It is about the various legislative acts for tobacco control in India

1. Tobacco Cessation
Legislations in India
Dr. Priyanka Sharma
III year MDS
Department of Public Health Dentistry

2. CONTENTS
• Introduction
• History of Tobacco
• Types of tobacco used in India
• Tobacco in Indian economy
• Prevalence of Tobacco use
• Health effects of tobacco in India
• Origin of Tobacco control in India
• Battle for tobacco control in India
• Land mark events
• Indian Law & Various Acts
• Implementation challenges
• Suggested other measures need to be taken
• FCTC implementation
• Education Approach Strategy
• Conclusion
• References

3. INTRODUCTION
• Caffeine, nicotine and ethyl alcohol are the three most widely consumed
psychoactive agents in the world.
• Tobacco, particularly cigarette smoking, has long been recognized as a health
threat.
• The tobacco epidemic is one of the biggest public health threats the world has
ever faced, killed nearly 6 million people a year.
• Tobacco use is recognized as the single most preventable cause of premature
death worldwide.
• Upto half of the current users will die prematurely of a tobacco related
disease.
• If current trends continue, tobacco use may cause one billion deaths in 21st
century.
• Unchecked, tobacco related deaths will increase to more than 8 million deaths
per year by 2030.
• Tobacco induced oral diseases contributes significantly to the global oral
disease burden.

4. • Data reported by cancer patients aid association of India in 2004, reveals the
prevalence to be cigarettes (20%), bidis (40%) and the remaining 40% is
consumed as chewing tobacco, pan masala, snuff, gutkha, masheri and tobacco
toothpaste.
• There is a growing pattern of tobacco users in India.
• 16.6% of the smokers live in India. Sixty-five per cent of all men and 33% of all
women use tobacco in some form. 35% of men and 3% of women smoke.
• In India, in 1990, 1.5% of total deaths were tobacco related . Tobacco
consumption is growing at a rate of 2-3% per annum. By 2020, it is predicted that
it will account for 13% of all deaths in India.

5. HISTORY OF TOBACCO
Tobacco cultivation has a history of about 8000 years.
Europeans were introduced to tobacco when Columbus landed in
America in 1492.
Portuguese traders introduced tobacco in India during 1600.
Tobacco became a valuable commodity in barter trade and its use
spread rapidly.
Gradually tobacco got assimilated into the cultural rituals and
social fabric due to presumed medicinal and actually addictive
properties attributed to it.

6. Increase in tobacco production during British rule:
Introduced initially in India as a product to be smoked, tobacco
gradually began to be used in several other forms.
The entry of European colonial powers into India spurred the import of
tobacco into India.
Investment in production and export came later during the British rule.
The policies of strong governmental support for tobacco agriculture,
initiated during British colonial rule, have continued after Independence.

7. TYPES OF TOBACCO USE IN INDIA
Smoked forms of tobacco use
Bidis, Cigarettes, Cigars, Cheroots, Chuttas, Dhumti, Pipe, Hooklis,
Chillum, Hookah.
Smokeless forms of tobacco use
Paan (betel quid) with tobacco, Paan masala with tobacco
Tobacco, areca nut and slaked lime preparations, Mainpuri tobacco,
Mawa, Khaini, chewing tobacco, snus, gutkha
Tobacco products for application: Mishri, Gul, Bajjar, Lal dantmanjan,
Gudhaku, Creamy snuff, Tobacco water, Nicotine chewing gum.

8. CONSTITUENTS OF TOBACCO
CONSTITUENTS ADVERSE EFFECTS
Poly aromatic hydro carbon Carcinogenesis.
Nicotine Potential carcinogenic agent
Phenol Ganglionic stimulation
and depressions
Tumor promotion.
Benzopyrene Tumor promotion
Irritation
Carbon mono oxide Impaired oxygen transport and
repair.
Formaldehyde Toxicity to cilia and irritation.
Nitrosamine Potential carcinogenic agent.
8

9. Tobacco in Indian Economy
Tobacco cultivation has sustained despite social disapproval because
of domestic demand (beedi tobacco) and the international market
(flue-cured Virginia tobacco).
Tobacco plays a significant role in the Indian economy as it
contributes substantially in terms of excise revenue, export revenue
and employment.
India is the world’s second largest producer of tobacco and also the
second largest consumer of unmanufactured tobacco. It is a major
exporter of unmanufactured tobacco.
The total social costs of tobacco products exceed the direct outlay on
them, owing to morbidity, mortality and negative externalities
associated with the consumption of tobacco products.

