SHIVA

World No Tobacco Day- 31-05-2015Chikkodi: STOP ILLICIT TRADE OF TOBACCODr.Jagadish Nuchin .MD, MBA.District Surveillance Officer, Belagavi, Karnataka.1SHIVA

World No Tobacco Day is observed annually on 31 May to raise awareness around the world about the dangers of tobacco products, the single largest preventable cause of disability and death.

2IntroductionTobacco plant is native to North and South American continents and they knew its cultivation 8000 years ago.It was Christopher Columbus who landed in America in the year 1492 who brought this plant to European countries..Portuguese traders brought tobacco plants to India during 1600 through Goa and Indians started cultivating it.

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Deadly PlantThus, the tobacco use spread from Americas to rest of the world.In India, earlier it was restricted to Royal people but later in 17th century even common people started using it.Gradually tobacco got assimilated into the cultural rituals and social fabric due to presumed medicinal and actually addictive properties attributed to it.

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Tobacco in IndiaBritish East India company grew tobacco in India as cash crop and its use became widespread wherever British ruled. Cultivated tobacco in India Exported to Britain Re-imported cigarettes to India to earn revenue 5

Tobacco can be consumed in the forms of smoking, chewing, dipping or sniffing.Smoking tobacco and Smokeless tobacco7 Smoking tobacco -- use in IndiaSmoked forms of tobacco useBidisCigarette Cigars CherootsChuttas DhumtiPipe Hooklis Chillum Hookah.

8Smokeless tobaccoKnown as spit tobacco, chew, snuff, and dip, is a form of tobacco that has become popular, especially with athletes. Chewing on an average-size piece of chewing tobacco for 30 minutes can deliver as much nicotine as smoking three cigarettes.

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Smokeless forms of tobacco use- in India

Pan (betel quid) with tobacco, Pan Masala with tobacco

Tobacco, areca nut and slaked lime preparations, Manipuri tobacco, Mawa, Khaini, chewing tobacco, snus, gutkha

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Smokeless forms of tobacco use

Tobacco products for application: Nicotine patch, Mishri, Gul, Bajjar, Lal dantmanjan, Gudhaku, Creamy snuff, Tobacco water, Nicotine chewing gum.

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12World Tobacco Facts130 Crore people worldwide smoke.6,00,000 Crore cigarette sticks are smoked worldwide every year.Tobacco kills up to half of its users. Half the people that smoke today that is about 65 Crore people will eventually be killed by tobacco. Tobacco kills nearly 60 Lakh people each year. More than 54 lakh of those deaths are the result of direct tobacco use, while more than 6 lakh are the result of non-smokers being exposed to second-hand smoke.

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Unless urgent action is taken, the annual death toll could rise to more than one Crore by 2020 and 1.6 Crore by 2025.Nearly 80% of the world's 130 Crore smokers live in low- and middle-income countries.Tobacco is the second major cause of death in the world. Approximately one person dies every six seconds and 10 per minutedue to tobacco, accounting for one in 10 adult deaths.14Children who are engaged in tobacco related works are especially vulnerable to "green tobacco sickness", which is caused by the continuous absorption of nicotine through the skin from the handling of wet tobacco leaves.

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Tobacco caused 10 Crore deaths in the 20th century. If current trends continue, it may cause 100 Crore deaths in the 21st century.Tobacco use is linked to a large number of diseases and is the single most preventable cause of death in the world, according to the World Health Organization.Smoking kills more people each year than AIDS, fires, car accidents, murders, suicides, alcohol and other drugs combined.

16 Tobacco is responsible for one in four deaths in the United States. In some countries, it is even more in Turkey, nearly 40% of deaths among males are related to tobacco. The prevalence is decreasing in developed countries but increasing in developing countries.

Developed countries have reduced smoking by 10% while developing countries have increased by 60% after 1970.

17Smoking is increasing in the developing worldMale adult prevalence, 1995US 28 % (was 61% in 1939)East Asia 61 %Europe, Central Asia57 %Latin America, Caribb40 %South Asia41 % (cigs + bidis)Sub-Saharan Africa29 %

18South Asia half cigs, half bidisAll low and middles income countries 49%All high income countries 38% World 47%USA18 and overUK16 and overJapan15 and over81%196078%197070%019861%1990 54%200061%196055%197042%198031%1990 28%199852%196544%1970 38%197928%1990 26%1999Physicians who smokeSmoking prevalence among physicians2000 or latest available data selected countries percentageswomen13menAustraliaBangladeshBosnia and HerzegovinaChileChinaColombiaDenmarkIcelandIndiaMoroccoRepublic of KoreaRussian FederationSaudi ArabiaSpainSwedenSyrian Arab RepublicUK50552440126122212029032418018Indonesia141Lao Peoples Democratic Republic1435304116383237662468028Smoking trends percentage of male smokers 19602000 selected countriesSmoking among males aged 15 and overlatest available data40% 49%

