specific research and review articles.
Complete information on the prevalence of tobacco use
among minors and adults aged 15 or above for 145 countries
was obtained from published Global Adult Tobacco Survey
(GATS), and Global Youth Tobacco Survey (GYTS) reports
of the World Health Organization (WHO). An organized
search was executed on various databases such as PubMed
and NIH and all recent research articles were given priority.
The incidence of tobacco use: worldwide
Tobacco smoking among adults aged 15 and above is highly
prevalent in countries of the European region followed by the
Western Pacific, South-East Asian, the Americas, and the
African and Eastern Mediterranean WHO regions respectively
(Fig. 1). Tobacco smoking among males is highest in the
Western Pacific region, followed by the European, Eastern
Mediterranean, and South-East Asia regions (especially in
countries like Indonesia, Jordan, Kiribati, Sierra Leone, and
Russia) and least in the African and Americas regions (notably
in Ethiopia, Ghana, and Panama). Nevertheless, among fe-
males, its prevalence is high in Europe followed by the
Americas and the Western- Pacific region of WHO respective-
ly (explicitly in countries such as Nauru, Kiribati, Serbia,
Chile, Croatia, Greece, Lebanon, and Bosnia Herzegovina)
and low in the African, South-East Asian and Eastern
Mediterranean regions of WHO, prominently in countries
J Public Health (Berl.): From Theory to Practice
such as Niger, Egypt, Lesotho, Azerbaijan, Sri-Lanka,
Ghana, Ethiopia, Bangladesh, Iran, Senegal, Barbados,
Cameroon, Benin, Oman, Nigeria, Vietnam, Uzbekistan,
Malaysia, Morocco, Armenia, Congo, China, and India,
where due to cultural and religious implications women are
less likely to use tobacco products (WHO 2016).
Traditionally, smokeless tobacco products are consumed as
a part of the culture in countries of South-East Asia, the
Eastern Mediterranean (mainly in Pakistan) and Western
Pacific (China, Cambodia, Malaysia, and Papua New
Guinea) regions of WHO respectively in order to express sol-
idarity and commensality amid individuals belonging to dif-
ferent classes and social groups (Niaz et al. 2017; WHO
2017). It is also widespread in migrant populations of UK,
South and East Africa, Australia, and North American re-
gions. Its prevalence is highest in the South-East Asia region
of WHO, accounting to about 90% of the overall tobacco
users of the world. Nearly 250 million individuals use smoke-
less tobacco in the South-East Asia region, extensively prac-
tised in Myanmar, India, Nepal, Bangladesh and Sri Lanka,
and less in Indonesia and Thailand (WHO 2013; Suliankatchi
et al. 2019).
Factors affecting tobacco consumption
in India
Age, exposure and gender-specific pattern of tobacco use:
Tobacco usage upsurges concomitantly with increasing
age. Its dependency is highest among individuals aged 45
and above, comparatively less among individuals from the
24–44 years age group, and least among individuals below
24 (Fig. 2a). The most susceptible age for the initiation of
tobacco use is late adolescence and early adulthood, i.e., 15–
24 years of age. GATS 2016–17 estimates have reported that
tobacco use among minors aged 15–17 has been reduced from
10% to 4% and the age at initiation of tobacco use has been
increased by about 1 year for both smoking (18.8 years) and
smokeless tobacco use (18.9 years).
India is home to 28.6% adult tobacco users, characterized
by 3.4% individuals (Fig. 2b) who are dual users of tobacco
(consuming both smoke and smokeless tobacco products).
GATS 2016–17 estimates in India revealed that approximately
42.4% of all men, 14.2% of all women, and nearly 4.0% of all
minors (aged 15–17) consumed tobacco in some form (GATS
2017). The incidence of smoking among men and women
varied significantly: 19% of all men and 2% of all women
smoke, while 29.6% of all men and 12.8% of all women use
smokeless tobacco products (Fig. 2b and c). The facts and
figures from the GATS estimate signified that a larger popu-
lation of males consumed smoking/smokeless tobacco prod-
ucts as compared to females, and the incidence of smokeless
tobacco use is more widespread (chiefly in the form of khaini,
J Public Health (Berl.): From Theory to Practice
Fig. 1 (a) Age-standardized prevalence of tobacco smoking among individuals aged 15 and above (%) WHO, 2015. (b) Prevalence of tobacco smoking
among males (%), WHO 2015. (c) Prevalence of tobacco smoking among females (%), WHO 2015
gutka, and betel quid, Fig. 2d) as compared to smoking tobac-
co among Indian adults (especially among women, Fig. 2c).
