Indian Journal of Public Health

: 2011  |  Volume : 55  |  Issue : 3  |  Page : 155--160

Tobacco use: A major risk factor for non communicable diseases in South-East Asia region

JS Thakur1, Renu Garg1, JP Narain2, Nata Menabde3,  
1 Non Communicable Diseases and Social Determinants of Health Cluster, WHO India Country Office, New Delhi, India
2 Department of Sustainable Development and Environment, WHO South East Asia Regional Office, New Delhi, India
3 WHO Representative of India, India

Correspondence Address:
J S Thakur
Cluster Focal Point, Non Communicable Diseases and Social Determinants of Health, WHO India Country Office, New Delhi - 110 011


Tobacco use is a serious public health problem in the South East Asia Region where use of both smoking and smokeless form of tobacco is widely prevalent. The region has almost one quarter of the global population and about one quarter of all smokers in the world. Smoking among men is high in the Region and women usually take to chewing tobacco. The prevalence across countries varies significantly with smoking among adult men ranges from 24.3% (India) to 63.1% (Indonesia) and among adult women from 0.4% (Sri Lanka) to 15% (Myanmar and Nepal). The prevalence of smokeless tobacco use among men varies from 1.3% (Thailand) to 31.8% (Myanmar), while for women it is from 4.6% (Nepal) to 27.9% (Bangladesh). About 55% of total deaths are due to Non communicable diseases (NCDs) with 53.4% among females with highest in Maldives (79.4%) and low in Timor-Leste (34.4%). Premature mortality due to NCDs in young age is high in the region with 60.7% deaths in Timor Leste and 60.6% deaths in Bangladesh occurring below the age of 70 years. Age standardized death rate per 100,000 populations due to NCDs ranges from 793 (Bhutan) and 612 (Maldives) among males and 654 (Bhutan) and 461 (Sri Lanka) among females respectively. Out of 5.1 millions tobacco attributable deaths in the world, more than 1 million are in South East Asia Region (SEAR) countries. Reducing tobacco use is one of the best buys along with harmful use of alcohol, salt reduction and promotion of physical activity for preventing NCDs. Integrating tobacco control with broader population services in the health system framework is crucial to achieve control of NCDs and sustain development in SEAR countries.

How to cite this article:
Thakur J S, Garg R, Narain J P, Menabde N. Tobacco use: A major risk factor for non communicable diseases in South-East Asia region.Indian J Public Health 2011;55:155-160

How to cite this URL:
Thakur J S, Garg R, Narain J P, Menabde N. Tobacco use: A major risk factor for non communicable diseases in South-East Asia region. Indian J Public Health [serial online] 2011 [cited 2023 Feb 8 ];55:155-160
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Tobacco use is an important modifiable risk factor common to major non communicable diseases (NCDs)-cancer, cardiovascular diseases, chronic respiratory diseases and diabetes, causing 1 in 6 of all NCD deaths. Almost 6 million people die from tobacco use each year, both from direct tobacco use and second hand smoke. By 2020, this number will increase to 7.5 million, accounting for 10 million deaths. [1] Data from several studies indicate that tobacco smokers have 2-3 fold higher relative risk of coronary heart disease (CHD), 1.5 times for stroke, 1.4 times for chronic obstructive pulmonary disease (COPD) and 12 fold risks for lung cancer. These risks have an age-gradient with higher relative risk (5-6 times) in the younger age groups, and are similar for men and women. [2],[3] and decreases rapidly after quitting smoking. [4] Even exposure to second-hand smoke (SHS) increases the risk of developing and progression of atherosclerosis. [5] Tobacco smoke has synergistic action with other risk factors.

A large multi-centric study in India had concluded that smoking imposes a higher risk for COPD among men, while SHS exposure was an important risk factor among women who were not significantly exposed to solid fuel combustion. SHS exposure was in fact a stronger risk factor than solid fuel combustion. [6] Additionally SHS exposure during childhood is a significant risk factor for the development of asthma in adults. Combined SHS exposure from parents during childhood and spouse during adulthood is associated with maximum risk. [7] The oral use of smokeless tobacco is widely prevalent in South East Asia Region (SEAR) countries; the different methods of consumption include chewing, sucking and applying tobacco preparations to the teeth and gums. Tobacco chewing in its various forms is directly responsible for cancers of the oral cavity, esophagus, pharynx, cervix and penis. Tobacco being key risk factors for NCDs, this paper highlights the crucial role of tobacco control, its impact on development and potential for integration along with other best buys for prevention and control of NCDs in SEAR countries. Information on tobacco use and exposure has been collected from published papers, reports, WHO STEP wise surveys, and reports of Global Youth Tobacco Survey, Global Adult Tobacco Survey and recently released report on Profile of implementation of WHO Framework convention on Tobacco Control in South Asia Region. [8]

