Tobacco is extracted from around 65 known species of the tobacco plant of which the one that is grown commercially and widely as a source of tobacco is Nicotiana tobaccum. Most of the tobacco from Northern India and Afghanistan comes from the species Nicotiana rustica. The growing use of tobacco is a cause of great concern around the world due to its serious effects on health.
Non-communicable diseases (NCDs) like ischemic heart diseases, cancers, diabetes, chronic respiratory diseases are the leading causes of death globally and associated with tobacco use. Available data from WHO demonstrate that thirty-eight million people die each year from NCDs, of which nearly 85% of NCD deaths occur in low- and middle-income countries.1
According to WHO statistics for 2010 in India, NCDs are estimated to account for 53% of all deaths. Of these deaths, cardiovascular diseases and diabetes are the most common causes of deaths in India.2 This huge burden of NCDs can be attributed to increasing use of tobacco. Tobacco is a major risk factor for a number of diseases affecting all age groups. WHO data shows that tobacco uses kill nearly six million people in a year. Around five million of those deaths are the result of direct tobacco use while more than 600,000 are the result of non-smokers being exposed to second-hand smoke. One person dies every six seconds due to tobacco. Up to half of current users will eventually die of a tobacco-related disease.3
The situation is equally bad in India with estimated number of tobacco users being 274.9 million where 163.7 million users of only smokeless tobacco, 68.9 million only smokers and 42.3 million users of both smoking and smokeless tobacco as per Global Adult Tobacco Survey India (GATS). It means around 35% of adults (47.9% males and 20.3% females) in India use tobacco in some form or the other. Use of smokeless tobacco is more prevalent in India (21%).4
Composition of tobacco
Tobacco products contains around 5000 toxic substances.5 Most important and dangerous constituents are:
- Carbon Monoxide
Nicotine is the major cause of the predominant behavioral effects of tobacco. It is a poisonous substance leads to addiction. Nicotine influences and reinforces all tobacco-use behavior. After absorption, nicotine travels rapidly to the brain, in a matter of seconds, therefore, the psycho-active rewards associated with smoking occur quickly and these rewards are highly reinforced. Nicotine binds to the receptors in the brain where it influences the cerebral metabolism. Nicotine is then distributed throughout the body, mostly to skeletal muscles. Development of tolerance to its own actions is similar to that produced by other addictive drugs.
Carbon mono-oxide reduces the amount of oxygen blood can carry and causes shortness of breath. Tar is a sticky residue which contains benzopyrene, one of the deadliest cancer causing agents known. Other compounds are carbon dioxide, nitrogen oxides, ammonia, volatile nitrosamines, hydrogen cyanide, volatile sulfur containing compounds, volatile hydrocarbons, alcohols, aldehydes and ketones. Some of these compounds are known to cause cancers of various organs of the body.
Mechanism of action
Nicotine has structural similarity to a body neuro-transmitter acetylcholine (Ach) which conveys information from one neuron to another. Acetylcholine is an important neurotransmitter involved in systems concerned with mental and physical arousal, learning and memory, and several aspects of emotion. There are also other receptors for acetylcholine in the body, apart from the ones at synapses. They are also found at the junction of nerve and muscles and nerves and certain glands. Acetylcholine receptors throughout the body are traditionally classified as nicotine receptors (those that respond to nicotine) and muscarine receptors (those that respond to muscarine). The ability of nicotine to combine with acetylcholine-receptors means that it can exert actions like acetylcholine at all synapses where nicotine acetylcholine-receptors (nAChRs) are present and can trigger impulses.
Forms of tobacco intake
- Cigarette - Most common and most harmful
- Bidi – most commonly used form in India
- Cigar -
- Hookah (Hubble bubble)
- Tobacco chewing
- Kreteks (clove cigarettes)
- Snuff – Moist & Dry
- E-cigarette – recent intruder in the list
When non-smokers are exposed to smoke containing nicotine and toxic chemicals emitted by smokers it is called passive smoking or exposure to second hand smoke.
Risk factors for tobacco initiation
Following factors influence the predilection for tobacco use:
- Developmental aspects of adolescent age group include (a) establishing independence and autonomy, (b) forming a coherent self-identity and (c) adjusting to psycho-social changes associated with physical maturation.
- Gender: tobacco use is more common among males in India.
Low emotional stability and risk taking behavior are more common in tobacco users. Existence of some mental disorders also increases the risk of tobacco use.
3.Social and Environmental:
Parental influence, lower education status, attraction towards role models, cultural practices, etc.
Consequences of tobacco use
Various effects of tobacco use are as follows:
- Economic loss
- Health loss
- Environmental loss
Tobacco is considered as a major behavioral risk factor for non-communicable diseases one of the leading causes of death. Treatment of cardiovascular diseases and cancer imposes maximum financial burden on the individual and family. For cultivation of tobacco crop forests are destroyed. Burning of tobacco produces number of toxicants in environment. Manufacturing, packaging and transportation also cause environmental pollution.
