Divya et al:

Tobacco Related Cancer before and after implementation of National Tobacco Control Program

Volume No: 8, Issue No: 4

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ISSN No: 2582-0559

ABSTRACT

India's responsibility towards the arrangement, and
progressively successful reduction in the usage of tobacco
under “Cigarette and Other Tobacco Products Act” (COTPA)
and “Framework Convention for Tobacco Control” (FCTC)
prompted the introduction of the National Tobacco Control
Program (NTCP) in 2007–2008. This study aimed to compare
the incidence of tobacco related cancers before and after
implementation of NTCP in India. All the sources which have
the statistics on cancer incidence in India were identified and
the data was extracted to compare the cancer incidences.
Secondary data from the sources such as National Cancer
Control Registry, Global adult tobacco survey report etc. were
collected and tabulated. The results showed that the usage of
smokeless tobacco has decreased to 17.6% in 2015 after the
implementation of NTCP from 23.4% in 2005. Same way the
prevalence in the usage of smoked tobacco has reduced
considerably from 18.3% in 2005 to 11.9% in 2009 after the
implementation of NTCP. In Mumbai, the number of cancer
patients due to tobacco usage has decreased from 7642 to 3625.
But in Chennai, the total number have increased from 2000-
2014. By the analysis of  incidence  of tobacco  related cancers
and tobacco consumption in India, it is evident that the usage of
tobacco products both smoke  and smokeless  tobacco
consumption have  decreased after the  implementation of  NTCP.

KEYWORDS:

National Tobacco Control Program, tobacco

related cancers, Comparison, Tobacco, India

TOBACCO RELATED CANCER INCIDENCE - A TIME TRAVEL

COMPARATIVE ANALYSIS BEFORE AND AFTER

IMPLEMENTATION OF NATIONAL TOBACCO CONTROL

PROGRAMME IN INDIA

Dr. N. Divya Lalitha*, Dr. Prabu.D, Dr. Rajmohan, Dr. Sunayana Manipal, Dr. Bharathwaj.V.V

* National Oral Health Programme Centre for Dental Education Research, All India Institute of Medical Sciences, India

Department of Public Health Dentistry, SRM Dental College,Ramapuram, Chennai, Tamilnadu, India

DOI: 1.37841/jidam_2021_V8_I4_02

Address for Correspondence:

Dr. N. Divya Lalitha, Research Officer,
National Oral Health Programme Centre for Dental
Education Research,
All India Institute of Medical Sciences, Ansari Nagar,
New Delhi –110029, India

Email id:

diyan2409@gmail.com

Received:

20.02.2021

First Published:

19.03.2021

Accepted:

16.03.2021

Published:

27.12.2021

OBSERVATIONAL RESEARCH ARTICLE

Divya et al:

Tobacco Related Cancer before and after implementation of National Tobacco Control Program

Volume No: 8, Issue No: 4

152

ISSN No: 2582-0559

INTRODUCTION

Oral Cancer is one among the significant issues in the India
and it takes a position in the first three kinds of cancers in
the nation

. It has a signiﬁcant importance in terms of

public health in India.

Age-balanced rates of oral malignant growth is high in
India, for instance, 20 for each 100,000 people and records
for about 30% of the tumours in the nation

. The variety in

incidences and prevalence of the infections can be credited
to the ageing of the people, just as territorial variations in

the common disease speciﬁc high risk factors

Basically, oral cancer is analysed at later stages which bring
about low treatment results and extensive expenses to the
patients who regularly can't afford this sort of treatments

Prior discovery of oral malignant growth offers the most
obvious opportunity for better prognosis and can possibly
improve treatment results and make medicinal services
affordable

. Oral diseases affects mainly those from lower

financial status, that is, individuals from the lower financial
strata of society because of a higher presentation to hazard
factors, for example, usage of tobacco

. Furthermore, rural

areas and  low-income nations additionally have lacking
access to skilled health  care providers.  Therefore, delay has
additionally been  to  a great  extent connected  with end
stages of oral  cancers

In 2003, India ordered the "Cigarette and Other Tobacco
Products Act," known as COTPA, yet the greater part of its
arrangements came in 2004. In 2004, India turned into a
signatory to the Framework Convention for Tobacco
Control (FCTC), drove by the World Health Organization.
From 2007 to 2008 ahead, the usage of all tobacco control
laws is under the National Tobacco Control Cell under the
National Tobacco Control Program