10. Tobacco economy in the post-Independence period
Year
Area
(x1000 hectare)
Production
(million kg)
Excise revenue
(Rs in million)
Export
revenue
(Rs in million)
Tobacco
consumption
(million kg)
1950–1951
1960–1961
1970–1971
1980–1981
1990–1991
2000–2001
2001–2002
360
400
450
450
410
290
-
260
310
360
480
560
490
601
258
540
2284
7553
2,6957
8,1824
-
150
160
320
1400
2630
9034
8885
245
328
367
360
474
470
-
Source: Tobacco Board 2002; Directorate of Tobacco Development 1997

11. The costs inflicted by tobacco consumption extend much beyond the
direct users to cover secondary smokers as well as non-users, and are
spread over a period much beyond the period of actual consumption of
tobacco.
The recognition of the costs of tobacco has been obfuscated and made
opaque by the unethical tactics and practices of the tobacco lobbies.
Total cost entailed by three major tobacco-related diseases is estimated
to be about USD 7.2 billion for the year 2001-02.

12. Prevalence of Tobacco Use
Tobacco use prevalence : 51.3% males & 10.3% females (1995 -1996) and 46.5%
males and 13.8% females (1998 -1999)
National Sample Survey 52nd Round and National Family Health Survey-2
55.8% of males currently use tobacco (12 - 60 years of age)
National Household Survey of Drug and Alcohol Abuse, 2002
Tobacco use prevalence among males is higher compared to females and among
older age groups compared to the younger age groups. The scenario is shifting to
middle and younger age groups at present.
The prevalence of tobacco use is higher in rural population compared to that in
urban areas.
India has a huge problem of widespread smokeless tobacco use among women,
particularly among disadvantaged women.
The prevalence of tobacco use in pregnant women is similar to that in non-
pregnant women of the same age.

13. 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 10 years is
increasing.
There are currently about 240 million tobacco users aged 15
years and above (195 million male users and 45 million
female users) in India.
Tobacco Use Among Youth in India

14. Tobacco Toll in India
7,00, 000 deaths per year due to smoking
8,00, 000 to 9,00, 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

15. Health effects of tobacco in India
The relative risk for death due to tobacco use in cohort studies from
rural India is:
40%-80% higher for any type of tobacco use;
50%-60% higher for smoking;
90% higher for reverse smoking;
15% and 30% higher for tobacco chewing in men and women,
respectively;
40% higher for chewing and smoking combined.
Overall, smoking alone currently causes about 700,000 deaths per
year in India.

16. BEEDI SMOKING IS EVEN MORE
DANGEROUS
 Cohort of 52568 individuals (> 35 years); follow-up of 5-6 years
 Ratios of excess deaths in tobacco users
100 male non-smoker deaths : 139 male cigarette smoker deaths
100 male non-smoker deaths : 178 male beedi smoker deaths
100 female non-tobacco user deaths : 135 female oral tobacco user deaths
- Mumbai Cohort Study; Gupta et al, WHO Bulletin, 2000

17. Studies in India have shown that tobacco use in its
various forms is directly responsible for increase in
cardiovascular diseases, cancers of the oral cavity,
espohagus, pharynx etc, and chronic obstructive lung
disease, TB, poor reproductive health outcomes, oral
precancerous lesions and green tobacco sickness.
Tobacco Use and Related Diseases

18. TOBACCO AND TUBERCULOSIS
 Prevalence of TB is about 3 times as great among the ever-
smokers as among the never-smokers.
 The heavier the smoking, either cigarettes or bidis, the greater
the prevalence of TB among smokers.
 Mortality from TB is 3 to 4 times as great in ever-smokers as in
never-smokers.
 Smoking contributes to half the male deaths from TB in India
and a quarter of all male deaths in the middle age (25-69 years);
of these 200,000 deaths, half occur in men who are in 30’s, 40’s or
early 50’s.

