Trends in age of tobacco use initiation over time in Bangladesh, India and Pakistan: analysis of cross-sectional nationally representative surveys.

OBJECTIVE: Tobacco use begins at an early age and typically leads to a long-term addiction. The age of initiation for tobacco use is not well studied in South Asia, where 22% of tobacco smokers and 81% of smokeless tobacco (SLT) users reside. METHODS: Data from the nationally representative Global Adult Tobacco Surveys in India, Bangladesh and Pakistan were analysed to examine patterns of initiation among smokers and smokeless tobacco users. RESULTS: Data on 94 651 individuals were analysed, of which 13 396 reported were ever daily smokers and 17 684 were ever SLT users. The proportion of individuals initiating tobacco use before the age of 15 years has increased over time. The rates of SLT initiation among those aged 15-24 years increased markedly in Bangladesh (by 7.8%) and Pakistan (by 37.7%) between 1983 and 1999-2000. Among males, the increase in SLT initiation was higher in individuals aged below 15 years compared with other age groups in India and Bangladesh. Smoking initiation among females aged below 15 years has also significantly increased in India over time. Compared with the initiation of tobacco smoking before the age of 15 years, a greater increase in the proportion of SLT users was observed in urban areas. CONCLUSION: Our findings indicate that the proportion of youth initiating tobacco (both smoking and smokeless) before the age of 15 years has increased over time in all three countries. Moreover, variations in age at initiation for different types of tobacco products across countries, and by rurality, were noticeable. Younger youths (aged up to 15 years) should therefore be a priority population for tobacco control interventions. Strategies such as raising the legal age of tobacco sale and use to 21 years, and, other measures under WHO Framework Convention on Tobacco Control (FCTC), may prevent underage use and avert lifelong addiction to tobacco products.

Trends and determinants of tobacco use initiation in India: analysis of two rounds of the Global Adult Tobacco Survey.

OBJECTIVES: Early initiation of tobacco use can lead to lifelong addiction and increases tobacco-attributable morbidity and mortality. This study assesses trends in tobacco use initiation and factors associated with tobacco use initiation using disaggregated data from two rounds of the Global Adult Tobacco Survey India (GATS; 2009-2010 (GATS 1) and 2016-2017 (GATS 2)). DESIGN: Secondary analysis of repeated cross-sectional studies. SETTINGS AND PARTICIPANTS: The study involved data from 69 296 individuals and 76 069 households in GATS 1 and 74 037 individuals and 77 170 households in GATS 2, two rounds of a nationally representative survey in India. OUTCOME MEASURES: Mean age of initiation (as recalled by the participants) of smoked and smokeless tobacco (SLT) use (dependent variable) was compared and analysed across different sociodemographic variables (independent factors). We assessed change in mean age of initiation of tobacco usage on a daily basis between GATS 1 and GATS 2, and investigated the factors associated with early tobacco use initiation in the GATS 2 dataset (reported using adjusted ORs (aORs) with 95% CIs). RESULTS: The mean age of initiation of smoked tobacco and SLT in GATS 2 was 20.9±8.5 and 22.3±10.6 years, compared with 18.5±9.7 and 19.7±12.0 years in GATS 1. The mean age of initiation increased with age and among those who were better aware of the adverse effects of tobacco. As per GATS 2, males initiated smoked tobacco and SLT use earlier (20.6±7.4 and 21.7±9.1) than females (23.3±14.2 and 23.2±12.6 years). Younger participants (15-24 years) reported earlier initiation of SLT (15.5±4.2 years) compared with others. Binary logistic regression depicted variables associated with early initiation of tobacco. Awareness about the harms caused by tobacco affected the odds of SLT (aOR 1.4, 95% CI 1.3 to 1.7) and dual usage initiation (1.8, 1.6 to 2.0), but not of initiation of smoked tobacco products (1.1, 0.9 to 1.2). CONCLUSIONS: More robust health advocacy campaigns that communicate the harmful effects of tobacco on health could be useful to delay tobacco initiation, along with reducing the ease of access and affordability of tobacco products among vulnerable groups.

