Research on Tobacco in India (Including Betel Quid and Areca Nut)

289 Pages·2003·1.18 MB·English

H N P D I S C U S S I O N P A P E R
Economics of Tobacco Control Paper No. 9
Research on Tobacco in India
(Including Betel Quid and Areca Nut)
About this series...
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entirely those of the author(s) and should not be attributed in any manner to the World An annotated bibliography of research on use,
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the countries they represent. Citation and the use of material presented in this series health effects, economics, and control efforts
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Cecily Stewart Ray, Prakash Gupta and Joy de Beyer
The Economics of Tobacco Control sub-series is produced jointly with the Tobacco Free
Initiative of the World Health Organization. The findings, interpretations and conclusions
expressed in this paper are entirely those of the authors and should not be attributed in
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zations or members of their Executive Boards or the countries they represent.
The editors for the Economics of Tobacco Control papers are: Joy de Beyer
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RESEARCH ON TOBACCO IN INDIA
(INCLUDING BETEL QUID AND ARECA NUT)
An annotated bibliography of research on
use, health effects, economics, and control efforts

Cecily Stewart Ray
with Prakash Gupta and Joy de Beyer
August 2003
Health, Nutrition and Population (HNP) Discussion Paper

This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank's
Human Development Network (HNP Discussion Paper). The papers in this series aim to provide a
vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and
debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the
author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or
to members of its Board of Executive Directors or the countries they represent. Citation and the use of
material presented in this series should take into account this provisional character. For free copies of
papers in this series please contact the individual authors whose name appears on the paper.

Enquiries about the series and submissions should be made directly to the Editor in Chief. Submissions
should have been previously reviewed and cleared by the sponsoring department which will bear the cost
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The Economics of Tobacco Control sub-series is produced jointly with the Tobacco Free Initiative of
the World Health Organization. The findings, interpretations, and conclusions expressed in this paper are
entirely those of the author/s and should not be attributed in any manner to the World Health Organization
or to the World Bank, their affiliated organizations or to members of their Executive Boards or the
countries they represent.

The editors for the Economics of Tobacco Control papers are: Joy de Beyer ([email protected]),
Emmanuel Guindon ([email protected]) and Ayda Yurekli ([email protected]).

For free copies of papers in this series please contact the individual author whose name appears on the
paper, or one of the editors. Papers are posted on the publications pages of these websites:
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ISBN 1-932126-81-3

© 2003 The International Bank for Reconstruction and Development / The World Bank
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Health, Nutrition and Population (HNP) Discussion Paper

ECONOMICS OF TOBACCO CONTROL PAPER NO. 9

RESEARCH ON TOBACCO IN INDIA
(INCLUDING BETEL QUID AND ARECA NUT)

An annotated bibliography of research on
use, health effects, economics, and control efforts

Cecily Stewart Raya with Prakash Guptab and Joy de Beyerc

a Epidemiology Research Unit, Tata Institute of Fundamental Research and Tata Memorial Centre,
Mumbai, India
b Tata Institute of Fundamental Research, Mumbai, India
c Senior Health Economist, Health, Nutrition and Population, Human Development Network, World
Bank, Washington DC, USA

Paper prepared for the World Bank for the meeting on Tobacco Control Research in India,
held in New Delhi, India on April 10-11, 2002.

The on-line version of this annotated bibliography will be updated periodically. Readers are encouraged
to send additional references and abstracts to the authors.

Abstract: This report is a compilation of references and abstracts of all research on tobacco in India
from 1985 to 2003. Studies are organised by subject matter, and within each sub-topic, are arranged by
year of publication with most recent studies listed first, and for studies published in the same year,
alphabetically by author’s last name. The studies include tobacco use surveys, studies on tobacco-related
mortality, tobacco-related diseases both cancerous and non-cancerous, according to body system and site,
and other health problems associated with tobacco use and environmental tobacco smoke. Other topics
include the toxicity of tobacco products, educational interventions and the psychology of tobacco use,
tobacco control measures and policies, reports on tobacco advertising and sponsorship and research into
the tobacco health hazards faced by tobacco workers. It also includes studies on tobacco employment,
tobacco growing and technology, and the economics of tobacco. The following databases were searched:
Pub Med, Medline, and J-Gate (a new Indian database). The keywords used for the searches were
‘(Tobacco OR smoking) AND India’, as well as names of diseases known from international research
findings to be associated with tobacco, ‘AND India’. In some cases, reports were excluded if they were
duplicative, or the methodology or findings were unclear.