 Prevalence of tobacco in SEAR

Comparable figures of smoking among men and women in the countries of SEAR region are shown in [Table 1]. Smoking among men is high in the region and the prevalence among countries varies significantly. Smoking among adult men ranges from 24.3% (India) to 63% (Indonesia) and among adult women from 0.4% (Sri Lanka) to 15% (Nepal). The low level of prevalence of smoking among women is because of the fact that smoking by women is not acceptable by most of the communities. In contrast to smoking, the use of smokeless tobacco is quite popular among women. The prevalence of smokeless tobacco use among men varies from 1.3% (Thailand) to 31.8% (Myanmar), while for women it is from 4.6% (Nepal) to 27.9% (Bangladesh). Finding from Global Youth Tobacco Survey (GYTS) show that the current use of any form of tobacco among student aged 13-15 years ranges from 8.5% (Maldives) to 54.5% (Timor-Leste) among boys and from 3.4% (Maldives) to 29.8% (Timor-Leste) among girls. Tobacco accounts for 6% of all female and 12% of all male deaths in the world. Smoking is estimated to cause about 71% of lung cancers, 42% of chronic respiratory diseases and nearly 10% of cardiovascular diseases. [1]{Table 1}

 Burden of NCDs and tobacco attributable mortality

The distribution of NCD deaths in SEAR countries due to NCD is shown in [Table 2]. About 55% of total deaths are due to NCDs with 53.4% among females. There is a lot of variation in NCD deaths of the total deaths in region with highest in Maldives (79.4%) and low in Timor-Leste (34.4%). Premature mortality due to NCDs in young age is high in the region with 34% of the deaths due to NCDs occurring below the age of 60 years, and 48% below the age of 70 years. Country-wise variations indicate 60.7% deaths in Timor Leste and 60.6% deaths in Bangladesh in this age group [Table 3]. Age standardized death rate per 100,000 populations due to NCDs varies significantly in the region. It ranges from 793 (Bhutan) and 612 (Maldives) among males and 654 (Bhutan) and 461(Sri Lanka) respectively among females per 100,000 population. The age standardized deaths rates due to cardiovascular diseases and diabetes are high among males and females in the SEAR countries with 465 among males in Bhutan and 387 among females in Bangladesh per 100,000 populations respectively. In 2008, 1.1 million people die of cancer in the Region. Among the 569,000 cancer deaths among males, the commonest site was lung (17%), followed by mouth and oropharynx (15%), and liver (7.5%).{Table 2}{Table 3}

Out of 5.1 millons tobacco attributable deaths in world, more than 1 million are in SEAR countries. Population attributable fraction due to tobacco is 8.7% of deaths as compared to 3.8% in the world. Death rate due to NCDs attributable to tobacco per 100,000 populations is 190 among males and 12 among females respectively in India. Similarly 16% of NCD deaths are attributable to tobacco among males and 1% among females in India (SEARO unpublished data). However, data about NCD deaths attributable to tobacco is not available for all countries in the region.

 Tobacco as a developmental issue

Tobacco use impedes economic and social development. One half of the smoker die from their tobacco use, and half of the deaths occur in economically productive years from 35 to 69 years. In low income countries, purchase of tobacco can divert up to 10% of the total household expenditure. [9] A recent systematic review conducted by WHO to find out the link between tobacco and poverty has shown an inverse relationship between income level and tobacco use prevalence, and its related consequences. [10] In analyzed population, low income people smoke more than higher income people (OR 1.48, 95% CI 1.38-1.59). This result is seen in each of the evaluated WHO regions including SEARO (OR 1.18, 95% CI 0.75-1.85) except for WPRO. A study of impact of tobacco related diseases in Bangladesh shows that 41% of eight selected tobacco related diseases (IHD, lung cancer, stroke, oral cancer, cancer of larynx, COPD, Pulmonary tuberculosis and Buerger's disease) were attributable to tobacco and annual cost of tobacco related illness was 50.9 billion taka; 5.8 billion taka for second hand smoke. [11] Member countries of the region have demonstrated that tobacco users from low income families spend up to 40% of their income on smoking at the cost of their basic needs which, in turn, thrust them deeper into a vicious cycle of poverty. [8] Progress towards achievement of MDGs will also be hampered in the region if tobacco control measures are not effectively implemented in SEAR countries.

 Evidence of association of Tobacco with NCDs

Ever since the work by Doll and colleagues in the 1950, there has been substantial interest in measuring the impact of tobacco use on health outcome at the population level. [12],[13] Tobacco causes at least 16 different types of cancer. It is most closely associated with lung cancer; the world's leading cause of cancer deaths, accounting for nearly one in five cancer deaths. [14] Tobacco use is known to cause several cancers of the throat and oral cavity, as well as cancer in diverse sites, such as the bladder, kidney, stomach and uterine cervix. Smokeless tobacco causes oral and other cancers, hypertension and heart disease. Cardiovascular disease is the leading cause of death in the world. [14] Smoking increases the risk of heart disease and stroke by two to four times. Smoking causes chronic lung diseases that can be severely disabling or fatal, increasing the risk of death 12 times. Smoking is an independent risk factor for diabetes, and it has been estimated that 12% of diabetes incidence in the United States is attributable to smoking. [14] Diabetics who smoke have an increased risk of death, and of complications associated with diabetes, such as amputations and problems with vision. There is significant tobacco related morbidity and mortality in the SEAR countries. About 1.2 million deaths occur in the region every year. [8] A study in 2010 estimated that smoking would lead to around 930 000 adult deaths in India alone in that year. [15]