Estimating the weight of consumed tobacco product waste in various Indian states: a novel method to assess the potential burden of tobacco product waste.

INTRODUCTION: The direct morbidity and mortality caused by tobacco are well documented, but such products also contribute to a range of environmental pollutants resulting from tobacco product waste. No previous studies have yet quantified tobacco product waste in a low-income and middle-income country (LMIC). This study estimates the potential annual waste generated due to consumption of smoked and smokeless tobacco products in India and its states. METHODOLOGY: We systematically collected samples of smoked and smokeless tobacco products from 33 districts of 17 Indian states/union territories. Stratified weights of plastic, paper, foil and filter packaging components, and gross empty package weights were recorded. Prevalence of smoking and smokeless tobacco use at national and state-level estimates was derived from the Global Adult Tobacco Survey (2016-2017) to quantify waste potentially generated by tobacco products. RESULTS: We included 222 brands of tobacco products (70 cigarette, 94 bidi and 58 smokeless tobacco brands) in the final analysis. A total of 170 331 (±29 332) tonnes of waste was estimated to be generated annually, out of which 43.2% was plastic, 3.6% was foil and 0.8% was filter. Two-thirds of the overall waste was contributed by smokeless products alone. Maximum waste was generated in Uttar Pradesh (20.9%; 35 723.7±6151.6 tonnes), Maharashtra (8.9%; 15 116.84±2603.12 tonnes) and West Bengal (8.6%; 14 636.32±2520.37 tonnes). CONCLUSION: This study provides first of its kind national-level evidence on the types (plastic, paper, foil and filter) and quantity of waste potentially generated by use of tobacco products in India. Similar studies from other LMICs can serve to raise consciousness about many negative environmental impacts of tobacco products and need for policies to address them.

Compliance to Online Retail of Electronic Nicotine Delivery Systems (ENDS) in India before and after the 2018 Ban Order of the Government of India.

Since their launch globally in 2012, electronic nicotine delivery systems (ENDS) were positioned as a harm reduction strategy and cessation device but it is yet to be proven to have clinical safety or public health benefits. Instead, recent reports suggest that the tobacco industry targeted youth and sponsored research whose evidence was used to mislead policymaking. On August 28, 2018, Ministry of Health & Family Welfare's advisory banned the sale, purchase, and trade of ENDS. A survey was done in two waves. The first survey was done between August 10 and 25 2018 all websites which sold ENDS product were mapped and documented. The survey was repeated (November 30, 2018) were after the restriction to trade on ENDS was proposed by the Department of Customs. The two waves of survey found that no website, whether comprehensive e-commerce portals or dedicated ENDS marketing platforms fully complied with government orders. National and states government enforcement agencies are currently unaware of internet-based sale of ENDS. Although some states have given specific directions to stop the sale and delivery of ENDS within the state through e-commerce, there is limited monitoring and legal compliance by seller. Public health advocates need to stay vigilant and monitor the online sale and point of sale retail of ENDS to ensure strict compliance of national and state regulations.

Banning Loose Cigarettes and Other Tobacco Products in India: A Policy Analysis.