The prevalence of both chewing and smoking forms of tobac-
co (mostly bidi in place of cigarette) was significantly higher
in rural, poor, and uneducated population, while cigarettes
were commonly preferred among people living in urban re-
gions. Early instigation of tobacco use widens the possibility
for subsequent polydrug abuse, school absenteeism, and re-
duced psychological and social development.
Social, cultural, and demographic correlates
of tobacco consumption
Tobacco consumption is strongly implanted in Indian culture.
Tobacco usage is related to the social-status and socio-cultural
codes of behaviour. In order to express harmony and
commensality within people from diverse castes and social
groups in rural India, hookah and other tobacco products are
still offered to elders and are shared among the different mem-
bers of the clan. Formerly regarded to be a stigma in Indian
patriarchal culture, smoking among women has been volun-
tarily adopted as a symbol of liberation, individuality, and
modernity. Smoking is booming among young people due to
declining constraints of strict and orthodox Indian traditional
behavioural diktat. Consequently, clandestine experimenta-
tion, uncontrollable predilection, peer pressure, desire to look
grown-up, western cultural inflkuence, exposure to advertise-
ments in the media and community, influence of cinema, nic-
otine addiction, family influence, anxiety, depression, inability
to refuse, and various other socio-cultural and socio-
behavioural factors have been projected as the possible rea-
sons for the initiation of tobacco use among Indian young
people. Inspired by antiquity and rural customs, hookah bars
and lounges are expanding in the cosmopolitan cities, imply-
ing tacit acceptability of tobacco usage (Gaur 2017).
Tobacco usage patterns differ markedly in different states of
India. Estimates presented by the GATS 2016–17 surveys
showed that there is a high prevalence of tobacco use in
north-eastern states of India, namely Tripura, Mizoram,
Manipur, Assam, Meghalaya, Odisha, Arunachal Pradesh,

Fig. 2 (a) Age-standardized prevalence of tobacco use (%) GATS 2016–
17. (b) Incidence of tobacco use (%), GATS 2016–17. (c) Tobacco use
among adults in the Indian population (%), GATS 2016–17. (d)
West Bengal, Nagaland, and Chhattisgarh. (Fig. 3) however, it
is less prevalent in Goa, Puducherry, and Kerala. There is wide-
spread use of smokeless tobacco products in the states of
Tripura, Manipur, Odisha, Assam, Arunachal Pradesh,
Nagaland, Chhattisgarh, Jharkhand, Uttar Pradesh, Karnataka,
Gujarat, Bihar, and Maharashtra. Conversely, Tobacco smoking
is more likely to be preferred among Indian adults in the states
of Meghalaya, Jammu and Kashmir, Haryana, Uttarakhand,
Himachal Pradesh, and Andhra Pradesh (Fig. 4). In recent
years, India’s standing has mounted from the third-largest to
the second-largest tobacco-producing country in the world.
Tobacco is cultivated in 13 Indian states, namely Odisha,
Assam, Chhattisgarh, Uttar Pradesh, Madhya Pradesh,
Maharashtra, Bihar, Gujarat, Karnataka, Telangana, Tamil
Nadu, Andhra Pradesh, and West Bengal. The GATS 2016–
17 facts and figures indicated that there is a high incidence of
tobacco use in tobacco-cultivating states, showing its easy ac-
cess and availability for the people living around tobacco-
cultivating regions. This suggests that with the escalating to-
bacco industry, an increasing number of individuals are falling
prey to the Bdemerit good.^ Hence, there is an imperative need
to advocate more stringent anti-tobacco laws in tobacco culti-
vating states.