19. Origin Of Tobacco Control Efforts In India
• India’s Journey from appreciating potential of tobacco production to
emerging as a leader in global tobacco control efforts:
 Increasing scientific evidence about mortality and morbidity
attributable to tobacco use provided impetus for legislative action in
India for tobacco control (Mid 1970s)
 Cigarettes (Regulation of Production, Supply and Distribution) Act,
1975
• Health Warning on Packages and Advertisements of Cigarettes :
“Cigarette Smoking is Injurious to Health”

20. Origin Of Tobacco Control Efforts In India
Tobacco Board Act of 1975 brought tobacco under a single Jurisdiction (The
Central Government)
Civil society groups, media and other agencies played a vital role in raising
public awareness of tobacco-related health issues (1980s and 1990s)
This led to:
- Civil litigation and favorable verdicts by courts
- Demands for tobacco control in Indian Parliament
- Increased pressure on government to impose restrictions
Resolutions of World Health Assembly in 1986 and 1990 urged member
states to impose stronger legislative measures to protect people from dangers
of tobacco
Regional and national consultations on “Tobacco or Health”, convened by
government of India (Ministry of Health) and WHO in 1991

21. Battle for Tobacco Control in India
- Activism and advocacy efforts by civil
society organization in India
- Strong role played by Indian judiciary
- Role of media in building positive
public opinion on tobacco control
- Commitment by the Government of
India (Ministry of Health and Family
Welfare) towards effective tobacco
control efforts
- Support of well informed
Parliamentarians and Policy-makers
- Tobacco industry’s continuous
resistance to strong tobacco control
laws or regulations
- Violation of regulations by the
industry (e.g. ad ban)
- Economic issues related to tobacco
production and tobacco control,
distorted by the industry.
- Over emphasizing employment issues
in connection with tobacco control
- Industry’s efforts to create fears of
adverse impact of tobacco control on
poor
Anti-Tobacco Influences Pro-Tobacco Influences

22. Land Mark Events
1975: Cigarettes (Regulation of Production, Supply and Distribution) Act
1980: Central and State Governments imposed restrictions on tobacco
trade and initiated efforts for comprehensive legislation for tobacco
control
1990: Central Government issued directive for prohibiting smoking in
public places, banned tobacco advertisements on National Radio
and T.V. channels, advised State Governments to discourage sale of
tobacco around educational institutions and mandated display of
statutory health warning on chewing tobacco products.
1991: Regional and National Consultations on “Tobacco or Health”
1991: Central Government directed the Central Board of Film Certification
to comply with the Cinematograph Act of 1952

23. 1995: The Parliamentary Committee on Subordinate legislation of the Tenth
Lok Sabha examined the rules framed under Cigarette (Regulation of
Production, Supply and Distribution) Act, 1975 and made specific
suggestions for stronger provisions to achieve better results in tobacco
control
1995: Expert Committee on the economics of tobacco use constituted by the
Central Ministry of Health.
1996: Delhi anti-smoking amd mom-smoker’s health protection act
1999: High Court of Kerala announced ban on smoking in public places
1999: Ministry of Railways banned sale of cigarettes and beedis on railway
platforms and in trains
2000: Central Government banned tobacco advertisements on cable television
2001: Supreme Court of India mandated a ban on smoking in public places.

24. 2001: Ministry of Railways imposed ban on sale of gutkha on railway station,
concourses, reservation centres and in trains
2001: The National Human Rights Commission of India (NHRC) convened a
South-East Asia Regional consultation on ‘Public Health and Human
Rights”, and advocated tobacco control as an essential measure to protect
human rights.
2001-2003: Ban on Gutkha production and sale of gutkha and paan masala
containing tobacco or not containing tobacco in states of Tamil Nadu,
Andhra Pradesh, Maharashtra, Madhya Pradesh, Bihar and Goa using the
provision of the Prevention of Food Adulteration Act.
2003: The Cigarettes and other Tobacco Products (Prohibition of Advertisement
and Regulation of Trade and Commerce, Production, Supply and
Distribution) Act, 2003

25. Indian Law- At a Glance
Key Provision of cigarettes and other tobacco product Act, 2003
 Ban on smoking in public places (including indoor workplaces)
 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 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)