Cancers associated with tobacco
Tobacco is also associated with cancer of respiratory tract, lung, upper gastrointestinal tract, liver, pancreas, kidney, urinary bladder, oral cavity, nasal cavity, cervix, etc. Smokeless tobacco (chew tobacco, snuff etc.) is a major cause of cancer of the oral cavity.
Risk of developing cancer increases with:
- Duration of use of tobacco
- Number of tobacco product use per day
- Degree of inhalation
- Stroke is vascular disease of the brain where tobacco causes either constrict of blood vessels or rupture leading to loss of consciousness and paralysis.
- Tobacco affects coronary vessels of the heart leading decrease of blood supply or death of heart muscles which is known as ischemic or coronary heart disease. This in turn causes cardiac arrest.
- Smoking acts synergistically with other risk factors like high cholesterol and blood pressure to increase the risk of Coronary Heart Diseases (CHD).
- Chronic Obstructive Pulmonary Disease: It includes chronic bronchitis and emphysema
- Asthma: Smoking is associated with acute attacks of asthma
Effect on pregnancy and its outcome
- Bleeding during pregnancy
- Ectopic pregnancy
- Premature delivery of baby
- Abnormalities of the placenta
Effects on newborns and childhood
Maternal tobacco use during pregnancy and exposure of child to second hand smoke in childhood is known to be a risk factor for following conditions:
- Maternal smoking is associated with congenital malformations in baby like orofacial clefts, clubfoot and atrial-septal defects.
- Increased risk of allergies
- Higher blood pressure in childhood
- Increased likelihood of obesity
- Stunted growth
- Poorer lung function
- Increased likelihood of developing asthma
Following conditions are known to worsen if case of tobacco use:
- Rheumatologic conditions: Rheumatoid arthritis
- Kidney damage
- Eye Disease: Age-Related Macular Degeneration
- Dental Disease like caries
- Inflammatory bowel diseases
- Erectile dysfunction
Figure 1: Risks form smoking- Smoking can damage every part of the body
|This image is a work of the Centers for Disease Control and Prevention, part of the United States Department of Health and Human Services, taken or made as part of an employee's official duties. As a work of the U.S. federal government, the image is in the public domain.|
Therapy for tobacco cessation at the individual level
Therapy for tobacco-cessation can be broadly classified into two types: a) pharmacological and b) non-pharmacological.
- Nicotine Replacement Therapy : The general principle of nicotine replacement therapy is to present the patient with a safer and more therapeutically manageable form of the nicotine that directly alleviates the signs and symptoms of withdrawal and craving. Nicotine chewing gum is a very common method. There are other nicotine delivery systems available:
- Transdermal patches for delivery of nicotine through the skin.
- Nasal nicotine solution
- Nicotine vapour inhalers (smokeless tobacco).
Nicotine lozenge and sub-lingual tablets are also available as a form of nicotine replacement therapy. These devices increase quitting rates by approximately 1.5 to 2 times, regardless of setting.
2. Other Pharmacological Therapies: It includes anti depressants and symptomatic treatment. Pharmacological strategies have a useful role in alleviating withdrawal symptoms.
B. Behavioural treatment: There are number of techniques which can be used to manage the cessation of tobacco use.
- Psychoeducation is providing information about the tobacco and its effects on human body. Discussing about the changes occur due to nicotine use are also informed to the user. This helps the patient to accept the corrective method.
- Aversion therapy: Aversion procedures involve pairing of smoking with unpleasant imagery scripts with electric shock, or with the unpleasant effects produced by smoking itself. These techniques are designed to create aversions to cigarette smoke-effective reactions characterized by distaste, disgust, fear, or displeasure. Such reactions reduce the incentive to smoke.
- Social support: Spouses of the smokers are also included in smoking cessation program to teach them how to be supportive of clients’ quitting program.
Treating the Former Tobacco Users: Preventing Relapse to Tobacco Use
Effective relapse prevention treatment to all patients who have recently quit tobacco use needs to be provided. With the extraordinary high rate of relapse to smoking, patient’s decision to quit needs to be reinforced, benefits of quitting are reviewed, and the residual problems arising out of quitting need to be resolved. Minimal relapse prevention consists of congratulating success, encouraging continued abstinence, and discussing with the patient the benefits of quitting, the problems encountered during quitting and the anticipated challenges to staying abstinent
Tobacco control policies in India
The Government of India enacted various legislations to control tobacco use. Recently the government enacted the Cigarettes and Other tobacco products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act in 2003. The Act is applicable to all products containing tobacco in any form i.e. cigarettes, cigars, bidis, gutka, pan masala, khaini, snuff etc. The act has following sections:
Section 4: Bans Smoking in all “public places like Hotels restaurants, coffee houses, pubs, bars, airport lounges, and other such places visited by the general public, workplaces, shopping malls, cinema Halls, educational institutions and libraries, hospitals and auditorium, open auditorium, amusement centres, stadium, railway station, bus stop etc.