Top tenhighest overall smoking rates of men and women combined60% and above30% 39%

50% 59%20% 29%

below 20%no dataSmoking prevalence for men50%49%47%44%48%54%47%52% GUINEA45%44%SAN CROATIA B-H YUGOSLAVIAITALY SLOVENIAREP. MOLDOVAUKRAINEESTONIA LATVIALITHUANIAALBANIAAUSTRIAFYR MACEDONIAHUNGARYBULGARIAROMANIAGREECEPOLANDBELARUSRUSSIAN FED.UNITED KINGDOMTUNISIATUNISIALIBYAN ARAB JAMAHIRIYAIRELANDDENMARKFRANCESPAIN PORTUGALGERMANYCZECHSWITZ.NETH. BELGIUMLUX.MOROCCOALGERIA ICELANDNORWAYFINLANDSWEDENREPUBLIC SLOVAKIAMALTAMARINOANDORRAA U S T R A L I A REP. KOREABARBADOS TRINIDAD & TOBAGOPALAUNAURUTUVALUTONGAST VINCENT & GRENADINESNICARAGUABAHAMASZIMBABWEUGANDATURKMENUZBEKISTANKYRGYZSTANARMGEOAZERHong KongSARSRI LANKACUBADOMINICAN REPUBLICPUERTO RICOBRUNEI DAR.M A L A Y S I A SAUDI ARABIAC H I N A MONGOLIA PDR VIETNAMCAMBODIALAOTHAILANDI N D I A BANGLADESHISL. REP. IRAN PAKISTANTURKEYSYRIANARAB REPUBLICIRAQCYPRUS LEBANONISRAELWEST BANK& GAZAJORBAHRAINQATAR UAEOMANKUWAITYEMENNEPALK A Z A K H S T A N U N I T E D S T A T E S O F A M E R I C A C A N A D A ALGERIACHADS U D A N NIGERIADEM. REP. CONGOE G Y P T MOROCCOSENEGALGAMBIACTE DIVOIREGHANANAMIBIASOUTH AFRICAMALAWIZAMBIAUNITED REP. TANZANIAKENYADJIBOUTISLGUATEMALAEL SALVADORMEXICOHAITIBOLIVIAPARAGUAYB R A Z I L VENEZUELACOLOMBIAHONDURASCOSTA RICAPANAMAECUADORPERUARGENTINAURUGUAYCHILEPHILIPPINESNEWZEALANDPAPUA NEW GUINEAI N D O N E S I A JAPANR U S S I A N F E D E R A T I O N GREENLANDMAURITIUSSEYCHELLESSINGAPOREMYANMARKIRIBATI TOKELAUSAMOANIUECOOKFIJIVANUATURWANDAMALDIVESSAO TOME& PRINCIPE2524feature on the landscape.Male Smoking global scenario

19RankingCountryNo. of Cigarettes per adult per year1Greece2,9242Serbia2,8223Bulgaria2,7864Russia2,4795Moldova2,4016Ukraine2,3607Slovenia2,2788Bosnia2,2669Belarus 2,15710Montenegro 2,13911Lebanon2,12512Czech 2,12513South Korea 1,95814Kazakhstan 1,93415Japan 1,93416Kuwait180017Spain175218Switzerland 174319China 171220Austria 165051USA102899Pakistan 468158India 98164Sudan 75165Somalia67170Afghanistan 69174Ghana44178Ethiopia42180Uganda 24184Solomon Islands18185Guinea920Indian Scenario700, 000 deaths per year due to smoking accounting for nearly 2200 deaths every day and 3 people every 2 minutes. 800, 000 to 900, 000 deaths per year due to all forms of tobacco use/exposure 4 lakh cases of cancer, 13 lakh cases of heart ailments, 80 to 90% of lung cancer cases due to smoking.Single most preventable cause of premature death

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Tobacco is used by the youth all over India with a wide range of variation among states.Two in every ten boys and one in every ten girls use a tobacco product.Initiation to tobacco products before the age of 15 years is increasing.Tobacco Use Among Youth in India22

There are currently about 24 Crore tobacco users aged 15 years and above (19.5 Crore male users and 4.5 Crore female users) in India. India is the worlds third largest producer of tobacco (Next to China and Brazil) and also the second largest consumer of unmanufactured tobacco. It is a second largest exporter of unmanufactured tobacco.

