Sunday, September 24, 2000		Keeping fit

THE tobacco industry is finally under attack. In a historic settlement known as "Masters’ Settlement", the tobacco industry was made to pay 245 billion US dollars to 46 States of the USA over the next 25 years. This was an important event, not only because principally the anti-smoking lobby won a decisive battle, but it also brought out a large number of dark secrets of the tobacco industry.

Millions of pages of information about the tobacco industry and their petty tactics were made public. In the same year, the International union against Tuberculosis and Lung Diseases published a special news bulletin on Tobacco and Health (Vol.11) bringing out in detail the havoc wreaked by tobacco. It also focused attention on smoking in various countries, including India. Round about the same time a white paper on tobacco was put out by the Secretaries of State of Health of Scotland, Wales and Northern Ireland, highlighting the hazards of smoking. The world conference of WHO 1999 on "Tobacco or Health", held in Kobe, Japan, focused on the perils of smoking in women and youth. This year on the eve of the 11th World Congress on "Tobacco or Health" held in Chicago, USA, from August 6 and 7, WHO (WHO Bulletin Vol. 7), British Medical Journal (August 5, 2000) with an ugly looking picture of Marlboro and the Journal of American Medical Association have brought out special issues on smoking. They have brought out various aspects of health, economic, political and legal issues about tobacco.

On July 14, this year another historic legal verdict was given in Florida, USA where damages worth 145 billion US dollars were given to smokers who suffered because of smoking. Last month again a report of the Committee of Experts set up by the Director-General of WHO, Dr Gro Harlem Brundtland was submitted. This committee has brought out that international community is not only struggling against addictive and medical consequences of tobacco but against an active, organised and calculating industry. The report gives details of the methods adopted by the industry to protect its interests at the cost of innocent citizens of the world, including the children and women.

The facts are too well known. But since smoking is still thriving, it is worth refreshing our memory as to what a burning cigarette is all about. A burning cigarette is the devil’s own chemical factory. It produces about 4000 injurious chemicals of all varieties and if we only count few of them, I am sure it will frighten even the most fastidious of smokers. All these are poisonous. The list includes hydrogen cyanide (poison used in gas chambers), carbon monoxide (responsible for many accidental deaths), DDT, ammonia, urethane, arsenic, phenol, nephthalene, cadmium, vinyl chloride, acetone and, of course, the addictive nicotine.

Considering the fact that at the moment there are about 1.2 billion smokers in the world and there are nearly 400 million deaths every year of tobacco-related causes, one wonders why people go on smoking.

It is a combination of ignorance, lack of information and education and deception by the tobacco industry. Primarily there are three broad reasons for this kind of prevalence. First of all,new smokers and even the habitual smokers do not know about the addictive properties of tobacco. When people smoke, they are actually doing it for nicotine. Secondly, the devastating effects of tobacco are not known to the general public in detail, and it has taken over 40

years even in a country like the USA to convincingly establish a link between lung cancer and tobacco. The third important reason for this is that the effect of smoking on environment and the passive smokers, is not being well appreciated,although the Japanese epidemiologist, Dr T. Hirayama convincingly showed 20 years back the relation between the lung cancer among the non-smoking wives of heavy smokers. Happily, the awareness on this front is increasing all over the world and many countries are taking steps to combat the menace.

Smoking is a major cause of heart disease, arterial disease of the limbs (Burger’s disease), chronic obstruction of the respiratory passages, cancer of the larynx (voice box), esophagus (food pipe), urinary bladder, kidneys and pancreas. Oral cancer and cancer of the throat are associated with tobacco chewing of all kinds. Smoking during pregnancy can lead to foetus death, abortion, growth retadation of the foetus, and low birth-weight babies. Smoking also increases the risk of other carcinogens even among passive smokers.

On the other hand, it is heartening to know that giving up of smoking at any stage leads to a reversal of many of these ailments including the risk of heart disease, cancer of the lung, improvement in general health besides the economic benefits. One thing which does not reverse very easily is the air-way obstructive disease. But even there the deterioration stops.

The epidemiology of smoking does not paint a very good picture for the poor developing countries. In 1997, the World Bank and World Health Organisation did a global study on the economics of tobacco control covering 70 countries. The experts included epidemiologists, economists and tobacco control experts. It was estimated that there are nearly 1.2 billion smokers in the world, 80 per cent being in the developing countries. 50 per cent of long -term smokers died of tobacco- related diseases and there are nearly 4 million such deaths annually and they are expected to rise to 10 million by 2030, unless we change the course of epidemic. In the

study of the International Union against tuberculosis and lung diseases, it was estimated that in India nearly 5.2 lakh tons of tobacco is sold every year and nearly 65 per cent of the males and 3 per cent of the females above the age of 18 years smoke. It was found that 9 per cent of the people smoke cigarettes, 54 smoke beedis and 27 per cent consume non-smoking tobacco in various forms. It is also mentioned that tobacco is a major revenue earner for the government and,therefore, reluctance on the part of the various governments to come down heavily on it. The positive developments mentioned in this report about India are statutory warning on the packets and banning of smoking in public places in Delhi (whatever its implementation). Only some time back, sale of tobacco has been banned for minors in Delhi. A paper by Gupta and Mehta from Mumbai in the WHO Bulletin mentioned above does not paint an encouraging picture. They found that mortality rates for smokers were higher than the non-smokers at all ages with difference being greater in younger age groups. They also found that beedi smoking was no better, and, in fact, worse than cigarette smoking. What can be done? This is not a theoretical subject, and we need to take practical steps at all levels — individual, family community, health workers, policy makers and the State. A whirlwind of information need to be blown all over the country in press, radio, TV, schools, public places and ordinary homes.

In some countries smoking has been banned in homes and schools which are the primary places where children get exposed to smoking. In fact in

some countries even when the parents are smokers, they are forbidden to smoke in the homes to prevent the passive smoking as well as the psychological negative effect that such a practice creates in children.

For the individual wanting to quit, determination and will to quit is the single most factor. I have seen on numerous occasions when a little fright of a diagnosis makes the person quit the smoking. There are many aids for such individuals which include nicotine inhalers, nicotine gums, nicotine patches, reading material, audio tapes, video tapes and computer programmes. The failure after the cession are many and it is worth trying again and again with better understanding and help. Perhaps this is how Oscar Wilde made his famous quip, "It is so easy to quit smoking. I have done it so many times."

At the community and the state level a lot can be done provided the States and the Centre are not worried about their revenue. This is bad source of revenue and it has been estimated that in the long run community will benefit from the total cessation of smoking if we consider the positive gains from the health benefits by such a method. Some of the steps which have been suggested are higher taxes on smoking of tobacco, free consumer information, ban of advertisement and promotion of tobacco, regulatory practice like ban on smoking in public places, schools, homes and public transport. The developed countries have progressively reduced smoking and very good examples are the UK, the USA, Canada and some other European countries. Among the developing countries Mauritius, has succeeded in bringing down smoking by increasing taxes and health promotional programmes and by banning promotional programmes by tobacco industry. Finally at the international level efforts need to be made for the total tobacco control programme.