The report is also available on-line, at to http://www.actindia.org/databases.html or www.actindia.org --
click on “databases”, or through www.worldbank.org/tobacco. In future, all the abstracts will be available
also on the WHO 'Health Internetwork' (HIN) website, that is under development. The electronic file is
available upon request, from the authors.
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Keywords: tobacco, nicotine, bidi, tendu, gutkha, paan masala, smoking, areca nut, betel-quid, chewing
tobacco, smokeless tobacco, reverse smoking, chutta, environmental smoke, passive smoking, second-
hand smoke, sidestream smoke, India, cancer, tuberculosis, pulmonary disease, CVD, coronary vascular
disease, respiratory disease, stroke, peripheral vascular disease, adverse pregnancy outcomes, nutritional
status, tobacco control, tobacco policy, economics of tobacco

Disclaimer: The findings, interpretations and conclusions expressed in the paper are entirely those of
the authors, and do not represent the views of the World Bank or the World Health Organization, their
Executive Directors, or the countries they represent.

Correspondence Details: Cecily Stewart Ray, Tata Institute of Fundamental Research, Mumbai,
India, tel: [phone] ext 2553) , fax: [phone]), email: [email protected]
Prakash Gupta, Tata Institute of Fundamental Research, Mumbai, India, tel: [phone]) , fax: (91-
22-2280-4610), email: [email protected]
Joy de Beyer, World Bank, 1818 H Street NW, Washington DC, 20433, USA, tel: [phone], fax:
[phone], email: [email protected]

The electronic file for this document (word.doc file) is available upon request from Cecily
Ray or Joy de Beyer, for readers who wish to be able to search or sort the file for
personal use. The file can be sent by email, or on CD or diskette.
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Table of Contents
Page No.
Preface…………………………………………………………………………………….vii
Acknowledgements………………………………………………………………………..ix
Introductory Note………………………………………………………………………….x

References and Abstracts (Reference Code) …………………………..…………………..1

1. Tobacco Use Surveys and Reports (TUS) …………………….……………………1
1.1 Youth in general………………………………………………….……………………1
1.2 School children ……………………………………………………………………….2
1.2.1 Independent surveys of school children……….………………………………….…2
1.2.2 Global Youth Tobacco Surveys in India………………………...…………………..7
1.3 College students……………………………………………………………………...10
1.4 Health professionals (including medical and dental students)……………………….12
1.5 Educational personnel and other professional groups…………………………….…15
1.6 Non student youth……………………………………………………………………17
1.7 General population…………………………………………………………………...19
1.8 Rural communities…………………………………………………………………...23
1.9 Urban communities…………………………………………………………………..26
1.10 Women……………………………………………………………………………….30
1.11 Data collection instruments…………………………………………………………..32
2. All Cause Morbidity and Mortality (All Mor)………………………………..…..33
3. Cancers ……..…………………………….……………...…………………………40
3.1 All cancers (in relation to tobacco use) (All Can ) ..………………………………...40
3.2 Oral cavity cancer……………………………………………………………………43
3.2.1 Oral cancer epidemiology (OC Epi)………….……………………………………44
3.2.2 Oral lesions and conditions, precancerous and non-cancerous (OL)……………...59
3.2.3 Oral submucous fibrosis (OSF) ……………………………………………….......67
3.3 Oropharyngeal cancer (OphC)….………………………………………………….. 73
3.4 Laryngeal cancer (LaC).………………….………………………………………….76
3.5 Oesophageal cancer (Eso) ………………………………………………..................77
3.6 Head and neck cancers (H&Nc)……………………………………………………..80
3.7 Lung cancer (LC)…………………………………………………………………….81
3.8 Digestive and aerodigestive tract cancers –general (Aero-digC, DigC)…..…………84
3.9 Stomach cancer StoC).………………………………………………………………86
3.10 Other cancers (OthC).………………………………………………………………..88
4. Non-cancerous Diseases and Adverse Impacts on Health………………………..90
4.1 Respiratory system…………………………………………………………………. 90
4.1.1 Chronic respiratory symptoms and diseases (Cresp)………………..……………..91
4.1.2 Tuberculosis (TB)……………………….………………………………………..100
4.2 Digestive system (Dig)…………………………………………………..…………102
4.3 Circulatory system………………………………………………………….………104
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4.3.1 Circulatory system diseases and stroke (Circ)…………………………………...104
4.3.2 Haematology (Haem)…………………………………………………………….129
4.4 Immune System (Im)……………………………………………………………….132
4.5 Endocrine system and metabolism…………………………………………………133
4.5.1 Thyroid (Thy)……………………………………………….……………………133
4.5.2 Diabetes (Dia)……………………………………………….……………………134
4.6 Nervous system and behavioral problems………………………………………….135
4.6.1 Psychology, including addiction (Psy)…………………….……………………..135
4.6.2 Neurological diseases (Neuro)…………………………….……………………...139
4.7 Reproductive system………………………………………………………………..140
4.7.1 Fertility and Virility (Fertil)…………………………….……………………..…140
4.7.2 Adverse pregnancy outcomes (Preg-outcome)…………….……………………..140
4.8 Nutritional Status…………………………………………………………………...145
5. Health Impact of Second-hand Smoke (ETS)……………………………………148
6. Toxicity of Tobacco Products (TP)………………………………………………..155
7. Interventions to Reduce Tobacco Use (Int)………………………………………168
8. Tobacco Control Policies and Measures (TC)……………………………………180
9. Health Hazards Faced by Tobacco Workers (Occ)……………………………...194
10. Bidi Workers (Bidi)………………………………………………………………..200
11. Tobacco Promotion - Advertising and Sponsorship (TProm)…………………...213
12. The Economics of Tobacco (ECON)………………………………………………215
13. Websites with Tobacco Statistics for India and On-line Articles……………….237
14. Index (listed alphabetically, by last name of first author) .……………………..238