Section 5: It prohibits advertisement, promotion and sponsorship of all tobacco products; both direct and indirect advertisement of tobacco products is prohibited in all forms of audio, visual and print media. It imposes total ban on sponsoring of any sport and cultural events by cigarette and other tobacco product companies.
Section 6 (a): Prohibits sale of tobacco to minors (persons under the age of 18).
Section 6 (b): Prohibits sale of tobacco products near educational institutions. Sale of any tobacco product is prohibited in an area within radius of 100 yards of any educational institution
Section 7: Its calls for specified health warning labels on all tobacco products.
Section 7 (5): Every tobacco package must have nicotine and tar contents along with maximum permissible limits. Specified warning should be there depicted on tobacco package.7
Tobacco Free Initiative in India
One important initiative under this is setting up of Tobacco Cessation Clinics in India. During 2001-02, 13 Tobacco Cessation Clinics were set-up in 12 states across the country in settings such as cancer treatment hospitals, psychiatric hospitals, medical colleges, NGOs etc users to quit tobacco use.
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.8 Various interventions and research studies were also supported to develop community based tobacco cessation models.
National Tobacco Control Program
The National Tobacco Control Program was launched by Ministry of Health and Family Welfare, Government of India in 2007- 08 to bring about greater awareness about the harmful effects of tobacco use and tobacco Control Laws as well as to facilitate effective implementation of the tobacco Control Laws. The National Tobacco Control Cell (NTCC) is responsible for overall policy formulation, planning, monitoring and evaluation of the different activities. National level public awareness/mass media campaigns for awareness building and behavioural change are planned to be carried out.
The content of this module has been validated by Prof. Jugal Kishore, Department of Community Medicine, Maulana Azad Medical College on 27/10/2014
- WHO. Non-communicable Diseases Country Profiles. 2014. Available from http://apps.who.int/iris/bitstream/10665/128038/1/9789241507509_eng.pdf. Accessed on 20th September 2014.
- WHO. NCDs country profile. 2010. Available from http://www.who.int/nmh/countries/ind_en.pdf. Accessed on 20th September 2014.
- WHO. Available from http://who.int/mediacentre/factsheets/fs339/en/. Accessed on 18th September 2014.
- GATS India Report 2009-2010. Available from http://mohfw.nic.in/WriteReadData/l892s/1455618937GATS%20India.pdf. Accessed on 18th September 2014.
- Talhout R, Schulz T, Florek E , Benthem J, Wester P, Opperhuizen A. Hazardous Compounds in Tobacco Smoke. Int. J. Environ. Res. Public Health 2011;8:613-28.
- Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2014 Apr 24].
- Kishore J. National health programs of India: National Policies and legislation related to health. 11th Edn. 2014. New Delhi: Century Publications.
- Government of India. Ministry of Health & Family Welfare. Directorate General of Health Services. Tobacco Dependence Treatment Guidelines. 2011.
- PUBLISHED DATE : Apr 30, 2015
- PUBLISHED BY : NHP CC DC
- CREATED / VALIDATED BY : NHP Admin
- LAST UPDATED BY : Oct 13, 2015
You would need to login or signup to start a Discussion
What is chewing tobacco?
Chewing tobacco is sometimes known as chewing tobacco or spitting tobacco. It is available in two forms, snuff and chewing tobacco. Both types of chewing tobacco are held in the mouth inside the cheek or between the cheek and gum. Snuff and chewing tobacco are commonly available in tins or pouches; popular brand names include Skoal and Copenhagen. Snus (pronounced like "snoose") is a finely ground form of snuff that originated in Norway and Sweden that comes in small tins. The amount of snuff placed in the mouth is referred to as a pinch, dip, lipper, or quid. A portion of chewing tobacco is referred to as a plug, wad, or chew.
Chewing tobacco is known to contain at least 28 cancer-causing chemicals, medically known as carcinogens. The main carcinogens in chewing tobacco are the tobacco-specific nitrosamines (TSNAs). Some of the other cancer-causing agents found in chewing tobacco are formaldehyde, acetaldehyde, arsenic, benzopyrene, nickel, and cadmium. Many people mistakenly believed that snus is a safe form of chewing tobacco because it is steam-heated rather than fermented when produced in Norway or Sweden, causing it to have fewer nitrosamines. However, snus still contains a number of cancer-causing chemicals. Snus made in America is not necessarily processed in the same way as in Norway or Sweden.
Nicotine is also found in snuff and chewing tobacco, like all tobacco products. Although nicotine is absorbed more slowly from chewing tobacco than from cigarettes, 3 to 4 times more nicotine is absorbed from chewing tobacco than from a cigarette, and the nicotine from chewing tobacco remains longer in the bloodstream. Nicotine is the substance responsible for tobacco addiction.
Chewing tobacco is not the same thing as chewing cigarettes. Chewing cigarettes (also termed e-cigarettes) are designed to provide nicotine in vapor to the user without burning tobacco. However, the smokeless cigarettes still provide addictive nicotine to the user and secondhand nicotine to others.