J Public Health (Berl.): From Theory to Practice
Consumption of various smokeless tobacco products among adults (%)
GATS 2016–17
Education, income, and occupation/work specific
pattern of tobacco-use
Education serves as the elite paradigm for the prediction of
smoking/smokeless tobacco prevalence. The GAT 2016–17
estimates indicated that in India, the practice of both chewing
and smoking tobacco products is significantly higher among
the rural population, especially among less educated, agricul-
tural and labour workers than among urban and more educated
populations both in men and women. Corsi et al. in 2014
through his study in rural Andhra Pradesh reported that uned-
ucated individuals were more likely to be tobacco smokers
than those with secondary/higher education, although ciga-
rette smoking was higher in men of high socioeconomic status
(SES) (Corsi et al. 2014). With increasing income, the odds of
smokeless/smoking tobacco use and the odds of smoking bidi
are higher among women and men respectively (Barik et al.
2016). Another study conducted in Gujarat by Kahar et al.
2016 reported that the prevalence of tobacco consumption in
rural Gujarat was lower among less educated individuals and
higher among older participants. Tobacco consumption also
varied by occupation; i.e., those who were self-employed and
employed for wages were more likely to use tobacco than
J Public Health (Berl.): From Theory to Practice
Fig. 3 Prevalence of smoking and smokeless tobacco use among different states of India, GATS 2016–17
those who were unemployed. Knowledge about the health
effects of tobacco lowered the odds of consumption by 30–
40% (Kahar et al. 2016). Several studies reported that the
prevalence of tobacco use is generally more among people
of older age; lower education and who are earning less income
(Berg et al. 2015; Prabhakar et al. 2012; Ruhil 2016). Palipudi
et al. (2014) investigated the prevalence of tobacco use among
different countries based on GATS estimates.
Exclusively smoking was more common in Indonesia and
Thailand and less common in Bangladesh and India. Dual use
of smoking and smokeless tobacco was found in Bangladesh
and India, but was negligible in Indonesia and Thailand.
Gender, age, education, and wealth have significant effects
on the odds ratios for most forms of tobacco use across all
four countries, with the exceptions of smokeless tobacco use
in Indonesia and dual-use both in Indonesia and Thailand. In
general, the different forms of tobacco use increased among
males and with increasing age; and decreased with higher
education and socioeconomic status (Palipudi et al. 2014). A
recent study in 2018 accessed the socioeconomic differences
of smoking in Jordan, Lebanon, Syria, and Palestine. It was
observed that the prevalence of cigarette smoking among
Arab men is high in Syria, Palestine, Jordan, and in Lebanon
compared to women. Cigarette smoking showed the expected
patterns of inequalities by education among men in Syria,
Palestine, and Lebanon, and among women in Jordan and
Lebanon. However, there was no clear-cut association found
between wealth and cigarette smoking as in few cases ciga-
rette smoking was higher among the wealthiest (Abdulrahim
and Jawad 2018). A similar kind of study conducted in 2018
reported that among Chinese people aged 45 years or older,
the influence of income on smoking behaviours was small and
even insignificant; occupation and education levels were sig-
nificantly associated with smoking behaviours (Wang et al.
2018). Individuals with higher educational attainment were
less likely to be associated with smoking behaviours. In addi-
tion, gender and urban–rural differences existed in the rela-
tionship between socio-economic and smoking behaviours.
Exposure to secondhand smoke (SHS) and its health
risks
SHS, the tobacco smoke generated by active smokers, remains
a widespread health hazard worldwide. SHS causes serious
cardiovascular and respiratory diseases in adults, including
coronary heart disease, leukaemia, lymphoma, lung cancer.
Noxious chemicals present in tobacco smoke can increase
the risk of breast cancer in women and brain tumours in

Fig. 4 Prevalence of tobacco use
among different states of India,
GATS 2016–17
children. Infants exposed to SHS are at an alarming risk of
sudden infant death syndrome, ear infections, cold, pneumo-
nia, bronchitis, more severe asthma, and slow lung growth.
Almost 50% of children regularly breathe air polluted by to-
bacco smoke in public places. WHO reported that SHS expo-
sure caused more than 0.603 million deaths in 2004, corre-
sponding to 1.0% of the worldwide mortality (Öberg et al.