BACKGROUND: Sale of single cigarettes (also known as singles or loosies) is a key driver for early initiation of smoking and is a leading contributor to the smoking epidemic in India. Sale of singles additionally deter implementation of tobacco control strategies of pictorial health warnings including plain packaging and defeat effective taxation and promote illicit trade. We review India's tobacco control policy responses towards banning singles and other products sold as loose tobacco and identify opportunities for future policy intervention especially in the context of the ongoing COVID-19 pandemic. METHODS: Existing national and sub-national policy documents were analyzed for their content since the inception of the tobacco control laws in the country. RESULTS: There are no effective provisions at national level to ban loose tobacco products in India. However, the implementation of multiple legislative and regulatory measures (Acts/circulars/letters/notifications/orders/court judgements) in 16 Indian states and jurisdictions provide sufficient legal framework to substantiate its complete ban pan India. While the majority of state governments have adopted state level measures, Rajasthan had issued specific directive to all the 33 districts banning loose cigarettes and other tobacco products. Himachal Pradesh introduced the most unique and comprehensive legislation, for banning the sale of cigarettes and beedis (Dated November 7, 2016). The most recent notification in the state of Maharashtra (September 24, 2020) is the first to leverage powers using a mix of national and state legislations including the legislation addressing the rapidly emerging challenge of managing COVID-19. CONCLUSION: A robust national policy which supports strong provision to deter tobacco companies, their distribution network and vendors from selling singles or loose tobacco products is urgently needed. Such policy should be backed by cautionary messaging for consumers as well. Eliminating singles and loose tobacco sale will help in blunting tobacco use prevalence besides curbing spread of infectious diseases like COVID-19 pandemic.

Raising the Age of Purchase and Use of Tobacco Product in Bangladesh: Benefits and Challenges in Protecting Youth from the Tobacco Epidemic.

BACKGROUND: Tobacco use among young and adolescents is the biggest threat to public health globally. In Bangladesh, every one in 14 youth (13-15 years) uses tobacco in some form. While this problem is growing in the country, we estimate the underage initiation of tobacco use and present evidence that policy measures like increasing the age of purchase and use from the current 18 years to 21 years in the country backed with current tobacco control efforts and adopting vendor licensing will significantly reduce future tobacco burden. METHOD: We analysed the two rounds of nationally representative Global Adult Tobacco Survey (GATS) data: GATS-1 (2009-10) and GATS-2 (2016-17) and segregated the data for two categories of tobacco consumption (smokers and smokeless tobacco users) based on the age of initiation (<18, 18-21 and >21 years). Consumption patterns were also analyaed by using the GATS-2 data. Projections from sub-national level analysis for youth initiating tobacco use before 21 years and change in the prevalence of overall underage tobacco users were calculated based on weighted value. RESULT: According to GATS-2, around 89% of current tobacco users initiated tobacco use into daily use before the age of 18 years in Bangladesh. Whereas, striking differences were observed (statistically significant) for the average age of initiation of smoking among smokers aged 20-34 increased from 17.4 in 2009 to 19.3 years; and 20.1 to 22 years for SLT.  Moreover, more than 24% of them initiated into regular smoking before the age of 15 years. CONCLUSION: There is an increasing trends of tobacco initiation among the underage youth of Bangladesh. By increasing the age of access, sale, purchase, and use of tobacco from current 18 years to 21 years will significantly reduce youth initiation and taper down the overall adult tobacco use prevalence over the long run in Bangladesh.

Raising the legal age for purchase and use of tobacco to 21 years: A step towards tobacco endgame in India.

BACKGROUND: Globally, policies to counter targeting of young people by the tobacco industry have proven to be effective and a key determinant of reducing the magnitude of tobacco epidemic. This paper presents a case for increasing the minimum legal age to access tobacco to 21 years in India. METHOD: We analysed the two rounds of nationally representative Global Adult Tobacco Survey (GATS) data: GATS-1 (2009-10) and GATS-2 (2016-17). We segregated data for two categories of tobacco consumption (smokers and smokeless tobacco users) at the age of initiation (<18, 18-21 and >21 years) and analysed for their consumption patterns found during the time of the survey (current daily, current less than daily, former and ever users) from GATS-2 (2016-17). Further, we compared the projections from the sub-national level analysis for youth initiating tobacco use before 21 years and change in the prevalence of overall underage tobacco users between the two survey rounds. RESULT: Nearly 77% of smokers and 75% smokeless tobacco users in India initiate tobacco use before or until the age of 21 years. Many large, most populous and high tobacco prevalence states had higher than national mean (14.1%) of youth initiating into tobacco use before 21 years. Overall, as compared to GATS-1, there is a perceptible increase in the prevalence of underage tobacco use in most states. CONCLUSION: Global best practices and the significant number of young tobacco users in India call for increasing the age of access to tobacco from the current 18 years to 21 years. This will help in reducing the overall adult tobacco use prevalence in the longer run in India.