26. Implementation of Indian Law
 Prohibition of smoking in public places
- mandates display of board containing the warning ”No Smoking Area- Smoking
Here is an Offence”
- Hotels & Restaurants should ensure:
•physical segregation of smoking and non-smoking areas
•these areas should be labeled as ”Smoking Area/Non-smoking Area”
•proper location of smoking and non-smoking areas
 Prohibition of advertisement of cigarettes and other tobacco products
- Point of sale advertisement not to exceed two boards
- This board should contain health warnings “Tobacco Kills or Tobacco Causes
Cancer”
 Prohibition of Sale to Minors
- Display board containing the warning “Sale of tobacco products to a person under
the age of 18 yrs is a punishable offence” to be put at point of sale
Rules Notified and Enforced from May 1, 2004

27. Rules notified and enforced from December 1, 2004
 Prohibition on Sale of Cigarettes and other Tobacco Products
around Educational Institutions
 Board outside the premises to be displayed stating that sale of
cigarettes and other tobacco products in an area within a radius of
100 yards of educational institution is strictly prohibited
 Distance of 100 yards shall be measured radically starting from the
outer limit of boundary wall or fence of the institution.

28. • Revised Smoke-free Rules came into effect from 2 nd October, 2008.
• The ban on smoking in public places, which included work places
also, was a remarkable achievement in terms of political will and
national commitment. Subsequently the law pertaining to pictorial
warnings on tobacco products packages was implemented with
effect from 31 st May 2009. After getting positive and supportive
judgments in other court cases, the Government was forthcoming
in notifying laws pertaining to ban on sale to and by minors and
sale of tobacco products within 100 yards of educational
institutions.

29. Proposed Indian Health Warning on Gutkha Pack

30. Proposed Indian Health Warning on
Cigarette Pack

31. National Tobacco Control Programme
As the implementation of various provisions under COTPA lies mainly with the
State Governments, effective enforcement of tobacco control law remains a big
challenge.
To strengthen implementation of the tobacco control provisions under COTPA and
policies of tobacco control mandated under the WHO FCTC, the Government of the
India piloted National Tobacco Control Programme (NTCP) in 2007-2008.
This was a major leap forward for the tobacco control initiatives in the country as
for the first time dedicated funds were made available to implement tobacco
control strategies at the central state and substate levels.

32. • The main components of the NTCP were:
National level
Public awareness/mass media campaigns for awareness building and behavior change.
• Establishment of tobacco product testing laboratories, to build regulatory capacity, as
mandated under COTPA, 2003.
• Mainstreaming the program components as part of the health care delivery mechanism
under the National Rural Health Mission framework.
• Mainstream Research and Training on alternate crops and livelihoods in collaboration with
other nodal Ministries.
• Monitoring and Evaluation including surveillance e.g. Global Adult Tobacco Survey (GATS)
India.
State level
Tobacco control cells with dedicated manpower for effective implementation and monitoring
of anti tobacco laws and initiatives.

33. • District level
Training of health and social workers, SHGs, NGOs, school teachers etc.
• Local IEC activities.
• Setting up tobacco cessation facilities.
• School Programme.
• Monitoring tobacco control laws.

34. WHO Tobacco Free Initiative in India
• Setting up of Tobacco Cessation Clinics in India has been one of the major
highlights of WHO/Ministry of Health and Family Welfare collaborative
programme in the area of tobacco control.
• NGOs and community settings to help users to quit tobacco use. This network of
Tobacco Cessation Clinics was further expanded in 2005 to cover five new clinics in
Regional Cancer Centers (RCCs) in 5 states of which two centers were in the
North-Eastern States of Mizoram and Assam, having high prevalence of tobacco
use.

35. • The Tobacco Cessation Clinics were renamed as Tobacco Cessation Centres (TCCs) and
their role was expanded to include trainings on cessation and developing awareness
generation on tobacco cessation. In 2009, two new TCC's were set up in Rajasthan and
Delhi. A model for Workplace TCC was also set up in Nirman Bhawan in Delhi, where
the Ministry of Health and Family Welfare is housed.
• The role of TCCs was further expanded in 2009 and they were designated as 'Resource
Centre for Tobacco Control (RCTC)'. Besides providing tobacco cessation services,
these RCTCs helped in capacity building of other institutes to develop tobacco
cessation facilities. Many of them have developed outreach programs for the
community and are regularly doing awareness programs at schools, colleges, slums
and workplaces.
• The Indian Dental Association, a professional organization has also initiated Tobacco
Intervention Initiative (TII) to train the dental professionals in tobacco cessation and
help set up cessation clinics.