2011); in addition, increasing evidence suggests that SHS also
affects smokers (Lai et al. 2011; Lam et al. 2005). In 2004,
SHS accounted for 28% of the deaths among children (WHO
2018). In India, the GATS 2009–2010 estimates revealed that
about 29.9% at the workplace and 29.0% in public places
were exposed to secondhand smoke. However, the GATS
2016–2017 estimates stated that about 30.2% of adults in the
workplace and 23.0% of adults in public places were exposed
to secondhand smoke.
Tobacco control and taxation
Tobacco taxation passed on to consumers as higher cigarette
prices has been considered as one of the most influential
population-based strategies for decreasing smoking and its
adverse health consequences (Jha and Chaloupka 2000;
Centers for Disease Control and Prevention (US) 2010;
Wardman and Khan 2005; Nikogosian 2010). A price rise of
10% on a pack of cigarettes would cut demand for cigarettes
J Public Health (Berl.): From Theory to Practice
by 4% for the general adult populace in high-income countries
(World Bank 1999). Tobacco taxation can help smokers who
wish to quit and decrease the overall tobacco usage burden.
Increased taxes have an additional positive outcome as they
cut the exposure of second-hand smoke to non-smokers
(Bader et al. 2011). In India, GATS 2016–17 reports revealed
that the average expenditure on the cigarette tripled and that
on bidi and smokeless tobacco doubled since GATS 2009.
This may be one of the reasons for the decline in the number
of tobacco users in India. Most studies found that raising cig-
arette prices through increased taxes is a highly effective mea-
sure for reducing smoking among young adults and individ-
uals of low socioeconomic status. The observations from a
study in 2016 by Vuolo et al., also reported that excise taxes
played a significant role in decreasing the number of smoking-
tobacco users in American population (Vuolo et al. 2016).
Role of anti-tobacco advertisements
in decreasing the tobacco burden
WHO has reported that bans on tobacco advertising, promo-
tion, and sponsorship can reduce tobacco usage by 7%, with
some countries achieving a decline in consumption of up to
16%. Hard-hitting anti-tobacco advertisements and graphics
pack warnings, especially those that include pictures have
resulted in the reduction in the number of children who begin
J Public Health (Berl.): From Theory to Practice
smoking and increased the number of smokers who quit
(WHO 2018). Graphic warnings have influenced smokers in
saving the health of non-smokers by smoking less inside the
home and avoiding smoking near children. Studies carried out
after use of pictorial package warnings in Brazil, Canada,
Singapore, and Thailand consistently showed that pictorial
warnings significantly increase people’s awareness of the ill-
effects of tobacco use. Mass-media campaigns can also reduce
tobacco consumption by influencing people to protect non-
smokers and convincing youths to stop using tobacco. In
India, the GATS 2009–10 estimates reported that 64.5% of
adults were aware of the advertising in general, of whom
25.6% noticed tobacco advertisement on radio/television/in-
ternet and 28.1% noticed tobacco advertisement on billboard/
wall/posters/public transport. An increase in awareness from
89% to 96% has also been reported among tobacco users.
GATS 2016–17 reports stated that about 61.9% of cigarette
smokers, 53.8% of bidi users, and 46.2% of smokeless tobac-
co users thought of quitting after noticing a warning label on
the tobacco package.
Tobacco use and its associated health risks
Over 7000 different chemicals are found in tobacco and to-
bacco smoke; more than 60 of them are understood to cause
cancer, and 250 are known to be harmful [Bonnie et al. 2015;
Office of the Surgeon General (US), Office on Smoking and
Health (US) 2004; Simet et al. 2010]. Numerous toxic sub-
stances such as polycyclic aromatic hydrocarbons (PAHs),
nitrosamines, polonium–210 (a radioactive element found in
tobacco fertilizer), acetaldehyde, aromatic amines, arsenic,
benzene, beryllium, cadmium, nickel, chromium, ethylene ox-
ide, formaldehyde, vinyl chloride, and various highly toxic
gases such as 1,3–butadiene, hydrogen cyanide, ammonia
and carbon monoxide (which coalesces with hemoglobin in
the blood and decreases its oxygen-carrying capacity). The
nicotine drug present inside the tobacco is highly addictive;
it is readily absorbed into the bloodstream through the tissues
of skin and lungs and travels to the brain within fractions of
seconds [Office on Smoking and Health (US) 2006]. The per-
nicious outcomes of elements present in tobacco include mu-
tagenicity, carcinogenicity, and genetic damage [National
Center for Chronic Disease Prevention and Health
Promotion (US) Office on Smoking and Health 2014].
