To the Editor: The article by Jha et al. (March 13 issue)1 onthe large and growing number of deaths in India due to smokingdraws attention to the need for effective implementation ofthe national tobacco control act of 2003 in India.2 Recent datashow that all forms of tobacco use in India increased duringthe 7-year period between the second National Family HealthSurvey (NFHS-2) conducted in 1998 and 1999 and the third NFHS(NFHS-3) conducted in 2005 and 2006.3 We analyzed data fromthese two nationally representative surveys and found that thegreatest increase in tobacco use occurred in persons betweenthe ages of 15 and 24 years, in the rich castes, and in urbanareas (Table 1). These findings are consistent with an earlierwarning by Reddy and others4 about a new wave of increased tobaccouse in the young population and urban areas of India. One ofthe major challenges for effective implementation of India'stobacco control act is the substantial funding of major Indianpolitical parties by tobacco companies.5
Jha P, Jacob B, Gajalakshmi V, et al. A nationally representative case-control study of smoking and death in India. N Engl J Med 2008;358:1137-1147. [Free Full Text]
The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003. New Delhi, India: Government of India, 2003.
National Family Health Survey–3 (2005-6). Mumbai, India: International Institute for Population Sciences, 2007. (Accessed June 6, 2008, at http://www.measuredhs.com.)
Reddy KS, Perry CL, Stigler MH, Arora M. Differences in tobacco use among young people in urban India by sex, socioeconomic status, age, and school grade: assessment of baseline survey data. Lancet 2006;367:589-594. [CrossRef][ISI][Medline]
To the Editor: In the article by Jha et al. about smoking inrural and urban India, the relative risks in a few subgroups(e.g., according to rural or urban residence, educational level,and alcohol consumption) are shown, but the important variableof caste is omitted. The authors' categorization of the subjectsas being Hindu, Muslim, or others is inadequate. The caste affiliationin India defines a person's socioeconomic position in society.1The government of India categorizes all castes and subcastesinto six groups: others, other backward class (which includesall "upper-caste" Hindus), scheduled caste, scheduled tribe,Vimukta Jati, and nomadic tribe, in descending socioeconomicorder. The scheduled caste, scheduled tribe, Vimukta Jati, andnomadic tribe are the lowest socioeconomic classes and mostdisadvantaged people. The caste system in India exists now asit has for more than 3500 years. Moreover, castism in Indiais much more inhuman than racism in North America. The lackof formal health insurance and inadequate social safety netsaffect the poorest of the poor.2 Ignoring castism in India wouldbe worse than ignoring race in North America; ignoring castismdenies socioeconomic disparities and their consequences.
Kabir Z. Demographic and socio-economic determinants of post-neonatal deaths in a special project area of rural northern India. Indian Pediatr 2003;40:653-659. [Medline]
Roy K, Howard DH. Equity in out-of-pocket payments for hospital care: evidence from India. Health Policy 2007;80:297-307. [CrossRef][ISI][Medline]
To the Editor: Jha et al. forecast about 1 million deaths peryear from smoking in India. The investigators have rightly focusedon smoking, but the almost ubiquitous habit of tobacco chewingalso requires attention. The scourge of chewing tobacco canbe estimated by the fact that oral cancer, which has a directand causal association with tobacco chewing,1 is among the mostcommon cancers in Indian men.2 Not only does this disease addto the burden of cancer in a country already struggling withlimited resources, but the treatment of such cancers involvesdisfiguring surgery and radiotherapy with obvious consequencesfor the patient's quality of life.3 The relative risk of deathfrom cancer would probably be greater if tobacco chewing wasincluded along with smoking. The problem of smoking has deservedlyreceived scientific attention, and we must expand this attentionto cover tobacco abuse in all forms and continue devising strategiesto curb this global problem.
Durgatosh Pandey, M.Ch. Rambha Pandey, M.D. Banaras Hindu University Varanasi 221005, India durgatosh{at}yahoo.co.in
References
IARC monographs on the evaluation of carcinogenic risks to humans. Vol. 89. Smokeless tobacco and some tobacco-specific N-nitrosamines. Lyon, France: International Agency for Research on Cancer, 2007.
GLOBOCAN 2002: cancer incidence, mortality and prevalence worldwide. IARC CancerBase. No. 5, version 2.0. Lyon, France: International Agency for Research on Cancer, 2004.
