Despite the decline in smoking among adolescents around the world, the overall rate of tobacco use among this age group has increased. Lung cancer is the leading form of cancer worldwide and is caused mainly due to smoking. In South Asia, though, where 22 per cent of tobacco smokers and 81 per cent of smokeless tobacco users reside, oral cancer is the leading cause of all cancer-related deaths, mainly due to the use of SLT.
According to the Global Adult Tobacco Survey India, 2016-17, 29 per cent of Indians aged 15 years and above — nearly 267 million people — are tobacco users. The most popular SLT products in India are paan masala (areca nut with tobacco and spices), gutka (mixture of tobacco, areca nut, and lime), khaini (tobacco and lime) and zarda.
Moreover, research indicates that the proportion of youth initiating tobacco use before the age of 15 years has increased over time in Bangladesh, India, and Pakistan. The rise in SLT consumption is becoming a major cause of concern in India, with even 10-year-olds initiating tobacco use. According to a 2021 study published in the National Library of Medicine, about 77 per cent of smokers and 75 per cent of smokeless tobacco users in India start before or at the age of 21 years. The Global Youth Tobacco Survey, Fact Sheet, India 2019 revealed that there is a significant number of young tobacco users in India, with 8.5 per cent of school students — 9.6 per cent of boys and 7.4 per cent of girls — currently using various tobacco products.
Also read: No gutkha, zarda, or khaini is ‘safe’. But here’s how their cancer-causing risk can be reduced
What isn’t working
Although various policy measures have reduced tobacco use in India in the last 15 years, the impact has been felt more among smokers than among users of SLT products. Project Mobilizing Youth for Tobacco-Related Initiatives in India (MYTRI) was able to reduce smoking among adolescents but unsuccessful in lowering SLT usage in the schools of Delhi and Chennai. The impact of Advancing Cessation of Tobacco In Vulnerable Indian Tobacco Consuming Youth (ACTIVITY), another cluster-based randomised controlled trial project conducted in 14 slum colonies in Delhi, on SLT consumption among adolescents was limited.
There are various reasons for the unabated use of SLT among Indian youth.
One, it is perceived as a less harmful product as compared to cigarettes. Health risk factors and addiction associated with SLT have often been misunderstood and neglected among young people. In high-income countries like Sweden and the United States, where smoking is the most prevalent form of tobacco use, SLT products like snus are sold as cigarette substitutes to reduce tobacco-related harm. Swedish snus is shown to have lower disease risks, but that does not hold true for the low-cost similar SLT products sold in India. Furthermore, the consumption of chewing tobacco is widely acceptable and deeply associated with family and cultural traditions, socialisation, and medicinal use in India.
Two, SLT products are marketed in a way that lures teenagers and young adults. Tobacco companies are now promoting their SLT products with full vigour — flavours like fruit, candy, and peppermint are added to mask the harshness and make the tobacco more palatable. Studies indicate that more than 70 per cent of young tobacco users in India prefer flavoured SLT products. According to the Centers for Disease Control and Prevention (CDC), United States, flavoured tobacco is more addictive than regular tobacco products, which increase the likelihood of developing long-term tobacco use and thereby the products become harder to quit. The use of flavoured paan masala, gutka, khaini, and zarda is on the rise among the Indian youth.
Three, low-cost SLT products are easily available. The SLT industry is highly fragmented and unorganised, as some products are commercially manufactured and the rest made in cottage industries and sold locally. The industry uses small packaging to lower the cost of the product and make it easily affordable. In retail stores, these products are strategically kept on countertops or next to candy displays. Such wide availability of these products at nooks and corners of roadside shops and misleading taglines in advertisements and promotions reduce the impact of health warnings. These factors are further compounded by low taxation policies in India. A 2021 study in the National Library of Medicine analysed pricing of tobacco products pre and post implementation of the Goods and Services Tax (GST). The result showed that out of the total 154 brands observed, about 33 per cent did not exhibit any increase in their price.
Finally, the tobacco industry continues to flout advertising bans in various ways despite the complete prohibition on direct and indirect marketing of tobacco products under the Cigarettes and Other Tobacco Products Act (COTPA) in 2003. Companies manufacturing commercial SLT products have started diversifying into non-tobacco products like paan masala, cardamom seeds, areca nut, dates, and mouth fresheners. The Trademarks Act allows the SLT industry to evade the law and advertise the same brand for non-tobacco items, so they carry the same brand name, image, and colour of established tobacco brands in violation of COPTA Section 5. One example is BABA varieties of chewing tobacco, BABA Supari (areca nut), and BABA Elaichi (cardamom seeds). Surrogate advertisements in print, digital, and outdoor media by Bollywood celebrities such as Akshay Kumar, Salman Khan, and Shah Rukh Khan, lure the youth into using tobacco.
In a nutshell, the easy availability of a variety of flavoured, cheap tobacco products, exposure to enticing product marketing, curiosity, susceptibility, and misperception about their reduced harms are the prime factors that promote SLT use among the Indian youth. Great diversity in composition and toxicity of SLT products make their regulation a challenge, especially in the context of weak enforcement of regulatory policies and aggressive marketing of SLT products by the tobacco industry.
What needs to be done?
In India, collaborative efforts between the government, health organisations, and educational institutions are crucial for the successful implementation of policies to control SLT use among adolescents. Community-based interventions that engage youth to create awareness about the health risks of SLT use, along with integrating national tobacco control programmes into existing school-based health projects are feasible and more efficacious. Banning flavoured tobacco products, encouraging visible pictorial health warnings on packages, and increasing the tobacco purchase age to 21 can discourage youth tobacco initiation. More intensive interventions, like increasing taxes, banning large media campaigns and introducing interventions to counter industry tactics and interference in policy are urgently needed to combat SLT use in the vulnerable youth population.
Alpana K Gupta is currently a research consultant, Centre for Health, Innovation and Policy (CHIP). Prof. Ravi Mehrotra, is the director of Indian Cancer Genome Atlas and
Founder of Centre for Health, Innovation and Policy. Views are personal.
(Edited by Humra Laeeq)