Tobacco smoking influences practically every part of the
human body and leads to various chronic disorders that emerge
at older ages. A dose–response relationship is observed be-
tween the amount of tobacco product used and the development
of disorders (National Toxicology Program 2004). Tobacco
usage can cause cancer of the lung, larynx (voice box), mouth,
oesophagus, throat, bladder, kidney, liver, stomach, pancreas,
colon and rectum, and cervix, and acute myeloid leukaemia
(AML). Chronic lung and cardiovascular diseases such as
pneumonia, tuberculosis, poor lung compliance, exacerbated
asthma, heart stroke, aortic aneurysm (a balloon-like bulge in
an artery in the chest), COPD (chronic bronchitis and emphy-
sema) and other airway infections can also arise due to tobacco
smoking [Centers for Disease Control and Prevention (US),
National Center for Chronic Disease Prevention and Health
Promotion (US), Office on Smoking and Health (US) 2010].
Furthermore, disorders such as diabetes, osteoporosis, rheuma-
toid arthritis, age-related macular degeneration, and cataracts
are also associated with tobacco smoking. Tobacco usage can
also gravely impact reproductive health (e.g., reduce fertility in
women, erectile dysfunction in men), the digestive process,
vision, bone metabolism, dental hygiene, and also impair the
immune system (Austonie et al. 2005; Hecht 2003; Nash et al.
2017). People consuming smokeless tobacco (snuff or chewing
tobacco) are at an alarming risk to heart stroke, gum disease,
leukoplakia, oral lesions and cancers of the mouth, oesophagus,
and pancreas (IARC 2007).
Smoking and reproductive health of women
Tobacco smoking is associated with broad-spectrum health
effects on women. Hormonal imbalance is induced inside
the body as nicotine; an active component of tobacco alters
the hypothalamic-pituitary axis through its stimulation of
growth hormone, cortisol, vasopressin, and oxytocin release,
which in turn inhibits luteinizing hormone and prolactin re-
lease. Consequently, reduced fertility (Rogers 2009), the de-
creased likelihood of conception, increased frequency of men-
strual abnormalities, and reduced age of spontaneous meno-
pause in women are the outcomes reported due to tobacco
smoking/smokeless tobacco use (Weisberg 1985). Pregnancy
represents a crucial time of life for both the mother and the
developing fetus, and this critical time window extends into
the neonatal period and infancy. It is estimated that more than
0.4 million infants are exposed each year to maternal smoking
in utero. Exposure to tobacco smoke causes numerous chal-
lenging health effects on the mother and fetus, and also in-
creases the risk of experiencing confrontational pregnancy
outcomes and infant survival. It is known to increase pregnan-
cy complications such as the encounter of ectopic pregnan-
cies, premature rupture of the membranes, placenta previa,
placental abruption, preterm delivery, shortened gestation, im-
peded fetal growth, premature delivery of low birth weight,
congenital malformations, specifically orofacial clefts, sudden
infant death syndrome (SIDS), etc (Farber et al. 2015).
Subsequently, newborns imperilled by SHS as a result of ma-
ternal smoking experience several unfavourable health conse-
quences such as high oxidative stress in blood, augmented
lower respiratory illnesses, otitis media, middle-ear effusion,
decreased lung function, congenital heart defects (Merritt et al.

2013), limb abnormalities, central nervous malformations
such as hypoplasia, lack of vascularization, cystic formations,
and reactive gliosis (Lavezzi et al. 2012), and respiratory
symptoms such as coughing, phlegm, wheezing, and dyspnea.
Tobacco epidemic: challenges ahead
In spite of all the gargantuan efforts envisioned at winning the
war against tobacco, its use is still widespread among individ-
uals in India which can be due to lack of awareness (especially
among poor and less educated individuals), poor implementa-
tion of anti-tobacco norms (chiefly in tobacco cultivating re-
gions), and the exalted practice of tobacco use as a part of the
culture in certain social groups. Nonetheless, another major
challenge is that tobacco trade brings about a lot of economic
gains for the country, and tobacco control measures can neg-
atively affect the country’s economy by projecting huge em-
ployment loss. Hence, tobacco contributions towards the
country’s economy are often upheld in an argument against
tobacco control. Therefore, a multifaceted approach and strat-
egies for intervention (especially in rural areas where there is
high tobacco dependence) is the imperative need of the hour.