Indirect tobacco advertising, promotion and sponsorships in the Indian Premier League 2020: Tobacco Industry's continuous presence in Indian cricket.

BACKGROUND: Indian Premier League (IPL) cricket tournament - a shorter version of the sport which is played between assorted company-owned or individual owner teams - has grown immensely popular over the last decade. There is long history of tobacco advertisement, promotion and sponsorship (TAPS) in cricket. While direct and indirect TAPS is completely prohibited under the Cigarettes and Other Tobacco Products Act (COTPA), 2003 the nexus between tobacco industry and cricket in India continues. We monitored any tobacco product and allied brand or surrogate advertisement, promotion, sponsorship (TAPS) or placement during every match played in the IPL-13 season in the year 2020. METHODS: Using an investigative approach, 60 match highlights during IPL-13 (during September 19 to November 10, 2020) were monitored for TAPS (both on-site i.e. sportswear and/or in stadia) shown on the official website (www.iplt20.com). All sponsors and advertisers were validated using brand names or logos from their respective official website. RESULTS: Two IPL teams (Rajasthan Royals and Royal Challengers Bangalore) were sponsored by major tobacco industry owned brands. Violations by a major smokeless tobacco company promoting their brand extension product i.e. Vimal Elaichi, on the official telecast websites (www.espncricinfo.com and www.cricbuzz.com) and television channels (www.Zeenews.india.com/Gujarati) was observed. Tobacco companies i.e. Kamla Pasand and ITC Limited were also listed as associate sponsors for the 2020 championship. CONCLUSION: Despite comprehensive ban under India's tobacco control law (COTPA, 2003), sponsorship by tobacco industry was found widespread in IPL-13. Advertisement and logos of tobacco companies are persistent during the telecast and promotion of the IPL events, in clear violation of India's tobacco control legislation and Article 13 of WHO's Framework Convention on Tobacco Control (WHO-FCTC) and its guidelines. Given that India and South Asia comprise the largest audience for televised cricket, strong exclusion criteria is needed by the international cricket authority and national cricket associations to ensure compliance with the national law and global good practice, making the cricketing world truly tobacco free.

Tobacco Industry Interference Index: Implementation of the World Health Organization's Framework Convention on Tobacco Control Article 5.3 in India.

In India, there has been no attempt to measure the implementation of World Health Organization's Framework Convention on Tobacco Control Article 5.3, which provides guidelines to address tobacco industry interference (TII). This study draws on a desk review conducted to assess the frequency and severity of TIIs and the government's response, reported between January and December 2017. This study highlights that the government of India does not allow tobacco industry to participate in policy development. However, the industry interferes by collaborating with the government's allied organizations. The tobacco industry has diversified as food industry in India, and directly or indirectly supports various government programs, by investing through their corporate social responsibility schemes. In addition, there are limited legislative measures to allow transparency in adoption of Article 5.3 guidelines across the country. Hence, the findings of this study underscore an exigent need to adopt and implement Article 5.3 at the national level in India.

Dual Burden of Smoked and Smokeless Tobacco Use in India, 2009-2017: A Repeated Cross-Sectional Analysis Based on Global Adult Tobacco Survey.

