A Million Deaths From Smoking in India by 2010s

Lisa Nainggolan

February 13, 2008

February 13, 2008 (Toronto, ON) – New research shows that by the year 2010 and beyond, around one million deaths per year in India will be attributable to smoking, and the majority of these will occur in middle-aged adults [1]. This will represent 10% of all deaths in the country--one in five deaths in men and one in 20 in women, say Dr Prabhat Jha (Centre for Global Health Research, Toronto, ON) and his team from India, Canada, and the UK in their special article published online February 13, 2008 in the New England Journal of Medicine.

Jha told heartwire : "This is the first study that is nationally representative; it covers the whole of India. It's also the first to study adult deaths consistently and the first reliable work looking at smoking and deaths in women. And it's a very large study, it covers over one million homes and 78 000 deaths.

"Our role is not to give recommendations but to give information. At the moment, people don't take the risk from smoking seriously, and the government doesn't take it seriously, but we want them to. We want people in India to understand their own risks reliably and to understand the four key messages--much bigger risk than thought, no safe smoking, smoking kills early, and stopping works. If this is taken seriously as an avoidable cause of death, it's very obvious what can be done."

To aid dissemination of the findings, the researchers have made available press releases and video releases in English, Hindi, and a number of regional Indian languages on the Centre for Global Health Research website [2]. There is also a PowerPoint slideshow and the New England Journal of Medicine paper, both of which are freely accessible.

Four key messages

In India, tobacco is commonly consumed in the form of bidis, which are smaller than cigarettes and typically contain only about a quarter as much tobacco, wrapped in the leaf of another plant and sold in small packages. The smoking of bidis is concentrated in rural areas, among the poor. In urban areas, richer Indians tend to smoke cigarettes.

Jha expands upon the four key findings from the paper. First, "the risks for the individual smoker are much bigger than previously thought. Thinking about the Indian smoking pattern--where people start smoking later than they do in the West and they reportedly smoke fewer cigarettes or bidis--one would expect the risk to be lower than in Western countries," he says. "In fact, we found the risk is substantial and similar to the risks reported in the West. Second, deaths occur early from smoking in India; smokers are losing decades of life vs nonsmokers."

Third, the study shows "that there is no safe level of smoking, even smoking a few bidis or cigarettes per day substantially increases the risk of death," he notes. The final key point is that smoking cessation must be made a priority. "We know from evidence worldwide that stopping smoking works, but in India only 2% of adults have quit smoking, and most of them only do so when they fall ill," he says.

"We estimate smoking will cause about 930 000 deaths in India in 2010, with one in five deaths in men caused by smoking and one in 20 deaths in women caused by smoking in the 30-to-69-years age group," Jha warns. "During the 2010s, the annual number of deaths from smoking in India will be about one million, which is similar to the annual number in China."

Women who smoke like men die like men

In their study in a sample of 1.1 million Indian homes, Jha et al compared the prevalence of smoking among 33 000 deceased women and 41 000 deceased men (case subjects) with the prevalence of smoking among 35 000 living women and 43 000 living men (unmatched control subjects). Mortality risk ratios comparing smokers with nonsmokers were adjusted for age, educational level, and use of alcohol.

They found that in men aged 30 to 69 years, the rate of death from any medical cause in smokers was 1.7 times higher than in nonsmokers of similar age, educational level, and alcohol status (use or nonuse). In women, mortality in smokers was double that of their nonsmoking counterparts.

"Although smoking is currently much less common in women--only about 5% of adult females smoke compared with almost 40% of adult males--there are reports that this is changing, particularly in young women in urban areas," says Jha. "We want women to understand that women who smoke like men will die like men--their risks of death are as large as those for men," he notes.

Another way to look at this, says Jha, "is that men who smoke bidis lose, on average, six years of life. Women who smoke bidis lose eight years of life, and men who smoke cigarettes lose about 10 years of life. Although amount matters, there is no safe level of smoking. Smoking one to seven cigarettes per day doubles your risk of death, and one to seven bidis a day increases the risk by 25% to 30%."