36. • With support from WHO, the following training and IEC material has been developed
for facilitating tobacco cessation in the country.
• National Guidelines for Treatment of Tobacco Dependence have also been developed
and disseminated by the Government in 2011, to facilitate training of health
professionals in tobacco cessation.

37. Other initiatives for tobacco control
• Advocacy for tobacco control - low awareness regarding the anti tobacco law and its
provisions at all levels of governance and policy making has been an important
impeding factor for effective implementation of tobacco control policies.
• The Government of India organized a series of advocacy workshops in the country
with the following objectives:
Sensitization and awareness building of policy makers, law enforcers at various
levels of governance and civil society groups;
Capacity building of the states.
Preparation of National and State-wise enforcement action plans for effective
implementation of COTPA and WHO FCTC.

38. • Between August 2008 and January 2009, one national and five regional workshops were organized
to cover all regions of the country. At the end of these workshops, nearly 2000 key personnel in the
Government(s) and civil society groups were duly sensitized on the provisions under COTPA and
the WHO FCTC with related enforcement strategies.
National Inter ministerial Taskforce for Tobacco Control - an inter ministerial taskforce has been
constituted under the chairmanship of union health secretary to reiterate the role of other
departments and ministries in tobacco control and to bring them on board for performing their
respective roles to reduce the demand and supply of tobacco in the country.
• Steering Committee on Section 5 of COTPA- as mandated under COTPA, a Steering committee has
been constituted under the chairmanship of union health secretary and notified in the Gazette of
India. On the direction of the national committee, state and district level Steering committees were
constituted to look into the matters of violations under Section 5 of COTPA.
• Alternate livelihood initiatives by Ministry of Labor - a series of training programmes were
undertaken in bidi rolling areas to train women bidi rollers in alternate vocations by the Ministry
of Labor.

39. • The Ministry of Health and Family Welfare has collaborated with Ministries of Rural Development and
Women and Child Development for providing alternate economically viable livelihood options to bidi
rollers under their ongoing schemes.
• Integration of TB and Tobacco Project- As per available evidence, smoking contributes to half the male
deaths, (200,000) in the 25-69 age group, from TB in India. [33] For the first time, tobacco cessation was
included in the training module of doctors under RNTCP (Revised National Tuberculosis Control
Programme). A pilot project to integrate TB and Tobacco control initiatives, incorporating brief advice
for tobacco cessation to tobacco using TB patients was initiated in two districts (Kamrup in Assam and
Vadodara in Gujarat) in 2010.
• Mainstreaming tobacco control in medical and dental education in the country- steps have been taken
to incorporate tobacco control in the curriculum of undergraduate medical and dental curriculum to
equip medical and dental graduates with skills for tobacco control, especially tobacco cessation.
• National Tobacco Control Helpline- a national level 24×7 toll free helpline has been set up for reporting
violations of provisions under COTPA. On an average 1000 calls are received every month from all over
the country. The same are then forwarded to respective state governments for taking action. This has
facilitated the implementation of provisions under COTPA and monitoring of the same by sensitizing
the state governments on the issue.

40. • National Consultation on Smokeless Tobacco - The Government is seriously
concerned about the high prevalence of smokeless tobacco in the country
and its growing use among the youth. The Supreme Court of India has also
expressed its concern over the high prevalence of tobacco use and its
hazardous effects on health and environment. A national consultation was
organized by the Ministry of Health and Family Welfare to deliberate the
modalities for control and regulation of smokeless tobacco under the
existing legislation in the country. The recommendations of this consultation
were shared with concerned stakeholders and the matter will also be
highlighted in the next meeting of the Conference of Parties of the WHO
FCTC.

41. In 2015 amendments COTPA
• The Union Ministry of Health and Family Welfare on 13 January 2015 proposed the
Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of
Trade and Commerce, Production, Supply and Distribution) (Amendment) Bill 2015
(COTPA).
• Provisions of the COTPA (Amendment) Bill 2015
• The bill proposes to ban on-site advertising of tobacco products and shops selling cigarettes
and other tobacco products will no longer be able to display the brand names.
• It proposed scrapping of designated smoking areas from hotels, restaurants and airports
making an exception only for international airports to prevent exposure of non-smokers to
harmful emissions.
• The penalty for smoking in restricted areas has been raised from 200 to 1000 rupees.