INTRODUCTION: The dual use of smoked and smokeless tobacco (SLT) poses a serious challenge to tobacco control efforts. This article examines the trends and patterns of this usage in India during the period 2009-2010 and 2016-2017. METHODS: Data from two rounds of nationally representative cross-sectional Global Adult Tobacco Survey (GATS) conducted in 2009-2010 and 2016-2017 have been used. Dual use was assessed based on current smokers and SLT users in both rounds. RESULTS: Findings reveal that dual use in India has dropped from 5.3% during 2009-2010 to 3.4% during 2016-2017, a decline of nearly 10 million dual users. However, some states have added nearly 4.6 million new dual users during this period. While dual use continues to remain high in rural areas, there has been a manifold increase in urban areas. Findings revealed that intention to quit tobacco was lower among dual tobacco users as compared to single users with considerable difference between urban and rural areas. CONCLUSION: Easy availability and affordability of SLT products compared to smoking products and restrictions on smoking in public places may have pushed current smokers and dual users to take to or intensify their SLT consumption. Measures relating to awareness, pricing, taxation, and enforcement of tobacco control laws should focus on all forms of tobacco, especially targeting high dual burden in rural and urban settings. IMPLICATIONS: Dual form of tobacco users represent 12% of all tobacco users in the country. The study reveals that intention to quit tobacco among dual users is significantly lower than that among single tobacco product users. This requires improving public awareness about the morbidity and mortality that arises from the use of all forms of tobacco products. Efforts to restrict the availability of tobacco products should focus on licensing the sale of all tobacco products. Reduction in dual tobacco use will not only result in multiplied health benefits but also help in achieving the Non-Communicable Diseases targets under the United Nations Sustainable Development Goals.

Fuelling the tuberculosis epidemic: The role of tobacco control in ending the TB emergency.

BACKGROUND: Ending the TB epidemic by 2030 is among the key targets for countries to achieve Sustainable Development Goals. In current times we are grappling with dual burden of tuberculosis as well as tobacco use. METHODS: There is sufficient evidence to establish that tobacco smoking significantly spikes up the risk of acquiring, developing and death among tuberculosis patients. Active or passive exposure to tobacco smoke is significantly associated with tuberculosis infection and tuberculosis disease, independent of a large number of other potential confounders. RESULTS: Despite having substantial evidence about the impact of tobacco control measures, particularly tobacco cessation, on TB outcomes, the integration of TB and tobacco control still remains far-off. CONCLUSION: It is high time when TB control programs must begin to address tobacco control as a potential preventive intervention to combat colliding epidemics of tobacco and tuberculosis. This white paper discusses about the role of tobacco control in reaching the ambitious goal of ending TB epidemic by 2030.

Capacity Building through Operational Research Training in Tobacco Control: Experiences and Lesson Learned.

BACKGROUND: Several competing priorities with health and development sector currently deter research, and as a result of which evidence does not drive policy- or decision-making. There is limited operational research (OR) within the India's National Tobacco Control Programme, as it is in other middle- and low-income countries, primarily due to limited capacity and skills in undertaking OR and lack of dedicated funding. Few models of OR have been developed to meet the needs of different settings; however, they were found to be costly and time-consuming. OBJECTIVE: To elucidate a cost-effective and less resource arduous training model for building capacity in OR focused on tobacco control. MATERIALS AND METHODS: This 5½-day partly funded course enrolled 15 participants across the country and nine facilitators. The facilitator-participants interactions were initiated 2 weeks before the course, which enabled them to develop possible research questions and a plan for data analysis. RESULTS: This article presents the new OR model along with experiences of the participants which will provide useful insights on lessons learned for planning similar courses in the future. While we faced several challenges in the process and the outputs were modest, several lessons were learned which will be instrumental in the future courses that we are planning to conduct. CONCLUSION: This low cost and less time intensive model can be applied in similar settings across range of public health issues.

Open access tools for quality-assured and efficient data entry in a large, state-wide tobacco survey in India.