India's responsibility towards the arrangement, and
progressively successful reduction in the usage of tobacco
under FCTC and COTPA prompted the instigation of the
National Tobacco Control Program (NTCP) in 2007–2008

Initially created as a pilot venture in two areas in every one
of nine Indian states

, the NTCP was extended in 2008–

2009 to cover an aggregate of 42 districts and 21 states and
has been extended to 400 regions across India

The  key objectives of  NTCP are  improving the awareness
about existing  tobacco  control  laws and the destructive
impacts of tobacco usage; and encourage powerful  usage  of
tobacco control laws and strategies

9-10

There is an improved awareness about tobacco products,
and reduction in the usage of tobacco products post NTCP
in India. This study aimed to compare the incidence of oral
cancer before and after implementation of NTCP in India.

MATERIALS AND METHODS:

This study was conducted to compare the incidence of oral
cancer before and after implementation of “National
Tobacco Control Program” in India. Secondary data
regarding the incidence of oral cancer from 2004-2019 was
collected and analysed.

The study population included patients who registered
themselves having cancer according to National Cancer
Control Registry. All men and women having cancer were
included to compare the incidence of cancer during the year
2004-2019, i.e. before and after the implementation of
National Tobacco Control Program.

The inclusion criteria included all the patients who
registered themselves in the cancer control registry during
the period of 2004- 2019.

Secondary data regarding the incidence of cancer in men
and women were collected and compared to see the
effectiveness of National Tobacco Control Program. The
incidence of cancer before and after 2007 i.e. after the
implementation of National Tobacco Control Program was
collected from different sources to do year wise
comparison. Articles from different databases such as Pub
Med, Medline, Scopus etc. using the keywords tobacco
related cancers and National Tobacco Control Program
were collected and included in the study.

All the sources which have the statistics on cancer
incidence in India were identified and the data was
extracted to compare the incidences. Secondary data from
the sources were collected and tabulated.

RESULTS:

TABLE 1: INCIDENCE OF CANCER IN INDIA
BEFORE AND AFTER NATIONAL TOBACCO
CONTROL PROGRAM AMONG MALES AND
FEMALES

Year

Incidences of

cancer in Male

Incidences of

cancer in Female

Total No. of

Patients

BEFORE National T obacco Control Program

2005

40000

43000

83000

2006

40000

45000

85000

2007

42000

47000

89000

AFT ER National Tobacco Control Program

2008

44000

49000

93000

2009

454842

507990

962832

Divya et al:

Tobacco Related Cancer before and after implementation of National Tobacco Control Program

Volume No: 8, Issue No: 4

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ISSN No: 2582-0559

2010

462408

517378

979786

2015

55000

60000

110000

2019 58000

65000

123000

Source: Cancer India growth statistics

Table 1 shows the Year wise Incidence of Cancer before
and after NTCP in Males and Females. It shows that there is
an increase in terms of cancer patients after 2008 that is
after the implementation of NTCP.

TABLE 2: DISTRIB UTION OF TOBACCO RELATED
CANCERS IN INDIA ACCORDING TO STATES

CANCE R

T YPE

HIGHLY

AFFECT ED ST AT E

MODERAT ELY

AFFECT ED

ST AT E

LEAST

AFFECT ED

ST AT E

Lung

Jammu and Kashmir,

Delhi, Himachal

Pradesh,

Maharashtra,

Rajasthan, Andhra

Pradesh. W. Bengal

Manipur,

Uttarakhand,
T ripura ,

Jharkhand,

Kerala

Nil

Cervix

Himachal Pradesh,

T amil Nadu,

Haryana

Goa, West

Bengal,

Rajasthan

Punjab,

Andhra

Pradesh,

Uttar

Pradesh.

Stomach

T amil Nadu, Goa.