 Best buys for Preventing NCDs

Reducing tobacco use is one of the best buys for preventing NCDs along with reducing harmful use of alcohol, promotion of healthy diet and physical activity [Table 4]. A best buy is an intervention that is not only highly cost effective but also cheap, feasible and culturally acceptable to implement. [1] Tobacco control interventions has high impact on burden of non communicable diseases, high feasibility and should be directed towards whole population and will be benefit for the poor, and reduce inequities. [16] The priority in SEAR countries should be immediate action to achieve global goal by 2040 of a world essentially free from tobacco where less than 5% of the population use tobacco. [16]{Table 4}

Full implementation of four of the Framework Convention on Tobacco Control strategies (Increasing tax on tobacco products to reduce prevalence, enforcement of smoke free workplaces, requirement of FCTC compliant packaging and labelling of tobacco products combined with public awareness campaigns about the health risk of smoking; and a comprehensive ban on tobacco advertising, promotion and sponsorship) would avert 5.5 million deaths over 10 year in 23 low income and middle income countries with a high burden of NCDs. [17] These are each considered best buys in reducing tobacco use and preventing NCDs. [1] FCTC implementation will have immediate health and economic benefit because reduction in exposure to tobacco smoke, both direct and second hand, will reduce the burden of cardiovascular diseases within one year and thus health expenditure. [18] Smoke free laws are expected to reduce lung cancers, illness from heart diseases and respiratory symptoms. [12] Between 1988 and 2004, a period during which the state of California implemented smoke-free legislation, rates of lung and bronchial cancer declined four times faster in California than in the rest of the United States, although at least some of the decrease may result from the sharper decline in smoking prevalence experienced in California compared with rest of the country that began in the early1980s. [19] Civic bodies of some of the cities of SEAR countries are also working for smoke free cities. Chandigarh, in the Northern part of India, became smoke free in 2007 by active participation of civil society, academic institutions and local administration. [20]

INTERHEART study, a case-control study, done in 52 countries involving more than 12000 cases and 14000 controls estimated the population attributable risk associated with various simple risk factors for incident myocardial infarction in several regions of the world. [21] Among South Asians countries (comprising of Bangladesh, Nepal, India, Pakistan and Sri Lanka) and South East Asian countries (comprising of Japan, Malaysia, Philippine, Singapore and Thailand), the population attributable risk (PAR) for smoking was 37.4% and 36% respectively and is a good starting point for prevention.

 Integrating tobacco control in health system framework

A large percentage of NCDs are preventable through the reduction of their four main behavioural risk factors: Tobacco use, physical inactivity, harmful use of alcohol and unhealthy diet. [1] These risk factors are interlinked and operate synergistically. So, comprehensive population services focusing on major risk factors is required instead of standalone vertical tobacco control programmes. Similarly, integrated risk factor surveillance by using WHO STEPS approach may be a better option than single risk factor surveillance as is being done presently. Although member states have specific requirements for WHO FCTC implementation, it should be seen as an opportunity for integration of tobacco control to become an integral part of population and individual services under the health system framework in national policies and health programmes. Recently, the Lancet NCD Action Group and the NCD Alliance proposed five overarching priority actions for the response to NCD crisis- leadership, prevention, treatment, international cooperation, and monitoring and accountability-and the delivery of five priority interventions-tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous intake of alcohol, and essential drugs and technologies. [16] The priority interventions were chosen for their health effects, cost effectiveness, low cost of implementation, and political and financial feasibility. [16] All such proposal makes a strong case for integrated comprehensive population services with multisectoral action. Tobacco taxes have been used not only as price-linked mechanisms for discouraging tobacco use, but also as a means of raising resources to fund health promotion and tobacco control programmes. Victoria (in Australia), California (in USA), Thailand, Nepal and India are among the countries that have supported public health programmes through 'sin tax.' [22] Thailand Health Promotion Foundation is generating sufficient funds for health promotion by having 2% cess on alcohol and tobacco which has the potential for replication in other member countries. The World Bank reviewed the evidence on the effectiveness of tobacco taxation in a 1999 report, and concluded that a 10% increase in the prices of tobacco products would reduce their use by about 4% in developed countries and by about 8% in developing countries. [23] Even lower rates of tax increase have produced beneficial effects. Regulatory measures should be supplemented by behavior change communication among target groups. Providing information to adults about tobacco dependence and health impact of tobacco can reduce consumption and is another best buy. [1] Therefore, comprehensive NCD prevention strategies should blend together two types of approaches of public health interventions aimed at reducing population level of risk factors including tobacco and medical interventions targeted specifically at high risk individuals.

 Conclusions and way forward

Tobacco smoking and smokeless tobacco use is widely prevalent in all countries and is contributing substantially to the burden of NCDs in SEAR countries. Tobacco control and WHO FCTC implementation by Member States should be accelerated and monitored in order reduce the rising burden of NCDs and sustain development in SEAR countries. Integrating tobacco control in broader population services appears to be a better strategy as compared to vertical tobacco control programme in SEAR countries.


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