More on the tobacco menace in India.

This issue of our journal has three original articles related to tobacco. Each one has a lesson and also raises some controversies.

The one by Goel et al. shows that while the smoking trends in men reduced between 1993 and 2009 in India, the trends in females more than doubled from 1.4% to 2.9%, during the same period.[1] Does this ring a bell? It is identical to what was seen in the western world several decades earlier. For USA, in 1924, smoking prevalence in women was 6%. This increased to 16% by 1929, became 24% (for women younger than 40 years) by 1935 and as high as 36% by the year 1944. In fact, ever smoking peaked among US women in the year 1985, being a staggering 46.2%.[2]

The habit of cigarette smoking in women has followed the trends among men, with a lag of several years.[3] It did so in USA and is now doing the same in India. Moreover it is well-established that the incidence of lung cancer mimics this trend – with a lag of about 7 years. Hence, we should be ready for the increasing incidence of lung cancer in Indian women.[4]

Thakur et al. have reported on the prevalence of cigarette smoking and its predictors among school going adolescents in Shimla.[5] They document an incidence of 11.8% cigarette smoking in school adolescents (9th to 12th grade). This study has several flaws. Their definition of cigarette smoking is limited to the 30 days prior to the questionnaire being administered. It also does not include use of tobacco in other forms – and we know that chewing (smokeless) tobacco is very common in India, including in school children. Whereas 32.7% of men and 1.4% of women smoke tobacco, many more (36.5% of men and 8.4% of women) chew tobacco.[6] The use of smokeless tobacco is also higher among nonsmokers (16-56% compared with 10-52% in smokers).[7] Let us not forget that the primary form of tobacco use as far back as in the 1800s was indeed chewing. Also, Thakur's data showing that the smoking incidence was 22% amongst boys, and 1% in girls is also misleading - which also reflects on the flaws in the methodology used in this study. Perhaps, it would have been better if they had also focused on measures to prevent and treat the tobacco habit in school adolescents using tested strategies.[8]

Reddy et al. studied 410 petrol fillers in Pune area between the age of 17 and 64 years.[9] They found that 242 (59%) used tobacco −77.68% were chewing it and 8.26% were smokers. The overall incidence of tobacco use matches that seen in our country, albeit on the higher side.[6] It is understandable that their profession prevented the people in this report from smoking and hence there is a significantly higher incidence of chewing tobacco. However, the incidence of premalignant lesions reported by them is 68.47% for leukoplakia, 27.45% for submucous fibrosis and 5.08% for erythroplakia - higher than reported elsewhere.[9101112] The annual incidence of leukoplakia in the general population varies from 0.2% to 11%.[13] Even among tobacco users, the incidence was reported to be 4.5%, rising to 7.1% when using both forms of tobacco (smoking and chewing).[14] This is also supported by a study in 2017 consecutive patients reporting to a dental college from around Chennai, the highest incidence of leukoplakia reported from those with oral complaints was only 6.82%.[15] Reddy et al., therefore, need to evaluate their data once more to confirm whether their incidence of premalignant lesions is really true.