Correspondence

Case–Control Study of Smoking and Death in India

N Engl J Med 2008; 358:2842-2845June 26, 2008

Article

To the Editor:

The article by Jha et al. (March 13 issue)1 on the large and growing number of deaths in India due to smoking draws attention to the need for effective implementation of the national tobacco control act of 2003 in India.2 Recent data show that all forms of tobacco use in India increased during the 7-year period between the second National Family Health Survey (NFHS-2) conducted in 1998 and 1999 and the third NFHS (NFHS-3) conducted in 2005 and 2006.3 We analyzed data from these two nationally representative surveys and found that the greatest increase in tobacco use occurred in persons between the ages of 15 and 24 years, in the rich castes, and in urban areas (Table 1Table 1Tobacco Use among Men between the Ages of 15 and 54 Years in India in 1998 and 2005.). These findings are consistent with an earlier warning by Reddy and others4 about a new wave of increased tobacco use in the young population and urban areas of India. One of the major challenges for effective implementation of India's tobacco control act is the substantial funding of major Indian political parties by tobacco companies.5

K.R. Thankappan, M.D., M.P.H.
G.K. Mini, Ph.D.
Trivandrum 695011, India
kavumpurathu@yahoo.com

5 References

1. 1

   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
   Full Text | Web of Science | Medline

2. 2

   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.
   

3. 3

   National Family Health Survey–3 (2005-6). Mumbai, India: International Institute for Population Sciences, 2007. (Accessed June 6, 2008, at http://www.measuredhs.com.)
   

4. 4

   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 | Web of Science | Medline

5. 5

   Tobacco money funds major Indian political parties. New Delhi, India: National Medical Journal of India, 2006. (Accessed June 6, 2008, at http://www.nmji.in/archives/Volume_19_3_May_June2006/news/index_news.htm.)
   

To the Editor:

In the article by Jha et al. about smoking in rural 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 variable of caste is omitted. The authors' categorization of the subjects as being Hindu, Muslim, or others is inadequate. The caste affiliation in India defines a person's socioeconomic position in society.1 The government of India categorizes all castes and subcastes into six groups: others, other backward class (which includes all “upper-caste” Hindus), scheduled caste, scheduled tribe, Vimukta Jati, and nomadic tribe, in descending socioeconomic order. The scheduled caste, scheduled tribe, Vimukta Jati, and nomadic tribe are the lowest socioeconomic classes and most disadvantaged people. The caste system in India exists now as it has for more than 3500 years. Moreover, castism in India is much more inhuman than racism in North America. The lack of formal health insurance and inadequate social safety nets affect the poorest of the poor.2 Ignoring castism in India would be worse than ignoring race in North America; ignoring castism denies socioeconomic disparities and their consequences.

Smita Pakhale, M.D.
McGill University, Montreal, QC H4X 1T9, Canada
spakhale@yahoo.com

2 References

1. 1

   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

2. 2

   Roy K, Howard DH. Equity in out-of-pocket payments for hospital care: evidence from India. Health Policy 2007;80:297-307
   CrossRef | Web of Science | Medline

To the Editor:

Jha et al. forecast about 1 million deaths per year from smoking in India. The investigators have rightly focused on smoking, but the almost ubiquitous habit of tobacco chewing also requires attention. The scourge of chewing tobacco can be estimated by the fact that oral cancer, which has a direct and causal association with tobacco chewing,1 is among the most common cancers in Indian men.2 Not only does this disease add to the burden of cancer in a country already struggling with limited resources, but the treatment of such cancers involves disfiguring surgery and radiotherapy with obvious consequences for the patient's quality of life.3 The relative risk of death from cancer would probably be greater if tobacco chewing was included along with smoking. The problem of smoking has deservedly received scientific attention, and we must expand this attention to cover tobacco abuse in all forms and continue devising strategies to curb this global problem.

Durgatosh Pandey, M.Ch.
Rambha Pandey, M.D.
Banaras Hindu University, Varanasi 221005, India
durgatosh@yahoo.co.in

3 References

1. 1

   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.
   

2. 2

   GLOBOCAN 2002: cancer incidence, mortality and prevalence worldwide. IARC CancerBase. No. 5, version 2.0. Lyon, France: International Agency for Research on Cancer, 2004.
   

