Tobacco and public health: It was the winter of despair; it “is” the spring of hope!

Till 1950, there was not much difference between tobacco and Hamburger, at least from the viewpoint of public health. The next couple of decades of research has changed the status of tobacco from an innocuous commodity to the “biggest killer,” as it was implicated in the major cause of premature mortality due to cancer and other chronic noncommunicable diseases.[1] With public health advocacy and resultant increase in awareness, use of tobacco reduced significantly in the developed countries, but the powerful multinational industries pushed their golden goose to the developing nations. The result was apparent. In the late 1990s, nearly two-third of all smokers lived in low- and middle-income countries (LAMICs) with the occurrence of 70% of total deaths due to tobacco use in these regions.[23] At the dawn of the 21st century, the macabre fact came to the fore; tobacco had caused about 100 million deaths in the last century; and the number would continue to rise further, to reach even up to a billion in this century, and would affect the LAMICs, predominantly.[1] Taking cognizance of these facts, the WHO convened the first global treaty, the framework convention on tobacco control (FCTC), an international legal instrument, to “give priority to the right to protect public health” and to address “concern of the international community about the devastating worldwide health, social, economic, and environmental consequences of tobacco consumption and exposure to tobacco smoke.” This convention was enforced since 2005 and has become one of the most “widely embraced treaties” in the history of the United Nations, ratified by 180 countries. India was one of them.[4] India has implemented the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act in 2003, before the FCTC, and started the National Tobacco Control Program in 2007, in response to the International mandate, with a comprehensive and multipronged approach of supply and demand reduction, summarized by the acronym MPOWER (Monitor, Protect, Offer help to quit, Warn about dangers, Enforce bans on tobacco advertisement, promotion, and sponsorship, Raise taxes).[5] In 2010, WHO conducted a review of implementation of MPOWER and observed that 40 countries adopted one or more strategies. WHO asserted that number of smokers was reduced by 14.8 million (from 2007 to 2010) and smoking-attributable risk would be reduced by 7.4 million, in these countries, due to the use of the policy. Although “smoke-free air” and “raising taxation” were found to have the greatest impact, these were alarmingly under-adopted.[6] Notwithstanding this limitation, the effectiveness of the MPOWER package as a public health tool to address the apparent insurmountable problem of tobacco use was found to be unquestionable. Data from India were not included in this study. In 2009–2010, the Ministry of Health and Family Welfare, Government of India, in collaboration with the WHO and the Centre for Disease Control conducted the first Global Adult Tobacco Survey (GATS).[7] It was a household survey of subjects 15 years or older, carried out across all the States and Union Territories, in a representative sample. Of late, the second GATS survey (2016–17) has also been completed and report is available for comparison.[7] The number of tobacco users and the prevalence of tobacco use have reduced by 8.1 million and 6%, respectively. Moreover, the relative reduction of current tobacco use is 17% which is at par with the Government of India's National Health Policy 2017. The National Family Health Surveys also portrayed a similar trend. Although there has been an overall reduction in the exposure to the secondhand smoke, the reduction is only modest for government buildings, healthcare facilities, public transport/stations, and restaurants. The average expenditure incurred for the use of tobacco has increased, but tobacco in India is still cheaper. Therefore, it seems that India lags behind in the implementation of both of the most effective strategies, i.e., smoke-free air and raise taxation. Despite this shortcoming, it has achieved a commendable reduction in tobacco use. There is scope for improvement and hope for further reduction. In the present paper, author and colleagues pointed noncompliance to COTPA in a health care institution, with regard to some important areas which could be easily addressed.[8] After a change in the hospital policy and its dutiful implementation, a repeat survey might be done to examine the status. It would also be worthwhile to see whether the change in policy has any impact on the actual tobacco use inside the hospital. To study this, intercept technique could be used as a simple, low-cost, but effective strategy. Overall, tobacco control epitomizes the success story of public health, unlike the control of alcohol and other drugs. The “winter of despair” of the 1970s has been surgically replaced by the “spring of hope” of the 21st century, with highly laudable leadership, advocacy, commitment, and cooperation across the globe.

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