Economy-wide impact of a reduction in tobacco use in India.

BACKGROUND: Public policy measures aimed at regulating tobacco use should consider the net gains for the nation, as the tobacco sector contributes to employment and tax revenue while also imposing substantial economic burden on the country. This study investigates the economy-wide impact of reducing tobacco consumption in India through the implementation of fiscal measures. METHODS: The study uses a computable general equilibrium model based on the Global Trade Analysis Project model and database and augments the same with several country-specific information on tobacco products, to examine the macroeconomic impact of a targeted reduction in the consumption of bidis, cigarettes and smokeless tobacco by 10% by the year 2026 through the adoption of fiscal measures. RESULTS: The model results suggest that the targeted reduction in consumption may result in a 0.14% reduction in the gross domestic product (GDP) and a 0.44% reduction in overall employment in the economy. However, after accounting for the averted premature deaths due to tobacco use, the results indicate a net 0.22% increase in GDP and a net increase in employment of about 1.36 million jobs (or 0.29% of the labour force) over 5 years. Further, the tax increase measures proposed in this model to achieve the targeted reduction in consumption would generate an additional US$2774 million in revenues to the exchequer. CONCLUSION: The impact of targeted prevalence reduction of tobacco use is a win-win for the country considering its positive macroeconomic impacts in terms of net increases in both GDP as well as employment.

The Burden and Correlates of Waterpipe (Hookah) Smoking among Adolescents and Youth: A Systematic Review.

BACKGROUND: This systematic review evaluated the available medical literature on the prevalence and trends of waterpipe tobacco smoking among adolescents and youth in jurisdictionally representative populations. METHODS: PubMed, Embase, and Scopus were searched for relevant studies from inception until 31 December 2022 that reported the burden of waterpipe smoking among adolescents and youth (10-24 years of age). We extracted qualitative data on the demographic characteristics, burden, and correlates of waterpipe smoking (PROSPERO ID: CRD42022310982). RESULTS: A total of 2,197 articles were screened and 62 were included in the analysis. The majority (29) of the studies was from the United States of America and there were no studies from the south-east Asian region. The prevalence of ever waterpipe smoking among the 10-24 years age group was noted to be 18.16% (95% CI, 18.03-18.29). The prevalence of current (30-day) waterpipe smoking was 6.43% (95% CI, 6.34-6.50). The age of initiation of waterpipe smoking was variable. The prevalence of waterpipe smoking was higher among males, among those who belong to the high- and middle-income groups, and among university students. The common risk factors of waterpipe smoking included cigarette smoking, alcohol, and substance use. Waterpipe smoking resulted in increased susceptibility to the use of conventional forms of tobacco (e.g. smoking) among those who were never smokers. CONCLUSION: Waterpipe smoking usage was significantly high among adolescents and young adults. Developing regulatory guidelines for water-pipe smoking, surveillance of its use, intervention, and specific policy frameworks may be considered a public health priority.

Occupational health hazards of bidi workers and their families in India: a scoping review.

BACKGROUND: Bidi workers and their families are exposed to harmful substances during bidi rolling, thereby jeopardising their health. We aimed to assess existing evidence on health conditions of bidi workers and their families in India. METHODS: We searched nine databases and relevant websites, and conducted citation screening to identify primary studies assessing occupational health hazards of bidi workers and their families. Two authors independently conducted screening and data extraction. We synthesised the findings narratively in a structured fashion. RESULTS: We found 3842 studies, out of which 95 studies met our eligibility criteria. High prevalence of disease conditions across all organ systems of the body was reported in bidi workers. Studies on female bidi workers showed decreased fertility (n=2), increased frequency of miscarriages (n=1) and higher risk of cervical cancer (n=1). Pregnant bidi workers were at an increased risk of anaemia and pregnancy-induced hypertension (n=2), higher frequency of neonatal deaths (n=1), stillbirths (n=1) and premature births (n=1) in comparison with non-bidi workers. Babies born to bidi workers reported low birth weight (n=5). Evidence from cohort studies suggests causal nature of the exposure to the disease condition. CONCLUSION: Our review shows that bidi rolling leads to numerous occupational health hazards in bidi workers and their family members. It is essential to provide alternative livelihoods, and safe and protective working environment, and cover bidi workers under various social security provisions to alleviate the deleterious effect of bidi making at home. It is also important to shift bidi making away from home and strengthen existing regulations and promulgation of new provisions, including India's Occupational Safety, Health, and Working Conditions Code 2020.