42. • Anyone found producing tobacco products without the specified warning
will be liable for imprisonment for up to two years for the first offence or
fine up to 50000 rupees or both.
• For the second and subsequent offences, the imprisonment can be up to
five years with a fine of up to 1 lakh rupees.
• Selling products without warning will incur a fine of up to 10000 rupees
or a jail term of up to one year or both and subsequent offence will draw a
fine of up to 25000 rupees and a jail term of two years.
• Tobacco products and cigarettes in approved packaging will now be sold
only to those above 21 years of age. The proposed age limit will be revised
after evaluating the impact of raising the minimum age.

43. • The draft Bill also proposes a ban on spitting of tobacco products, pointing it out as
the biggest cause of spread of diseases like Tuberculosis, Avian Flu and H1N1 virus.
• It has also been proposed to extend the ban on sale of cigarettes and tobacco
products from 100 yards of an educational institution to 100 metres.
• The bill proposes to set up a National Tobacco Control Organisation (NTCO) that
will implement and monitor the provisions of COTPA, 2003.

44. Implementation challenges being faced
Violation of Ad ban through:
- Surrogate methods (Red & White Bravery Awards-GPI)
- Brand stretching (Wills Life Style Apparel-ITC)
- Sponsorship of events (Formula 1 news in print media-Marlboro)
Violation of ban on smoking in public places due to:
- Lack of awareness among stakeholders (managers of restaurants, hotels etc.)
- Low compliance levels among the management of public places
- Low motivation at Health Ministries at State Level
Violation of provision allowing point-of-sale advertisement
- Display board specifications being violated
- Health warning area specified on this board has been reduced by the industry

45. Other measures that need to be taken to strengthen
tobacco control
Tax Net to be Uniform
- Current financial budget (2005-06) increased specific (excise) rate on
cigarettes by about 10% and a surcharge of 10% ad valorem duties on other
tobacco products (gutkha, chewing tobacco, snuff and pan masala)
- Bidis to be brought under similar tax regime to avoid cost influenced
product choice by youth and poor
Ban on Gutkha by Centre
- State governments to request the Centre to impose such a ban (as per
Supreme Court judgment)

46. Framework Convention on Tobacco Control
(FCTC) Implementation in India
The Indian Act enactment preceded the adoption and enforcement of the FCTC
Indian Legislation needs to be upscale 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)

47. EDUCATIONAL APPROACH
STRATEGY
• Evidence for Effectiveness of Health Professional Intervention
• A Cochrane review of 16 RCTs found simple advice from doctors had a significant
effect on cessation rates (OR for quitting 1.69; 95% confidence interval 1.45–1.98).
• When trained providers are routinely prompted to intervene with people who
smoke, they achieve significant reductions in smoking prevalence (up to 15 percent
cessation rates compared with 5 to 10 percent in non-intervention sites).
• Doctors and other health professionals using multiple types of intervention to
deliver individualized advice on multiple occasions produce the best results.
Frequent and consistent interventions over time are more important than the type
of intervention

48. Smoking Cessation Program
• The only way any country can substantially reduce smoking and other
tobacco use within its borders is to establish a well-funded and
sustained comprehensive tobacco prevention program that employs a
variety of effective approaches.
• Nothing else will successfully compete against the addictive power of
nicotine and the tobacco industry's aggressive marketing tactics.

49. ESSENTIAL COMPONENTS
The following elements must all be included to
maximize the success of any program to reduce tobacco
use. Conducted in isolation, each of these elements can
reduce tobacco use, but done together they have a much
more powerful impact:
• Public Education Efforts
• Community-Based Programs
• Helping Smokers Quit (Cessation)
• School-Based Programs
• Enforcement
• Monitoring and Evaluation
• Related Policy Efforts

50. Public Education Efforts:
Research has demonstrated that tobacco industry marketing
increases the number of kids who try smoking and become
regular smokers. Not surprisingly, one of the best ways to
reduce the power of tobacco marketing is an intense campaign
to counter these pro-smoking messages.

51. Public Education Efforts (cont.):
• These efforts must include multiple paid media (TV, radio,
print, etc.), public relations, special events and promotions,
and other efforts.
• Counter-marketing efforts should target both youth and
adults with prevention and cessation messages.