Hammerlid E, Taft C. Health-related quality of life in long-term head and neck cancer survivors: a comparison with general population norms. Br J Cancer 2001;84:149-156. [CrossRef][ISI][Medline]
The authors reply: As Thankappan and Mini point out, smokingin India might well be increasing at younger ages but perhapsnot as steeply as is suggested by the comparison between theNFHS-2, conducted in 1998 and 1999,1 and the NFHS-3, conductedin 2005 and 2006.2 The proportion of men between the ages of15 and 24 years who smoke was much higher (19%) in the NFHS-3than among our controls of the same age in 2004 and 2005 (10%).The 2004 survey of 1.3 million homes by the Registrar-Generalof India showed that 12% of boys and men between the ages of15 and 29 years smoked (13% of boys and men in rural areas and9% of boys and men in urban areas).3 These discrepancies requirefurther investigation.
An increase in any type of smoking in persons at young ageswould primarily affect deaths due to tobacco around the middleand later half of the 21st century.4 Potential increases donot affect our estimates that India will have about 1 milliondeaths from smoking per year during the 2010s (including 700,000deaths among persons between the ages of 30 and 69 years) orour conclusion that smoking cessation is key to a reductionin deaths due to tobacco over the next few decades.5 Unfortunately,however, at 30 years of age or older, only 1.9% of Indian menand 0.2% of Indian women describe themselves as being formersmokers.3
With regard to the comments of Pakhale, although caste was notrecorded in our nationally representative study, we did examinerisks according to the subject's educational level and urbanor rural residence. Patterns of smoking in scheduled-caste populationsare broadly similar to those among uneducated rural adults,1and both populations most commonly smoke bidis, which are smallerthan cigarettes and typically contain only about a quarter asmuch tobacco (they are wrapped in the leaf of another plant).In a comparison between smokers and nonsmokers, the relativerisk of death from any medical cause did not depend on educationallevel, but it did depend on whether bidis or cigarettes weresmoked and the amount smoked (Figure 1). The risk ratio fora given number of bidis or cigarettes smoked was greater forcigarettes than for bidis. However, we found a dose–responserelationship between smoking and mortality among men who smokedonly bidis and among men who smoked only cigarettes (P<0.001for both trends), with particularly elevated risk ratios forcigarette smoking.
Figure 1. Risk of Death in Men between the Ages of 30 and 69 Years, According to the Type and Amount of Tobacco Smoked.
Risk ratios are for smokers as compared with nonsmokers. The mean numbers of bidis smoked per day were divided into three categories: 4.4 (1 to 7 bidis), 10.2 (8 to 14 bidis), and 23.9 (15 bidis). The mean numbers of cigarettes smoked per day were divided into two categories: 4.0 (1 to 7 cigarettes) and 13.7 (8 cigarettes). More results are available on the Web site of the Centre for Global Health Research at www.cghr.org/tobacco.
In response to Pandey and Pandey, the additional adjustmentfor tobacco chewing did not materially alter the relative riskof death from any medical cause or the relative risk of deathfrom cancer in a comparison of smokers and nonsmokers.
Prabhat Jha, M.D., D.Phil. University of Toronto Toronto, ON M5B 1C5, Canada prabhat.jha{at}utoronto.ca
Prakash C. Gupta, D.Sc. Healis-Sekhsaria Institute for PublicHealth Mumbai 400614, India
Richard Peto, F.R.S. University of Oxford Oxford OX3 7LF, United Kingdom
for the Million Death Study Collaborators
References
Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco use in India: prevalence and predictors of smoking and chewing in a national cross sectional household survey. Tob Control 2003;12:e4-e4. [Free Full Text]
National Family Health Survey–3 (2005-6). Mumbai, India: International Institute for Population Sciences, 2007. (Accessed June 6, 2008, at http://www.measuredhs.com.)
Sample registration system: baseline survey report — 2004. New Delhi, India: Registrar-General of India, 2007.
Peto R, Lopez AD. Future worldwide health effects of current smoking patterns. In: Koop EC, Pearson EC, Schwarz MR, eds. Critical issues in global health. San Francisco: Jossey-Bass, 2002.
Jha P, Chaloupka FJ, Moore J, et al. Tobacco addiction. In: Jamison DT, Breman JG, Measham AR, et al., eds. Disease control priorities in developing countries. 2nd ed. New York: Oxford University Press, 2006:869-86. (Also available at http://files.dcp2.org/pdf/DCP/DCP46.pdf.)
Previous
15 bidis). The mean numbers of cigarettes smoked per day were divided into two categories: 4.0 (1 to 7 cigarettes) and 13.7 (