BACKGROUND: A large state-wide tobacco survey was conducted using modified version of pretested, globally validated Global Adult Tobacco Survey (GATS) questionnaire in 2015-22016 in Tamil Nadu, India. Due to resource constrains, data collection was carrid out using paper-based questionnaires (unlike the GATS-India, 2009-2010, which used hand-held computer devices) while data entry was done using open access tools. The objective of this paper is to describe the process of data entry and assess its quality assurance and efficiency. METHODS: In EpiData language, a variable is referred to as 'field' and a questionnaire (set of fields) as 'record'. EpiData software was used for double data entry with adequate checks followed by validation. Teamviewer was used for remote training and trouble shooting. The EpiData databases (one each for each district and each zone in Chennai city) were housed in shared Dropbox folders, which enabled secure sharing of files and automatic back-up. Each database for a district/zone had separate file for data entry of household level and individual level questionnaire. RESULTS: Of 32,945 households, there were 111,363 individuals aged ≥15 years. The average proportion of records with data entry errors for a district/zone in household level and individual level file was 4% and 24%, respectively. These are the errors that would have gone unnoticed if single entry was used. The median (inter-quartile range) time taken for double data entry for a single household level and individual level questionnaire was 30 (24, 40) s and 86 (64, 126) s, respectively. CONCLUSION: Efficient and quality-assured near-real-time data entry in a large sub-national tobacco survey was performed using innovative, resource-efficient use of open access tools.

Opening gambit: Strategic options to initiate the tobacco endgame.

Endgame strategies to rapidly hasten the decline of tobacco are already well within reach; a few plausible policy options are outlined herein for policy practitioners, tobacco control advocates, and public health specialists. The implementation of these measures which already exist within the gamut of existing legislation requires the galvanization of political will. The options we essay include liquidating existing public investments in tobacco, holding tobacco companies accountable within the jurisdictions of their operations, fixing liability for injury and the imposition of realistic costs on insurance providers.

Education differential in relation to tobacco use and its predictors across different regions of India.

BACKGROUND: Tobacco use and education of an individual are linked to each other. Educated people are more likely to practice healthy behaviors and are aware of the harms of tobacco use. This paper uses the Global Adult Tobacco Survey data (GATS-India) to study the education differential associated with tobacco use and its predictors across India. METHODOLOGY: Secondary data analysis was conducted for GATS conducted in 2009-2010 in India. Data for "illiterate" and "literate" study subjects were analyzed according to study subject's "tobacco consumption pattern," their "quitting behavior," "exposure to second hand smoke (SHS)" and "observing health warnings on tobacco products." RESULTS: Tobacco smokers and smokeless tobacco users were more likely to be illiterate (odds ratio [OR] for smoking tobacco = 1.2; for smokeless tobacco = 1.5) as compared to their counterparts. Significantly, more illiterate initiated smoking tobacco (OR = 1.1; 1.02-1.26) and smokeless tobacco habit (OR = 1.3; 1.21-1.44) before 17 years of age. Illiterate people were less likely to try quitting tobacco (smoking tobacco = OR = 0.8; 0.79-0.94; smokeless tobacco = OR = 0.7; 0.70-0.81) and also less likely to think of quitting tobacco in near future (smoking tobacco = OR = 0.6; 0.59-0.71; smokeless tobacco = OR = 0.6; 0.57-0.66). Illiterate people were more likely to be exposed to SHS at home (OR = 1.8; 1.7-1.9) and less likely to notice health warnings on cigarette packets (OR = 0.2; 0.26-0.28) and smokeless tobacco pouches (unadjusted OR = 0.5; 0.49-0.53). CONCLUSION: The results confirm that education differential exists for tobacco use and its determinants in India. It is recommended that all people of our country should have access to quality education. Policy makers should target uneducated people so as to reverse the tobacco epidemic.

In harm's way: tobacco industry revenues from sales to underage tobacco users in India.