52. Community-Based Programs:
• Because community involvement is essential to reducing
tobacco use, a portion of the tobacco control funding should
be provided to local government entities, community
organizations, local businesses, and other community
partners.

53. Community-Based Programs (cont.):
•These groups can effectively engage in a
number of tobacco prevention activities
right where people live, work, play, and
worship, including:
–direct counseling for prevention and to help
people quit,
–youth tobacco education programs,
–interventions for special populations,
–worksite programs, and
–training for health professionals.

54. Helping Smokers Quit (Cessation):
• A comprehensive tobacco control program should
not only encourage smokers to quit but also help
them do it. In fact, most smokers want to quit but
have a very difficult time because nicotine is so
powerfully addictive.
• To help these smokers, cessation products and
services should be made more readily available and
more affordable.
• Moreover, treatment programs are most effective
when they utilize multiple interventions, including
pharmacological treatments, clinician provided
social support, and skills training.

55. Helping Smokers Quit
(Cessation) (cont.):
• Cessation services can be provided through primary health care
providers, schools, government agencies, community
organizations, and telephone "quit lines.“
• Staff training and technical assistance should be a part of all
programs to treat tobacco addiction; and following the cessation
guidelines from the Agency for Health Care Policy and Research
will increase the effectiveness of any cessation efforts in clinical
settings.

56. School-Based Programs:
• School-based programs offer a useful way to prevent and
reduce tobacco use among kids, especially when based on the
CDC’s Guidelines for School Health Programs to Prevent Tobacco
Use and Addiction.
• To operate most effectively, school-based programs must
include curricula that have been shown to be effective, as well
as tobacco-free policies, training for teachers, programs for
parents, and cessation services.

57. School-Based Programs (cont.):
•Students must learn not only the dangers
of tobacco use but life skills, refusal skills,
and media literacy in order to resist the
influence of peers and tobacco marketers.
•It is critical that the school programs be
integrated with other community-based
programs and with counter-marketing
efforts.

58. Enforcement:
• Rigorously enforcing laws prohibiting tobacco sales to youth and
limiting exposure to secondhand smoke is an essential element of
creating an environment conducive to reducing tobacco use.
• These enforcement efforts should include penalties for violators,
and compliance enhancing education.

59. Enforcement (cont.):
•To increase tobacco control enforcement,
funds must be provided to enforcement
agencies to make sure other enforcement
efforts are not compromised.
•Other agencies and organizations should
also be supported to provide related
educational efforts to raise awareness of
the laws and their enforcement and to
promote compliance.

60. Monitoring and Evaluation:
• Every element of a comprehensive tobacco control program
should be rigorously evaluated throughout its existence.
• Careful monitoring and evaluation methods should be built-
into the programs to provide the data necessary for
continual improvement.

61. Monitoring and Evaluation (cont.):
•Process measures should be developed to
monitor the activities conducted under the
program from the outside, as well, in order
to block the misuse of funds and promote
their most efficient and effective use.
•Regular measurements of key outcomes
should also be conducted to assess
progress and further improve their
performance.

62. Related Policy Efforts:
•Additional policy initiatives have been
proven effective in reducing tobacco use --
especially as part of a comprehensive
strategy.
•These policies include:
–increases in cigarette excise taxes,
–restrictions on tobacco marketing to kids,
–increased penalties for selling tobacco to kids,
–new restrictions on environmental tobacco
smoke in public places.

63. GUIDING PRINCIPLES
Past experience with tobacco control
efforts indicates that five principles should
guide the development of a successful state
program to prevent and reduce tobacco use:
•1. It must be comprehensive.
Stopgap or partial measures will meet with
only partial success. Elements work most
effectively when they are combined in
complementary fashion.

64. GUIDING PRINCIPLES (cont.)
2. It must be well funded.
– Unless properly financed, tobacco prevention will have
little effect against the marketing efforts of the tobacco
industry (over $8 billion each year).
– CDC has issued funding guidelines for state tobacco
control programs, which can serve as a basis for planning.

65. GUIDING PRINCIPLES (cont.)
3. It must be sustained over a long period of
time.
–While short-term attitudinal changes can occur
relatively early, it will take years to achieve the
significant behavioral and cultural changes
necessary to reduce tobacco use substantially and
maintain low levels.
–If tobacco control programs are not sustained over
many years, the chances for success will be
diminished, and any early gains may be lost in
subsequent years.