Andhra Pradesh,
Uttarakhand

Jammu and
Kashmir,
Arunachal
Pradesh,
Sikkim,
Manipur,
Nagaland

Oesophagus Karnataka, Assam

Jammu and

Kashmir

None

Oral cavity

Uttar Pradesh,

Gujarat, Pondicherry,
Orissa

None

Assam

Tongue

Goa,

MadhyaPradesh

None

Oro-

pharynx

Haryana, Meghalaya

None

Naso-

pharynx

None

Manipur, Assam

None

Neck

None

T ripura

Uttarakhand

Larynx

None

Uttarakhand

None

Source: Cancer India growth statistics

Table 2 shows the State-wise distribution of tobacco related
cancers in India. It shows that the states highly affected
with oral cancer in India are Uttar Pradesh, Gujarat,
Pondicherry, Orissa. The least affected state in India with
oral cancer is Assam.

TABLE 3: CANCERS COMMON AMONG MALE,
FEMALE AND CHILDREN IN INDIA

Male

Female

Child

Oral Cavity

Leukemia

Oesophagus

Breast

Central nervous system and

Brain related tumours

Leukemia

Thyroid

Lymphoma

Pharynx

Stomach

Wilms tumour

Stomach

Leukemia

Neuroblastoma

Lymphoma

Oesophagus

Bone Cancer

Lung

Ovary

Retinoblastoma

Brain and Nervous

system

Cervix

Rhabdomyosarcoma

Liver

Pharynx

Osteosarcoma

Larynx

Lymphoma

Ewing Sarcoma

Source: Cancer India growth statistics

Table 3 shows Cancer common among Men, Women and
Children. Oral cancer is more prevalent in case of men as
well as women in India.

TABLE 4: TRENDS IN THE PREVALENCE OF
TOBACCO CONSUMPTION AMONG ADULTS IN
INDIA B EFORE AND AFTER NATIONAL
TOBACCO CONTROL PROGRAM

YEAR

SMO KELESS

T OBACCO

SMO KED

T OBACCO

Before National Tobacco Control Program

1987

15.0 %

19.8 %

1993

13.2%

17.2%

1995

14.1%

17.6%

1998

17.2%

13.7%

2005

23.4%

18.3%

After National T obacco Control Program

2009

24.2%

11.9%

2015

17.6%

12.5%

2016

19.3%

8.6%

Source: Trends in tobacco consumption in India 1987–
2016: impact of the World Health Organization Framework
Convention on Tobacco Control. International journal of
public health. 2019;64(6):841-51

Table 4 shows the trends in the prevalence of tobacco
consumption among adults in India before and after
National Tobacco Control Program. It shows that the usage
of smokeless tobacco has decreased to 17.6% in 2015 after
the implementation of National Tobacco Control Program

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from 23.4% in 2005. Same way the prevalence in the usage
of smoked tobacco has reduced considerably from 18.3% in
2005 to 11.9% in 2009 after the implementation of National
Tobacco Control Program.

TABLE 5: TOBACCO RELATED CANCERS IN
MAJOR CITIES OF INDIA B EFORE AND AFTER
NATIONAL TOBACCO CONTROL PROGRAM

YEAR

MUMBAI

CHENNAI

DELHI

BAN GALO RE

Total number of persons

2000-

2004

7642

1288

7467

3219

2004-

2005

5411

2622

5958

2401

2006-

2008

8547

3254

6793

2955

2009-

2011

5917

1046

7621

3213

2012-

2014

3625

2217

5326

1905

Source:

Ncdirindia.org

Table 5 shows tobacco related cancers in India before and
after National Tobacco Control Program. It shows that in
Mumbai, the number of cancer patients due to tobacco
usage has decreased from 7642 to 3625. In contrast, the
total number of cases in Chennai has increased from 2000-
2014.

DISCUSSION:

Tobacco use slaughters almost 6,000,000 individuals every
year worldwide. According to World Health Organization
(WHO), all inclusive, there were about 100 million
unanticipated deaths due to tobacco in the 12th century. In
case if the current pattern of tobacco usage proceeds, this
number is required to ascend in the 21st century to 1
billion

in India; tobacco is a major public health burden.

The total cancer cases due to tobacco usage are nearly 45%
of cancer in males and 20% of cancers in females

. This

study aimed to compare the incidence of tobacco related
cancers before and after implementation of National
Tobacco Control Program.