BACKGROUND: In 2010, the global adult tobacco survey (GATS) for India revealed that nearly 40% of current smokers and 42% of current chewers had initiated tobacco use before they were of the legal age (18 years old or over). Global evidence shows that those who initiate earlier have a lower probability of quitting the use of tobacco during their lifetime. In order to sustain its profits, the tobacco industry will make every effort to recruit underage users who become lifelong users of their products. AIMS AND OBJECTIVES: We estimate the consumer expenditure on tobacco products by underage users in India. METHODOLOGY: Using nationally representative data we estimated the number of daily underage tobacco users for a year and their annual expenditure on different types of smoked and chewed tobacco products. RESULTS: There are nearly 4.4 million underage daily tobacco users (age group 15-17 years old) in India. Approximately 7.2% of the population in the 15-17 age group are current daily users of tobacco (0.1% cigarette smokers, 0.5% bidi smokers and 6.6% tobacco chewers). Underage users spend nearly US$16.9 million and US$270.8 million respectively on smoking and chewing tobacco products. CONCLUSION: There is a substantial expenditure on tobacco products by underage individuals in India. A significant number of new users are added every year that provide an estimate for the size and nature of the future of the tobacco epidemic, one on which the tobacco industry depends on for its sustenance. The government of India's efforts to reduce sale to underage users has had limited effect and needs to be strengthened.

Predictors of Tobacco Use among Youth in India: GATS 2009-2010 Survey.

BACKGROUND: Tobacco use among youth in India is an increasingly rising burden. It is affected by various socio-demographic factors, which form predictors of use. Focus on these predictors can help policy makers in curbing the major morbidity and mortality due to tobacco among youth. OBJECTIVE: To study the various socio- demographic variables associated with tobacco use among youth in India. MATERIALS AND METHODS: The study was a secondary analysis of data from the Global Adult Tobacco Survey, India 2009-10, in the age group of 15-24 years. Predictors of smoking and smokeless tobacco were analysed using data on occupation, education, and other sociodemographic factors place of living. Epi Info used for conducting the analysis. RESULTS: The total population interviewed in GATS India -2010 was 69,926. Of these the youth population between 15- 24. The total number of tobacco users (smokers and smokeless) was 2,969 (22.%). There were 11 (3.05%) dual users. Smokeless form of tobacco (15.1%) was used more than smoked form among youth. Males and urban youth preferred smoked form of tobacco over smokeless form. Smoking among youth had an inverse relation with increasing education level. Majority of smokeless form of tobacco users and dual users belonged to poor economic classes. CONCLUSIONS: This productive age group is more susceptible to tobacco addiction, especially smokeless tobacco. Rural youth, students, female sex and poor socio-economic strata prefer smokeless whereas urban, male and lesser educated youth preferred smoked form of tobacco. Efforts should be directed towards discouraging tobacco use initiation among the young population in India.

The Single Cigarette Economy in India--a Back of the Envelope Survey to Estimate its Magnitude.

BACKGROUND: Sale of single cigarettes is an important factor for early experimentation, initiation and persistence of tobacco use and a vital factor in the smoking epidemic in India as it is globally. Single cigarettes also promote the sale of illicit cigarettes and neutralises the effect of pack warnings and effective taxation, making tobacco more accessible and affordable to minors. This is the first study to our knowledge which estimates the size of the single stick market in India. MATERIALS AND METHODS: In February 2014, a 10 jurisdiction survey was conducted across India to estimate the sale of cigarettes in packs and sticks, by brands and price over a full business day. RESULTS: We estimate that nearly 75% of all cigarettes are sold as single sticks annually, which translates to nearly half a billion US dollars or 30 percent of the India's excise revenues from all cigarettes. This is the price which the consumers pay but is not captured through tax and therefore pervades into an informal economy. CONCLUSIONS: Tracking the retail price of single cigarettes is an efficient way to determine the willingness to pay by cigarette smokers and is a possible method to determine the tax rates in the absence of any other rationale.