66. GUIDING PRINCIPLES (cont.)
4. It must operate free and clear of political
and tobacco industry influence.
–History warns us that the tobacco industry will
employ every manner of tactics to divert money
from tobacco prevention and to interfere with
any tobacco prevention efforts that are
undertaken.
–To avoid this tobacco industry sabotage, new
tobacco control programs must be set up to be
independent of these influences and insulated
from them.

67. GUIDING PRINCIPLES (cont.)
5. It must address high-risk and diverse
populations.
–The needs of special populations can and must
be taken into account in designing and
disseminating the various elements of the
tobacco control program (e.g. youth, and
women).

68. CONCLUSION
• In view of tobacco control being a major public health challenge in India, the
Government has enacted and implemented various tobacco control policies at
national and sub national level. The states have implemented the tobacco control
policies and programmes with various levels of success. Effective tobacco control is
dependent on balanced implementation of demand and supply reduction
strategies by the Government and intersectoral coordination involving stakeholder
departments and ministries. The implementation of the Government policies,
synergized with tobacco control initiatives by the civil society and community are
pivotal in reducing prevalence of tobacco use in the country.

69. References
• http://ocf.org.in/professional/IncidenceAndPrevalence.aspx/
• http://www.iarc.fr/en/publications/list/bb/
• Isaäc van der Waal. Potentially malignant disorders of the oral and
oropharyngeal mucosa; terminology, classification and present concepts of
management. Oral Oncology. Article in press.
• Grace Bradley and Iona Leong. Chapter 4. Oral cancer. Book of comprehensive
dentistry.
• Textbook of community dentistry, S.S.Hiremath 2007 – 2nd edition.
• World Health organization site.
• M. Krishnan Nair, Cherian Varghese, R. Swaminathan. Cancer: Current Scenario,
Intervention Strategies And Projections For 2015. NCMH Background
Papers·burden Of Disease In India
69

70. •Peter S. Essentials Of Preventive And
Community Dentistry. 4th Edition 2010.
Arya Publications.
•Marya CM. A Textbook Of Public Health
Dentistry. 1st Edition 2011. Jaypee
Publications.
•John J; Textbook of preventive dentistry;
2nd edition
•Ghom A G.Textbook of oral medicine.
Jaypee publications.
70

71. •Pulino B F B,2, Santos J F M, Pastore G P,
Filho G P C, Pereira R A. Oral cancer:
potentially malignant lesions and statistics
of diagnosed cases in the municipality of
Santo André-SP. J Health Sci Inst.
2011;29(4):231-4
•Peterson P E. Oral cancer prevention and
control – The approach of the World Health
Organization. Oral Oncol (2008): 1-7
71

72. •Takiar. Projections of Number of Cancer Cases in
India (2010-2020) by Cancer Groups. Asian Pacific
J Cancer Prev, 11, 1045-1049
•Kumar S. K.S , Zain R.B. Aetiology and Risk
factors for Oral Cancer – A Brief Overview. Annal
Dent Univ Malaya 2004; 11: 41–50.
•Saman D M. A review of the epidemiology of oral
and pharyngeal carcinoma: update. Head & Neck
Oncology 2012, 4:1
72

73. • Liu L. Oral squamous cell carcinoma incidence
by subsite among diverse racial and ethnic
populations in California. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2008;105:470-80
• Peterson P E. Strengthening the prevention of
oral cancer: the WHO perspective.Community
Dent Oral Epidemiol 2005; 33: 397–9
• Global data on incidence of oral cancer . WHO
2005,2008,2012.
73

74. •Dikshit R. et al. Cancer mortality in India: a
nationally representative survey. The Lancet,
Early Online Publication, 28 March 2012
doi:10.1016/S0140-6736(12)60358-4
•Chadda RK and Sengupta SN. Tobacco use by
Indian adolescents Tobacco Induced Diseases
2002; 1(2):111–119
•National oral health survey and fluoride mapping
2002-2003, India
74

75. •Johnson N. Tobacco Use and Oral Cancer:
A Global Perspective. Journal of Dental
Education 2001; 65(4): 328-339
•Nair U. Alert for an epidemic of oral cancer
due to use of the betel quid substitutes
gutkha and pan masala: a review of agents
and causative mechanisms. Mutagenesis
2004;9(4):251-262
75

76. Thank you