An Observational Study of the Implementation of the Tobacco-Free Film and Television Policy in India.

Background: Positive portrayals of tobacco use in entertainment media can normalize and perpetuate use. In 2012, the Government of India implemented the Tobacco-Free Film and Television Rules, a first-of-its-kind comprehensive regulation to restrict tobacco depiction in films and television programs. Two complementary studies were undertaken to assess the implementation of the film rules on television and in movie theaters. Methods: In the first part, movie theater observations and exit surveys were conducted from Feb. 3 to March 24, 2015. In total, 308 movie theaters were selected for the observation of films. A total of 3080 exit surveys were conducted to assess moviegoers' reactions toward the film rule. The second part comprised the systematic observation of 424 prerecorded television programs that aired from Nov. 20 to Dec. 30, 2015. Results: Compliance with the Tobacco-Free Film and Television Rules policy was lower on television than in movie theaters. While 66% of television programs with tobacco scenes implemented at least 1 of the 3 elements of the film rule, not a single program executed all required elements correctly. In movie theaters, 99% of films that contained tobacco scenes implemented at least one element of the film rule. However, all elements of the film rules were implemented correctly during 27% of the films observed. Exit surveys showed that among moviegoers who recalled viewing at least one element of the film rule, there was increased concern about tobacco's harms and intentions to quit. Conclusion: Implementation of the film rules was higher in movie theaters than on television, though there were gaps in implementation for both. Despite inconsistent application, audience reactions to the anti-tobacco messages were favorable, with increased concern about tobacco's harms and intention to quit. Overall, the film rules offer a strong tool for countering tobacco promotion, reaching hundreds of millions with anti-tobacco messaging.

Changes in tobacco depictions after implementation of tobacco-free film and TV rules in Bollywood films in India: a trend analysis.

BACKGROUND: India's tobacco-free film and TV rules were implemented from 2012. To assess the effect of the rules, we studied tobacco depictions in top-grossing Bollywood films released between 2006 and 2017 and rule compliance after 2012. METHODS: Tobacco incidents and brand appearances were coded in 240 top-grossing Bollywood films (2006-2017) using the Breathe California method. Trends in number of tobacco incidents per film per year were studied before and after implementation of the rules using Poisson regression analysis. Compliance with rules over the years was studied using Pearson product-moment correlations. RESULTS: Forty-five films were U-rated (all ages), 162 were UA-rated (below age 12 years must be adult-accompanied), and 33 were A-rated (age 18+ years only). Before implementation of the rules, the number of tobacco incidents per film was increasing by a factor of 1.1/year (95% CI 1.0 to 1.2, p=0.002). However, beginning year 2013, the number of incidents per film started falling significantly by a factor of 0.7/year (95% CI 0.6 to 0.9; p=0.012) compared with the previous increasing trend. The percentage of youth-rated (U and UA) films with any tobacco incidents also declined from a peak of 76% in 2012 to 35% in 2017. The percentage of films complying with the rules (audio-visual disclaimers, health spots, static warnings) did not change significantly from 2012 to 2017. CONCLUSION: India's 2012 rules were followed by a reduction in tobacco depictions in Bollywood films. Enhanced monitoring of compliance is needed to ensure the continued effectiveness of the rules.

Revisiting the tax treatment of bidis in India.