In the present study, table 1 shows the Incidence of Cancer
before and after NTCP in Males and Females. It shows that
there is an increase in terms of cancer patients after 2008
that is after the implementation of National Tobacco
Control Program. The total number of cancer patients has
increased from 83000 in 2005 to 123000 in 2019.Although
the various tobacco control programs implemented in India
should have reduced the usage of tobacco, there is a rise in
cancer. This could be due to the flaws in planning and

implementation of National Tobacco Control Program or
might be the various other confounding factors too.

Tobacco is dangerous in any structure or camouflage.
Logical proofs have unequivocally settled that usage of
tobacco causes demise, infections and various disabilities

According to the “International Agency for Research on
Cancer” (IARC) monograph, there is enough evidence in
human beings that smoking tobacco  causes disease of  the
oral cavity, lung, oro, naso and hypo-pharynx, paranasal
sinuses and nasal cavity, larynx, throat, pancreas, stomach,
kidney,  liver, urinary bladder, ureter, cervix and bone
marrow. Colorectal malignancy supposedly is related with
smoking cigarettes, although there are no sufficient
evidences,  for  it to be the cause

. Such tobacco related

cancers and their state-wise distribution in India are
discussed in Table 2. The states highly affected with oral
cancer in India are Uttar Pradesh, Gujarat, Orissa which
might be due to habit of smoking and tobacco usage being
high in these states. The study done by Goud ML et al

showed a significant association of tobacco chewing and
oral disease with a direct connection with the amount and
term of use proves these findings. Pednekar et al

. In their

study in Mumbai unveiled that the frequency of oral
malignant growths  was  42% higher  in bidi smokers  than
that of  cigarette smokers.  Same  way these  might be the
reason for oral cancers being more prevalent among men
and women in India according to table 3.

Results  in table  4 show  that  the usage of smokeless tobacco
has decreased to 17.6% in 2015 after the implementation of
NTCP from 23.4% in 2005. Same way the prevalence in the
usage of smoked tobacco has reduced considerably from
18.3% in 2005 to 11.9% in 2009 after the implementation
of NTCP. This might be attributed to the 2013 ban of sale,
manufacture and  distribution of  Gutka, a smokeless,
chewed form of tobacco containing areca nut in various
states of India such as Andra Pradesh, Tamilnadu,
Maharashtra, Assam, Madya Pradesh and Gujarat. The
implementation of pictorial warnings in cigarette packets
under the Cigarette and Other Tobacco Products Act in
2003 and advertisements on the ill effects of tobacco usages
could also be  a  reason

In the present study, table 5 shows tobacco related cancers
in India before and after National Tobacco Control
Program. It shows that in Mumbai, the number of cancer
patients due to tobacco usage has decreased from 7642 to
3625. Whereas in Chennai, the total number has increased
from 2000-2014. These findings can be due to the high
illegal availability of tobacco products in a major city like
Chennai. Vidhubala E et al

in their study have reported

that the ban on smokeless tobacco has been systematically

Divya et al:

Tobacco Related Cancer before and after implementation of National Tobacco Control Program

Volume No: 8, Issue No: 4

155

ISSN No: 2582-0559

violated in Chennai city due to which there might be illegal
availability of such tobacco products in large amounts,
which can be regarded as a reason for such a finding in the
present study.

The “Ministry of Commerce and Industry”, Government of
India under the “Tobacco Board Act” in 1975, initiated the
Tobacco Board, replacing the “Tobacco Export Promotion
Council”. The Tobacco Board Act, 1975 aims at the
development of Tobacco Industry in the country. It
regulates the production of Virginia Tobacco with regard to
the demand in India

. On the other hand, the “Ministry of

Health and Family Welfare” have implemented National
Tobacco Control Programme and the National Tobacco
Control cell to control tobacco products in India. Inspite of
rise in the usage of tobacco and tobacco related cancers in
India; the government promoting the production of tobacco
and tobacco industries is a menace. The fact that on one
hand  India promotes  the production of tobacco promotion
board for the high revenue in this field and on the other
hand trying to control tobacco by implementing National
Tobacco Control cell can be an act of duplicity. The
revenue from tobacco products in India being 19255 crores
is the major reason for the promotion of tobacco products in
India. Direct medical expense of treating disease related to
tobacco in India is about $907 million in case of smoked
and $285 million  in  the  case of smokeless tobacco.
Promoting tobacco for its midget revenue and spending
double the cost to treat its complication is vapid. It can be
looked through  as a total  waste of  time,  money  and energy.
Strict action to ban tobacco products must be taken to rule
out the deaths due to tobacco.

