A study shows that Indians are
not immune to health consequences of smoking and that smokers have a
higher death rate than non-smokers.
Recently, a parliamentary
committee declined to extend the size of health warnings on cigarette
packets due to lack of independent evidence on the health impacts of
smoking on the Indian population. A longitudinal study conducted by the
National Council of Applied Economics (NCAER) and University of Maryland
shows that in India too, smoking kills.
The India Human
Development Survey (IHDS) was first conducted in 2004-05. In this
survey, 41,554 households were surveyed in both urban and rural areas in
all States and Union Territories with the exception of Andaman-Nicobar
and Lakshadweep. At this time, extensive information about the
lifestyles of over two lakh individuals residing in these households was
collected. In 2011-12, these same households were surveyed again. We
were able to re-interview about 83 per cent of the original households.
At the time of the re-interview, information on current location of the
individuals from the original household was obtained, including whether
they are still alive. Thus, we have access to a prospective data set,
which contains both information on smoking tobacco products and whether
the individual has died in the seven years between the two interviews.
The results unambiguously show that even after we take into account
individuals’ age, gender, education and household wealth, those who are
reported to be daily smokers are more likely to die.
In the
initial interview, 26 per cent men and 1.6 per cent women above the age
of 15 smoked. These statistics are very similar to those observed in the
Global Adult Tobacco Use Study by Professor Ram and his colleagues at
International Institute of Population Sciences, conducted on behalf of
the Ministry of Health and Family Welfare in 2009-10. The GATS study
also noted that 24.3 per cent of men and 2.9 per cent of women aged 15
and above smoked.
Categorising smokers
Since
smoking is often underestimated for younger people, when smokers tend to
hide their habits from the older family members, we focus on
individuals who are 30 and above. In this age group, nearly 36 per cent
men in the IHDS sample smoke; 29 per cent smoke daily. Among women, only
2.5 per cent smoke. Although men from all walks of life smoke, smoking
is disproportionately concentrated among Dalit, Adivasi and Muslim men.
Among this group, about 45 per cent men smoke; 37 per cent smoke daily.
Lack of education also plays a role. About 46 per cent of illiterate men
smoke, while only 16 per cent of the college graduates smoke. Moreover,
smoking is concentrated among the lowest income group. Nearly 46 per
cent of the men in bottom fifth smoke compared to only 20 per cent in
the upper fifth. Death rates are higher for daily smokers than for
non-smokers or occasional smokers. About 11.3 per cent of men aged 30
and above and who smoke daily died in the seven years followingour
initial survey; only 10.2 per cent of the non-smokers and occasional
smokers died. However, as we noted above, smokers come from lower
socio-economic strata. Hence, it is difficult to know if these
characteristics, rather than smoking, may be the cause of higher death
rates among smokers. So we compare like with like and control for
education, marital status, age, caste/religious background, urban/rural
residence, state of residence and whether the individual was employed at
the first interview. We also control for household wealth. This does
not change the relationship observed above.
Even after taking
into account all these differences, we find that smokers have a higher
death rate than non-smokers. Among men, daily smokers are 1.14 times as
likely to die between the two interviews as the non-smokers and
occasional smokers. Lest this seem like a small difference, the
improvement in survival by giving up smoking would be more than by
difference between illiterate and those with eight years of education or
between men living in Uttar Pradesh and Karnataka. For women, smoking
is even more harmful but given the very small number of women who smoke,
this impact is not significant.
Delaying anti-smoking campaigns
will take a heavy toll on the Indian population, particularly poorer and
less educated men. What is disturbing about the current debate is the
message that it sends to current and potential smokers. Whether the
pictorial warning covers 20 or 30 per cent of the package is less
important than the implication that Indian population’s risk profile is
somehow different from that of non Indians and that until a study has
been conducted in India, we should not believe that smoking increases
health risks in India. Nonetheless, the results we show above should lay
to rest the argument that Indians are not somehow immune to health
consequences of smoking that beset non-Indian populations.
Debate in other countries
This
debate is reminiscent of similar battles fought in other countries. In
the U.S., for decades cigarette companies tried to throw a smoke screen
over research results that unambiguously showed that smoking caused
cancer and increased mortality. In France, even in the late 20th
century, the legislature argued that controlling public smoking was
pitting non-smokers’ rights against smokers’ rights. Financial interests
played an important role in the French debate too. Constance Nathanson
notes that by 1990, French tobacco market had been captured by
multinationals, leading a smoking proponent to grumble that anti-smoking
advertising would selectively weaken French tobacco industry and,
“there will no less smoking or drinking in sweet France but smoking and
drinking will be less French and more American.” These delays in
anti-smoking legislations have led to slower decline in smoking in
France than in other high income countries; as World Atlas of Smoking
shows, today 34 per cent French men smoke compared to 23 per cent in
neighbouring Switzerland.
Let us not give mixed messages to our
young men and increasingly, young women; smoking is not harmless,
smoking is not cool. Smoking kills, even in India.
(Sonalde
Desai isSeniorFellow at NCAER and Professor of Sociology at University
of Maryland. Debasis Barik is Associate Fellow at NCAER. Views are
personal.)