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Tobacco deaths are on the increase in India

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24Tobacco deaths tend to be grossly under estimated, because tobacco is not listed among the causes of death. Efforts in some countries to record tobacco use on death certificates, to be able to attribute deaths more accurately. Difficulty in making the estimates shown by the huge differences in the estimates made by WHO, Prakash Gupta (a distinguished Indian epidemiologist) and the Indian Council for Medical Research. WHO estimates look very conservative, and the national estimates show a substantial contribution from tobacco to Indian death (and disease) burden.Tobacco in IndiaIn late Nineteenth century Beedi industry grew in India Oldest Beedi manufacturing firm established in 1887 Introduction of Gutkha aggravated the problemBihar, Jharkhand, Chhattisgarh, Nagaland, Orissa, Tripura and Mizoram show more than 40% of the prevalence where as Karnataka 19%.

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Pattern of Consumption in India

54% Bidis, 19% Cigarette and 27% Pan Masala, Snuff, Chewing tobacco55,000 children start smoking in an year. Indians smoke 9000 Crore cigarettes an year. At an average Rs. 12 a cigarette, Rs. 1,08000 Crores goes up in smoke.

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According to Indian Council of Medical Research the cost of treating tobacco related diseases and cancers was Rs. 27760 Crores. Whereas the value of tobacco products sold nation wide is about 24,400 Crores. If this trend goes unchecked 13% of all deaths in India would be solely due to tobacco.27

Nicotine is highly addictiveNicotine --> release of serotonin, dopamine, norepinephrine

Neuro-adaptation

Each year, nearly 3.5 Crore people make a concerted effort to quit smoking. < 7% stay smoke-free for a year; most start smoking again within days.

28Strong physical and emotional reactions feelings of pleasure, relaxation, alertness etc

Takes 10-19 seconds for the nicotine to reach the brain and stimulate the release of hormones. Ammonia speeds this uptake, which is why its added to cigs. Rapid behavioral reinforcement enhances the addiction.Nicotine distributes extensively to other body tissues, and is released slowly.Half life of nicotine in the blood is 2-3 hours (takes that long for nicotine level to half). After a single use, nicotine remains in body 8-12 hours. With repeated smokes, nicotine levels accumulate over 6-8 hours, and then plateau. Overnight, they gradually fall, leaving smokers primed and ready for a huge effect from the first cig the next day.Neuro-adaption: brain develops more nicotine receptors, and so needs increasing amounts of nicotine to achieve the same effects. Constant amount of nicotine seems to give less and less of a rush. Brain gets used to nicotine, and needs it to function normally.Smoke-A DEADLY MIXTURECigarettes burn at 900 0 C 10000 CCigarette smoke contains over 4000 chemicals and 69 of these are known to cause cancer. Even if you don't smoke you can still get sick from these poisonous chemicals just by breathing in other people's smoke. The smoke contains: Tar,a black, sticky substance that contains many poisonous chemical such as:ammonia (found in floor and window cleaner), toluene(found in industrial solvents) andacetone(found in paint stripper and nail polish remover)Nicotine, the addictive drug in tobacco

29carbon monoxide,a poisonous gas that reduces the amount of oxygen taken up by a person's red blood cellshydrogen cyanide,the poison used in gas chambers during World War llmetals, includinglead,nickel,arsenic(white ant poison) andcadmium(used in car batteries)pesticidessuch asMethoprene(found in flea powder). Other chemicals such asBenzene(found in petrol) andNaphthalene(found in mothballs) are also in tobacco smoke.

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And even including radioactive polonium 210. These chemicals are absorbed into the blood, reaches every organ system in the body and are cancer causing, mutagenic and tumor causing.

31Are some cigarettes better?No such thing as a safe cigarette

light, low tar cigarettes are deceptive - Manipulation by maker- Compensation by smokers so actual yields not = FTC (machine) yield

32Nicotine content is very carefully calibrated nicotine is removed from tobacco, and then added back in carefully controlled amounts to maximize addiction. Ammonia added to speed the absorption of the nicotine. Cigs deliver constant amounts of nicotine.A cigarette is a highly engineered nicotine delivery device

FTC Federal Trade Commission did tests 1967-1985, since then the industry does the tests itself, to FTC standards. Method uses machines. Place cig into holder and light it, then 35 ml simulated puffs are taken via syringe over 2 seconds, once every minute, until cig reaches specific butt length. Smoke is collected and passed through a filter that allows particulate matter (tar and nicotine) to be collected. Gases that pass through the filter are collected and used to determine levels of carbon monoxide (and other things).

Ways to lower the FTC yields - longer filter (esp for tar), narrower cig, shorter cig, faster burn rate of the paper, dilute smoke with air vents, less tobacco.Could also reduce nicotine, but tests show that so called low yield cigs have more, not less nicotine.

Smokers: cover ventilation holes, draw longer, deeper puffs, and more often. Studies of actual intake of nicotine, tar and carbon monoxide etc measured in smokers show practically no correlation with machine yields.

Is a bottom limit: tar < 1 mg, nicotine