Heart attacks leading cause of deaths in urban smokers

The researchers also found that the prime causes of death from smoking varied in different areas. While the majority of smoking-related deaths in rural India were linked to tuberculosis (TB), in India's urban settings, MIs were the first cause of death among smokers.

Overall, smoking in India causes around 38% of deaths from TB, 31% of deaths from other respiratory causes, around 33% of deaths from cancer, and 20% of deaths from heart attacks or stroke, Jha says.

Jha explains that because TB is rife there, "smoking is probably increasing the activation of the TB bacillus, which many people carry. Most of them won't develop the disease unless they smoke. But then when they do smoke and the bacillus becomes active and they develop TB, they are coughing and spreading it to other people. So smoking may be contributing to the spread of TB in the Indian population as well."

Indian men aged 30-69: Number of deaths studied and smoker vs nonsmoker death rate ratio (RR)
Underlying fatal disease Deaths studied, n Smokers (%)a Smoker vs nonsmoker RRb
TB 3119 66 2.3
Respiratory disease 3487 60 2.1
Stroke 2200 53 1.6
Heart disease 5409 52 1.6
Cancers 2248 59 2.1
All diseases 25 290 55 1.7
a. Vs 37.0% of 31 661 living men who had smoked
b. Risk ratio adjusted for age, alcohol use, and education
Source: Centre for Global Health Research

Chief executive of the UK Medical Research Council, Dr Leszel Borysiewicz, says: "This research confronts us with the scale of the problem. It shows that smoking kills in different ways in different areas. The results suggest an even higher risk of smoking-related cardiovascular disease among Indian populations than predicted."

Indian women aged 30-69: Number of deaths studied and smoker vs nonsmoker death rate ratio (RR)
Underlying fatal disease Deaths studied, n Smokers (%)a Smoker vs nonsmoker RRb
TB 1363 13 3.0
Respiratory disease 2288 14 3.1
Stroke 1597 8 1.6
Heart disease 2473 7 1.7
Cancers 2153 8 2.1
All diseases 16 386 9 2.0
a. Vs 4.5% of 26 678 living women who had smoked
b. Risk ratio adjusted for age, alcohol use, and education
Source: Centre for Global Health Research

India and other Asian nations must heed alarm call

Jha says experience in the West means that "we know what works," in terms of tobacco control. Smoking bans in public places, for instance, need to be implemented and enforced, with the important stipulation that "warnings about smoking and bans need to be pictorial and large, because more than half of the deaths from smoking in India are in illiterate adults. We need to adapt warnings from the West to effectively convey information about risks to smokers without depending on literacy."

Other important interventions include higher taxes and banning the advertising of cigarettes, says Jha. "Once societies figure out that tobacco is something they can do something about, it's very simple to know what to do; there is a lot of evidence."

Jha says there are "some signs for optimism. If you look at China 10 years ago, the smoking quit rates were the same as in India now--only 2% of Chinese smokers had quit--and now they've gone up to 9%. The reason? They had a large study released in 1998 and they had a world conference on smoking that year. India now has this large study, and next year we will have the world's largest assembly on smoking and health."

India's Health Minister, Dr Abumani Rammadoss, says: "We are going to take the results of this study very seriously. I am particularly concerned about protecting India's 600 million young people below the age of 30. These young people are our national assets, and they must be protected against smoking deaths. We plan to take comprehensive steps against tobacco and strengthen our Tobacco Regulatory Authority to enforce the laws."

Dr Poonam Singh (South East Asian Regional Office of the World Health Organization, New Delhi, India) said Asia has become the new battleground for global tobacco control. "India, Indonesia, and Bangladesh represent just a few of the countries that lie in the path of the tobacco tsunami. This study should sound the alarm that we desperately and quickly need action to curb this most avoidable of epidemics."

  1. Jha P, Jacob B, Gajalakshmi V, et al. A nationally representative case-control study of smoking and death in India. New Engl J Med 2008; DOI:10.1056.NEJMsa707719. Available at: http://www.nejm.org .

  2. Centre for Global Health Research

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