BACKGROUND: Bidi use remains an intractable public health problem for India. This is partly due to the informal nature of the bidi supply chain, including tax exemptions for small producers. The aim of this paper is to assess the impact of making all bidis subject to duty and Goods and Services Tax. Although this may require legislative changes and incur some extra administrative costs, the net benefits would include greater oversight of the supply chain as well as increased tax revenues and reduced consumption. METHODS: We use a form of gap analysis (the difference between duty paid and total bidi consumption) to estimate the number of tax-exempt bidis. We then use local evidence on the price elasticity of demand for bidis to assess the impact of eliminating these exemptions on the price and consumption of presently tax-exempt bidis. FINDINGS: Total bidi consumption is estimated at 400 billion sticks per annum, including 275 billion duty paid sticks and 125 billion duty exempt sticks. Removing the small producer exemptions would increase the price of currently exempt bidis by INR4.6/pack. Total bidi consumption would decrease by 6% and the number of smokers would decrease by 2.2 million adults. This would bring the rate of bidi smoking down from 7.7% to 7.5%, while generating INR14.8 billion in tax revenues. CONCLUSIONS: Eliminating India's tax exemptions for small bidis producers would make a significant contribution to tobacco control, both directly by reducing the number of smokers and indirectly by plugging a loophole in the supply chain.

Tobacco imagery in on-demand streaming content popular among adolescents and young adults in India: implications for global tobacco control.

BACKGROUND: India implemented tobacco-free film and TV rules (Rules) to protect adolescents and young adults from tobacco exposure. OBJECTIVE: To assess tobacco imagery in online series popular among adolescents and young adults. METHODS: Ten popular online series on streaming platforms were identified after discussions with participants (aged 15-24 years) in New Delhi, and content-coded for tobacco imagery following the Breathe California protocol. Incidents of tobacco use and brand appearances in each series episode were counted, and compliance with Indian Rules was recorded. RESULTS: 188 episodes across 10 series on Netflix and Amazon Prime Video were coded. Seven series were rated age 16+, two were 18+ and one was 13+. The median number of tobacco incidents per episode in foreign productions was as follows: Amazon's 'The Marvellous Mrs Maisel' (87.5, IQR 62.0-116.0) and Netflix's 'The Crown' (29.0, 18.0-36.0) were higher than Indian productions: Netflix's 'Sacred Games' (9.0, 0.5-14.5) and Amazon's 'Mirzapur' (7.0, 4.0-11.0) (p=0.84). Tobacco incidents per hour ranged from 0 (Bodyguard, Riverdale, 13 Reasons Why) to 106.1 (The Marvellous Mrs Maisel). Seven of 10 series had tobacco imagery and none were compliant with the Rules. CONCLUSION: Contrary to Section 5 of India's Cigarettes and Other Tobacco Products Act, its Rules are not being complied with by the streaming platforms. US-produced streaming media contains more tobacco incidents than Indian-produced media. There is an urgent need for better enforcement of existing Rules on streaming platforms in India, and modernisation of the WHO Framework Convention on Tobacco Control, Article 13 guidelines to account for new streaming platforms to protect youth from tobacco imagery globally.

Economic Costs of Diseases and Deaths Attributable to Tobacco Use in India, 2017-2018.