3. 3

   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 | Web of Science | Medline

Author/Editor Response

As Thankappan and Mini point out, smoking in India might well be increasing at younger ages but perhaps not as steeply as is suggested by the comparison between the NFHS-2, conducted in 1998 and 1999,1 and the NFHS-3, conducted in 2005 and 2006.2 The proportion of men between the ages of 15 and 24 years who smoke was much higher (19%) in the NFHS-3 than among our controls of the same age in 2004 and 2005 (10%). The 2004 survey of 1.3 million homes by the Registrar-General of India showed that 12% of boys and men between the ages of 15 and 29 years smoked (13% of boys and men in rural areas and 9% of boys and men in urban areas).3 These discrepancies require further investigation.

An increase in any type of smoking in persons at young ages would primarily affect deaths due to tobacco around the middle and later half of the 21st century.4 Potential increases do not affect our estimates that India will have about 1 million deaths from smoking per year during the 2010s (including 700,000 deaths among persons between the ages of 30 and 69 years) or our conclusion that smoking cessation is key to a reduction in deaths due to tobacco over the next few decades.5 Unfortunately, however, at 30 years of age or older, only 1.9% of Indian men and 0.2% of Indian women describe themselves as being former smokers.3

With regard to the comments of Pakhale, although caste was not recorded in our nationally representative study, we did examine risks according to the subject's educational level and urban or rural residence. Patterns of smoking in scheduled-caste populations are broadly similar to those among uneducated rural adults,1 and both populations most commonly smoke bidis, which are smaller than cigarettes and typically contain only about a quarter as much tobacco (they are wrapped in the leaf of another plant). In a comparison between smokers and nonsmokers, the relative risk of death from any medical cause did not depend on educational level, but it did depend on whether bidis or cigarettes were smoked and the amount smoked (Figure 1Figure 1Risk of Death in Men between the Ages of 30 and 69 Years, According to the Type and Amount of Tobacco Smoked.). The risk ratio for a given number of bidis or cigarettes smoked was greater for cigarettes than for bidis. However, we found a dose–response relationship between smoking and mortality among men who smoked only bidis and among men who smoked only cigarettes (P<0.001 for both trends), with particularly elevated risk ratios for cigarette smoking.

In response to Pandey and Pandey, the additional adjustment for tobacco chewing did not materially alter the relative risk of death from any medical cause or the relative risk of death from cancer in a comparison of smokers and nonsmokers.

Prabhat Jha, M.D., D.Phil.
University of Toronto, Toronto, ON M5B 1C5, Canada
prabhat.jha@utoronto.ca

Prakash C. Gupta, D.Sc.
Healis-Sekhsaria Institute for Public Health, Mumbai 400614, India

Richard Peto, F.R.S.
University of Oxford, Oxford OX3 7LF, United Kingdom

for the Million Death Study Collaborators

5 References

1. 1

   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
   CrossRef | Medline

2. 2

   National Family Health Survey–3 (2005-6). Mumbai, India: International Institute for Population Sciences, 2007. (Accessed June 6, 2008, at http://www.measuredhs.com.)
   

3. 3

   Sample registration system: baseline survey report — 2004. New Delhi, India: Registrar-General of India, 2007.
   

4. 4

   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.
   

5. 5

   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.)
   

Citing Articles (5)

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1. 1

   Muthusamy Santhosh Kumar, P. Sankara Sarma, Kavumpurathu Raman Thankappan. (2011) Community-based group intervention for tobacco cessation in rural Tamil Nadu, India: A cluster randomized trial. Journal of Substance Abuse Treatment
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2. 2

   JingQi Yan, XiaoJing Di, CaiYi Liu, HuiMin Zhang, XiouQin Huang, JunJing Zhang, Yan Zhao, LongZe Zhang, YanZhong Chang, YongLin Liang, Ran Tao, BaoLu Zhao. (2010) The cessation and detoxification effect of tea filters on cigarette smoke. Science China Life Sciences 53:5, 533-541
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   C. U. Thresia, K. R. Thankappan, M. Nichter. (2009) Smoking cessation and diabetes control in Kerala, India: an urgent need for health education. Health Education Research 24:5, 839-845
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4. 4

   Prabhat Jha. (2009) Avoidable global cancer deaths and total deaths from smoking. Nature Reviews Cancer 9:9, 655-664
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5. 5

   Dorairaj Prabhakaran, Panniyammakal Jeemon, Shifalika Goenka, Ramakrishnan Lakshmy, K.R. Thankappan, Faruq Ahmed, Prashant P. Joshi, B.V. Murali Mohan, Ramanathan Meera, Mohas S. Das, Ramesh C. Ahuja, Ram Kirti Saran, Vivek Chaturvedi, K. Srinath Reddy. (2009) Impact of a Worksite Intervention Program on Cardiovascular Risk Factors. Journal of the American College of Cardiology 53:18, 1718-1728
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