Public health awareness programmes, raising any mass
development  against usage of tobacco and  cancer due to  its
use, sharpening  and  instructing all  human services experts
for tobacco control and educational programs on cancers,
nursing educational plan, different CMEs, meetings,
scientific meetings, workshops are being done in India but
are not viable at all in a country like ours. There is a major
difference  between awareness, control and ban  which  is the
understanding needed.  Awareness could not help  whereas
control can slightly bring down the tobacco usage, but only
bans on tobacco can halt this public health disaster. Strict
bans on tobacco and  its products  can only be  a panacea.  The
ban on Gutka, a smokeless, chewed form of tobacco
containing areca nut in various states of India such as Andra
Pradesh, Tamilnadu, Maharashtra, Assam and Gujarat must
be implemented in all the other states also to bring down the
cancers due to tobacco usage.

Tobacco usage is the leading cause of preventable deaths all
over the world

. India has probably the most noteworthy

pace of oral malignant growth on the planet, with over half
of it from smokeless tobacco use

Even after the implementation of strict tobacco control acts
if the tobacco usage and cancer related to it have not
reduced a considerable amount in India, then there might be
other confounding factors which might be the cause for
such cancer. Hence all such factors have been discussed in
this study.

Environmental pollution in industrialized Western
countries, concerns that air pollution is the main cause of
lung cancer in the current day scenario. This is based upon
the fact that some carcinogens are still being released into
the external environment from sources such as industries,
motor vehicles and power plants

. This could eventually be

a confounding factor causing cancer in humans other than
tobacco products.

Irrational use of pesticides in the food products has made it
poisonous which can be the major cause for cancers in
India. Arsenic, Benzene, Ethyl oxide, Formaldehyde and
Sulfax used in turmeric, ethephon used to ripen mangos and
chillis, are turning to be major cancer causing carcinogens.
Organophosphate pesticides like fonofos, phorate, and
parathion which are very harmful for the human body and
are carcinogenic are being used in wheat crops

. These can

be the potential reason for rise of cancer in India even after
the implementation of strict rules and programs for the
control of tobacco in India.

RECOMMENDATIONS:

Exact factors:

1. Public health awareness, different CMEs,

meetings, scientific meetings, workshops are being
done in India but are not viable at all in a country
like ours. Strict bans on tobacco and its products
can only be a panacea.

2. A strong ban on tobacco products, smoke or

smokeless must be immediately implemented to
overcome this public health burden of increasing
tobacco related cancers in India.

3. Agricultural promotion of tobacco must be banned

to stop its production such that the usage of
addictive nicotine tobacco reduces.

4. Prohibition of smoking in public places which

includes workplaces, shopping malls, airports, bus
and train stations, hotels, cinema halls, shops and
restaurants is a rule under COTPA, in-spite of
which people smoke in public places which is the
major problem concerned with second hand smoke
which is affecting non tobacco users also. Strict

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action must be taken against those who prohibit
the law to reduce the cancers in India.

5. Strict implementation of COTPA rules must be

done to reduce the usage of tobacco in India.
Smoking in roads causing cancer to others due to
second hand smoke must be punished severely.
Road side shops selling tobacco products must be
banned and punished.

CONFOUNDING FACTORS:

1. Pesticides that are banned in United States, Brazil

and chine are still being used in India. All that
should be banned. Organic farming must be
encouraged and practiced by all the people to
reduce the incidences of cancer due to pesticides.
Food control officers must be appointed to control
the adulterations in food which causes cancer.

2. Pollution control board must take action to reduce

the pollution that is a major confounding factor
causing cancer.

CONCLUSION:

By the analysis of incidence of tobacco related
cancers and tobacco consumption in India, it is evident that
the usage of tobacco products both smoke and smokeless
tobacco consumption have decreased after the
implementation of NTCP and in the same manner, the
incidence of tobacco related cancers have declined in
Mumbai, Bangalore and Delhi but has raised in case of
Chennai. If the above recommendations or not followed and
put into action, India might soon transform to be a
graveyard of tobacco users.

FINANCIAL SUPPORT AND SPONSORSHIP

Nil

CONFLICTS OF INTEREST

There are no conflicts of interest.

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