INTRODUCTION: About 28.6% of Indian adults use tobacco. This study estimates the economic burden of deaths and diseases attributable to smoking and smokeless tobacco (SLT) use for persons aged ≥35 years. METHODS: The National Sample Survey data on healthcare expenditures, the Global Adult Tobacco Survey data on tobacco use prevalence, and relative risks of all-cause mortality from tobacco use were used to estimate the economic burden of diseases and deaths attributable to tobacco use in India, using a prevalence-based attributable-risk approach. Costs are estimated under the following heads: (1) direct medical and nonmedical expenditures; (2) indirect morbidity costs; and (3) indirect mortality costs of premature deaths. RESULTS: Total economic costs attributable to tobacco use from all diseases and deaths in India in the year 2017-2018 for persons 35 years or older amount to INR 1773.4 billion (US $27.5 billion), of which 22% is direct and 78% is indirect cost. Men bear 91% of the total costs. Smoking contributed 74% and SLT use contributed 26% of the costs. CONCLUSIONS: The economic costs of tobacco use amount to approximately 1.04% of India's gross domestic product (GDP), while the excise tax revenue from tobacco in the previous year was only 12.2% of its economic costs. The direct medical costs alone amount to 5.3% of total health expenditure. The enormous costs imposed on the nation's health care system due to tobacco use could potentially stress the public health care system and strain the economy and it warrants massive scaling up of tobacco control efforts in India. IMPLICATIONS: The study finds that the economic burden from tobacco constitutes more than 1% of India's GDP, and the direct health expenditures on treating tobacco-related diseases alone accounts for 5.3% of the total private and public health expenditures in India in a year. It shows that, for every INR 100 that is received as excise taxes from tobacco products, INR 816 of costs is imposed on society through its consumption. It establishes that tobacco consumption is a major resource drain on the national exchequer, and its effective regulation through comprehensive fiscal and non-fiscal policies is highly warranted.

Estimating illicit cigarette consumption using a tax-gap approach, India.

OBJECTIVE: To estimate the magnitude of illicit cigarette consumption in India using a tax-gap approach. METHODS: In the tax-gap analysis, illicit cigarette consumption in India was defined as the difference between total and legal consumption. Data on total cigarette consumption came from two national Global Adult Tobacco Surveys carried out from 2009 to 2010 and from 2016 to 2017. Legal consumption was derived from Government of India data on domestic cigarette production and trade. FINDINGS: Estimated total cigarette consumption was 104.8 billion sticks in 2009 to 2010 and 94.2 billion sticks in 2016 to 2017, a decrease of 10.6 billion sticks, or of 10%, over the time period. Legal cigarette consumption fell from 99.4 to 88.5 billion sticks over the same period, a drop of 11%. Estimated illicit cigarette consumption was, therefore, 5.4 billion sticks in 2009 to 2010 and 5.6 billion sticks in 2016 to 2017, and accounted for 5.1% and 6.0% of the market in these periods, respectively. Consequently, only about 1 in 20 cigarettes consumed in India was illicit. Between 2016 and 2017, the estimated equivalent retail sales value of illicit cigarettes was 49 billion Indian rupees (753 million United States dollars, US$) and the estimated tax revenue foregone was 25 billion Indian rupees (US$ 390 million). CONCLUSION: Illicit cigarette consumption is relatively modest in India by global standards. Nonetheless, India should strengthen its capacity to control the illicit tobacco market as part of a comprehensive tobacco control strategy, while also continuing to implement traditional demand reduction measures, such as tobacco taxation.

The Indian Bidi Industry: Trends in Employment and Wage Differentials.

Background: The bidi industry in India is predominantly an unorganized sector. It continues to enjoy tax benefits, arguably, to protect bidi workers' interests and employment. Our objective was to study trends in employment and wage differentials in the bidi industry using nationally representative data. Methods: We studied trends in employment and wages in the bidi industry using secondary data from the National Sample Survey Office (NSSO) and the Central Statistics Office (CSO), Government of India-the Annual Survey of Industries (ASI) (2000-2001 to 2011-2012) and Enterprises Survey (2000-2001, 2005-2006, 2010-2011). Results: The bidi industry contributed to only 0.65% of the total gross value added (GVA) by the entire manufacturing industry. Employment in this industry was primarily through contractors. Bidi workers earned only 17% of wages compared to workers in other manufacturing industries. Although females constituted the majority of bidi workers, they earned INR 7,000 to 8,000 (USD 155.7 to 178) less than male bidi workers annually. Despite the increase in bidi industry profits from INR 1.7 billion (USD 37.8 million) in 2005-2006 to INR 12.8 billion (USD 285 million) in 2010-2011, the wages of bidi workers have continued to decline over this period. Conclusion: Bidi workers earn much less compared to workers in other manufacturing industries and are subject to income inequality. There is a need to increase registration of the bidi industry for better administration of taxes and prevention of exploitation of the bidi workers. Skill building and alternative employment could provide better job quality, wages, social security and employment benefits.