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PREFACE

In 1999, the World Bank published “Curbing the Epidemic: governments and the economics of
tobacco control”, which summarizes trends in global tobacco use and the resulting immense and
growing burden of disease and premature death. In 2000, there were nearly 5 million deaths from
tobacco each year, and this huge number is projected to grow to 10 million per year by 2030, given
present consumption trends. Already about half of these deaths are in high-income countries, but
recent and continued increases in tobacco use in the developing world is causing the tobacco-related
burden to shift increasingly to low- and middle-income countries. By 2030, seven of every ten
tobacco-attributable deaths will be in developing countries.

“Curbing the Epidemic” also summarizes the evidence on the set of policies and interventions that
have proved to be effective and cost-effective in reducing tobacco use, in countries around the world.
Tax increases that raise the price of tobacco products are the most powerful policy tool to reduce
tobacco use, and the single most cost-effective intervention. They are also the most effective
intervention to persuade young people to quit or not to start smoking. This is because young people,
like others with low incomes, tend to be highly sensitive to price increases.

Why are these proven cost effective tobacco control measures –especially tax increases– not adopted
or implemented more strongly by governments? Many governments hesitate to act decisively to
reduce tobacco use, because they fear that tax increases and other tobacco control measures might
harm the economy, by reducing the economic benefits their country gains from growing, processing,
manufacturing, exporting and taxing tobacco. The argument that “tobacco contributes revenues, jobs
and incomes” is a formidable barrier to tobacco control in many countries. Are these fears supported
by the facts?

In fact, these fears turn out to be largely unfounded, when the data and evidence on the economics of
tobacco and tobacco control are examined. The team of about 30 internationally recognized experts
in economics, epidemiology and other relevant disciplines who contributed to the analysis presented
in “Curbing the Epidemic” reviewed a large body of existing evidence, and concluded strongly that in
most countries, tobacco control would not lead to a net loss of jobs and could, in many circumstances
actually generate new jobs. Tax increases would increase (not decrease) total tax revenues, even if
cigarette smuggling increased to some extent. Furthermore, the evidence shows that cigarette
smuggling is caused at least as much by general corruption as by high tobacco product tax and price
differentials, and the team recommended strongly that governments not forego the benefits of tobacco
tax increases because they feared the possible impact on smuggling, but rather act to deter, detect and
punish smuggling.

Much of the evidence presented and summarized in “Curbing the Epidemic” was from high income
countries. But the main battleground against tobacco use is now in low- and middle-incomes
countries. If needless disease and millions of premature deaths are to be prevented, then it is crucial
that developing counties raise tobacco taxes, introduce comprehensive bans on all advertising and
promotion of tobacco products, ban smoking in public places, inform their citizens well about the
harm that tobacco causes and the benefits of quitting, and provide advice and support to help people
who smoke and chew tobacco, to quit.

In talking to policy-makers in developing countries, it became clear that there was a great need for
country-specific analytic work, to provide a basis for policy making, within a sound economic
framework. So the World Bank and the Tobacco Free Initiative of the World Health Organization (as
well as some of the WHO regional offices and several other organizations, acting in partnership or
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independently) began to commission and support analysis of the economics of tobacco and tobacco
control in many countries around the world.

Most of the other papers in this Discussion Paper series report results of new, previously unpublished
analyses of tobacco economics and tobacco control issues. Clearly, this annotated bibliography is
different, being a compilation of references and abstracts of research which has been published
elsewhere, often in refereed journals.

Our hope is that the information compiled in this report will be a useful reference for researchers and
others who are looking for information on tobacco use and its impact in India, or on tobacco control
in India.

Joy de Beyer

Tobacco Control Coordinator
Health, Nutrition and Population
World Bank

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