Possible measures for tobacco control
The tobacco menace can be countered and diminished through
various strategies which necessitate political will and
community-based societal commitment. A few feasible mea-
sures are; advocating more stringent anti-tobacco norms, ban
on tobacco smoking in all indoor public places, increases in
taxes on all tobacco products, effective monitoring of tobacco-
control policies (especially in tobacco cultivating states), a
reduction of the tobacco cultivation area, and compensation
of employment loss due to tobacco control policies by offering
employment opportunities to workers in other labor-intensive
services. Healthcare and awareness campaigns should be or-
ganized to make people aware of the health hazards of tobacco
use. There are certain myths existing in the Indian population,
particularly among rural Indians, that smokeless tobacco is
less harmful than bidis and cigarettes, and that tobacco use
can help in relieving anxiety, body pain, and swelling. These
myths must be eliminated from society through digital and
print media. Targeted approaches must be set in order to de-
crease the tobacco burden, counselling sessions must be orga-
nized especially in rural areas to make women aware of the ill-
effects of tobacco use on their reproductive health. Stringent
monitoring of tobacco control norms can be regulated by pro-
viding toll-free helpline numbers to people so that any com-
plaints regarding violation of the law is reported to the con-
cerned authorized department, which will also help in reduc-
ing the number of individuals imperilled to second-hand
J Public Health (Berl.): From Theory to Practice
smoke. Students in schools and colleges must be forewarned
about the health hazards associated with tobacco use, and
encouraged to keep their schools and campuses tobacco-free.
If these measures are successfully enforced and implemented
nationally and internationally, it can help in reducing the ill-
effects of tobacco use in society.
Conclusions
In India, the number of tobacco users has reduced by 8.1
million in 2017 compared to 2009 as reported by GATS sur-
veys, which could be due to the increase in awareness among
people through anti-tobacco campaigns and a two- to three-
fold increase in tobacco taxes implemented by the
Government of India. Despite the decrease in the prevalence
of tobacco use, it is still widespread among middle-aged
adults, illiterate people, and people living in rural areas in
India. This could be due to lack of awareness among people
who belong to poor socioeconomic strata of the society who
do not have access to the digital and print media and adver-
tisements, and poor implementation of anti-tobacco norms.
Excessive tobacco use has serious health implications, leading
to diseases such as cancer of oral cavity, lungs, colorectum,
and associated organs, as well as tuberculosis, diabetes, and
COPD, leading to poor quality of life and increased mortality.
Therefore, there is a need to design and implement innovative
strategies for spreading awareness of the hazards of tobacco
use among the economically poorer sections of the society and
the rural areas of the country. The adolescent and young adult
population who are vulnerable to falling prey to peer -pressure
should also be targeted for anti-tobacco programs, which
could be achieved by organizing awareness camps, display
of advertisements, counseling sessions, and hosting educa-
tional events in schools and colleges including engagement
of national and international brand ambassadors which may
help restrain tobacco usage at an early age. The government
should initiate widespread and efficient implementation of the
anti-tobacco strategies among various sections of people,
which could have a high impact on increasing tobacco cessa-
tion rates and reduce disease burden among the population.
This review provides the latest updates in tobacco smoking
trends, particularly in the Indian population, and could be
useful for academicians, clinicians, policymakers, and the
population at large, providing information about various as-
pects of tobacco use and its health hazards.
Author contributions A.C. and S.R. drafted the manuscript based on the
conceptual ideas of S.R. S.H. provided critical feedback and helped in
shaping the manuscript.
Funding This research received no specific grant from any funding agen-
cy in the public, commercial, or not-for-profit sectors.
J Public Health (Berl.): From Theory to Practice
Compliance with ethical standards
Conflict of interests The authors declare that there is no conflict of
interest in the publication.
Ethical approval and consent to participate This study does not include
any medical research performed on human participants by any of the
authors.
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