Changes in the affordability of tobacco products in India during 2007/2008 to 2017/2018: a price-relative-to-income analysis.

BACKGROUND: Increasing the price of tobacco through taxation is a very effective means of reducing tobacco use. However, the impact of price increases can be diluted if consumer incomes are growing strongly. The affordability of tobacco products has, therefore, become an important indicator for tobacco control. This study asks whether tobacco products in India became more or less affordable during 2007/2008 to 2017/2018. METHODS: Survey data on the retail price of chewing tobacco, bidis and cigarettes were used to measure affordability at state and national levels. We adapted the price relative to income measure by calculating the percentage of net state domestic product (NSDP) per capita needed to purchase 1000 g of tobacco in each form and then calculating the average annual percentage change (AAPC) in affordability. We used ordinary least squares regression analysis to test for any changes. RESULTS: In 2017/2018, it took 1.72% and 1.18% of NSDP/capita to purchase 1000 g of tobacco in the form of bidis and chewing tobacco respectively. The affordability of bidis remained unchanged, while chewing tobacco became more affordable (AAPC = -1.83%, 95% confidence interval -2.87 to -0.80, P = 0.003). For cigarettes, it took 7.56% of NSDP/capita to purchase 1000 g of tobacco in 2017/2018; although affordability decreased in many states, national average affordability was unchanged. CONCLUSION: Tobacco products, especially indigenous forms such as bidis and chewing tobacco, have not become measurably less affordable over the past decade. India should raise taxes on all tobacco products to significantly reduce the affordability of these products and to promote public health.

Raw and real: an innovative communication approach to smokeless tobacco control messaging in low and middle-income countries.

The evidence on the efficacy of tobacco control messages in low and middle-income country (LMIC) settings is limited but growing. Low message salience and disengagement, in the face of tobacco control messages, are possible barriers to self-efficacy and cessation-related behaviours of tobacco users. Although adaptations of existing pretested graphic and emotional appeals have been found to impact on behaviours, more personalised, culturally relevant and compelling appeals may more fully engage message receivers to elicit optimal behavioural responses. The objective of these case studies is to use lessons learnt from high-income country tobacco control communication programmes, and adapt practical approaches to provide cost-effective, culturally nuanced, graphic and personalised messages from tobacco victims to achieve the optimal behavioural impact for population-level communication campaigns in the resource-constrained settings of LMICs. The 'raw and real' messaging approach, which emanated from message pretesting in India, outlines creative and production processes for the production of tobacco victim testimonials, given the need to source patients, facing life-threatening conditions. This cost-efficient approach uses real tobacco victims, doctors and family members in a cinéma vérité style approach to achieve more personalised and culturally resonant messages. The methodological approach, used for the development of a number of patient testimonial messages initially in India, and later adapted for tobacco cessation, smoke-free and graphic health warning communication campaigns in other countries, is outlined. Findings from campaigns evaluated to date are encouraging as a result of the simple fact that true stories of local people's suffering are simply too difficult to ignore.

Study of impurity carryover and impurity profile in Febuxostat drug substance by LC-MS/MS technique.

Febuxostat is used in the treatment of hyperuricemia and gout. Several impurities were detected in Febuxostat drug substance. Impurities were identified with the help of LC-MS/MS and were characterized after synthesis by IR and NMR. Reverse phase gradient system was used with Kromasil C18, 150mm×4.6mm, 5µm particle size column for the separation of impurities. Q-TOF mass spectrometer with electrospray ionization (ESI) source was used and operated in ESI positive mode, which gives exact mass up to four decimal places and fragmentation with mass accuracy, it is useful for the identification of impurities. Four impurities were identified as amide, sec-butyl, des-cyano and des-acid in Febuxostat drug analog. These impurities were further confirmed by NMR and FT-IR spectral data.