slthough there id nothing new in this presentation but i have try to present in in brief,hope it will b useful.

1. SMOKELESSTOBACCOAND Related
legislations
Presenter : Dr. WALIED K. BALWAN
Moderater: Dr. Abdul Majid Ganai (Prof and Head)
S/R incharge: Dr. FEROZ A. WANI
DEPARTMENT OF COMMUNITY MEDICINE,
SKIMS- SRINAGAR

2. Table of Contents;
 INTRODUCTION/ BURDEN
 SMOKELESS TOBACCO
 COMPONENTS
 EFFECTS OF SMOKELESS TOBACCO
 PREVENTION AND CONTROL
 LEGISLATIONS

3. INTRODUCTION
India has one of the highest rates of oral cancer in
the world.
Tobacco is responsible for a significant amount of
morbidity & mortality among middle aged adults.
Tobacco-related cancers - 1/2 of all cancers - men &
1/4 th among women.
Oral cancer - 1/3rd total cancer ; 90% - tobacco
chewers.
Men are affected 2-3 times than women due to
higher use of alcohol & tobacco .
 Tongue & intra-oral cancer - equal in both as
chewing tobacco among women is common.
 Effects of tobacco use, heavy alcohol consumption ,
and poor diet together explain over 90% of head &
neck cancers.

4.  According to WHO’s Mortality Attributable to
Tobacco Report, globally 12% of all deaths
among adults aged 30 years and above were
due to smokeless tobacco in compared with
16% in India, Pakistan (17%)
and Bangladesh (31%).
 According to GATS 33% of adults use tobacco
in some form , and prevalence of smokeless
tobacco use 26%
 According to GYTS 13.6% school going
children out of which 9% were using
smokeless tobacco

5. What Is Smokeless
Tobacco?
Smokeless tobacco / spit tobacco / chewing
tobacco.
Mainly two forms: snuff and chewing
tobacco.
Snuff - users "pinch" or "dip" between their
lower lip and gum.
Chewing tobacco - users put between their
cheek and gum.
 The tobacco juice is sucked and chewed -
nicotine -absorbed into the bloodstream
through the oral tissues.
 No need to swallow

6. Consumption
Chewed : gutkha, pan, mawa,
mainpuri tobacco, khaini, zarda
Applied on gums and teeth : mishri,
gudhaku, bajjar, tooth paste
Inhaled : snuff.

7. gutkhA
Leads to Oral sub-mucous fibrosis (SMF).
Main component - arecanut along with tobacco.
KHAINI
 Paste of tobacco + slaked lime & is used with
arecanut.
 Mixed with the thumb to make the mixture alkaline-
premolar region of mandibular groove

8. MAINPURI TOBACCO
Tobacco+ slaked lime + finely cut arecanut +
camphor + cloves.
Mainly-Uttar Pradesh.
High incidence of oral cancer & leukoplakia.
MAWA
Gujarati preparation made from shavings
of arecanut, tobacco and slaked lime.
 Sold by tobacco vendors in cellophane
papers tied like a small ball.

9. SNUFF
Finely powdered air-cured & fire-cured
tobacco leaves.
Used orally/nasally.
Carried in a metal container-a twig is
dipped into it-placed in oral vestibule.
Causes oral squamous cell carcinoma.
ZARDA
Tobacco leaves + lime+spices – boiled in
water.
Residual tobacco –dried & coloured.

10. Oral cancer, Oral submucosis fibrosis
Cracking & bleeding lips & gums.
Receding gums –tooth falls out.
 Increased heart rate, high B.P, irregular
heartbeats - greater risk of heart attacks.
 Can lead to nicotine addiction.
 Can increase risks for early delivery and
stillbirth when used during pregnancy.
 Can cause nicotine poisoning in children.
EFFECTS OF SMOKELESS TOBACCO

11. Why do people Use Tobacco?
 This may depend on social class and
local factors, some of which are :
1. Peer influence and pressure
2. Advertisements/promotions of tobacco
products through films, free distribution,
sponsorships, etc
3. Curiosity and experimentation.
4. Fun and enjoyment
5. A challenge, a sign of rebellion.
6. Relief of Negative feelings like stress,
anxiety, boredom.

12. Prevention and Control
Levels of Prevention
Disease prevention in tobacco users
always involves informing users about
the health risks the face and
promoting cessation of tobacco use.
PRIMORDIAL PREVENTION to
prevent initiation of tobacco use;
1. To be provided in the community and
the clinic.
2. Health education especially at school
level.

13. PRIMARY PREVENTION to help
tobacco users quit
1. To be provided at clinics
2. Tobacco cessation services for
tobacco users who haven’t yet
exhibited any disease.
SECONDARY PREVENTION
for early diagnosis and treatment of
diseases in tobacco users.(
screening for oral cancer and pre
cancerous lesions).

14. TERTIARY PREVENTION
 To help heavy users quit, many of
whom have tobacco related symptoms
and diseases.
 Has to be done in special clinics or
hospitals.
 Treatment for heavy users.

15. Why Intervene?
 The intervention by health care
professional, can help motivate
patients to change their behavior.;
 Intervention helps them to think about
the importance of quitting tobacco use
because of the authority and standing
the health care professional enjoys in
society.
 Physicians are viewed not only as
clinicians, but also educator and role
models.

16. Behaviour Counselling for
Tobacco cessation (5 ‘A’s)
1. Ask- Ask the patient if he/she is a
tobacco user, at every visit.
2. Advise- Briefly advise against
continuing tobacco use and link the
current condition/ ailment to
continued tobacco use.
3. Asses- Asses readiness to quit by
asking the patient whether he/she is
ready to quit (eg. ‘ How recently you
have thought of quitting tobacco’)

17. If the patient appears ready to
change( quit),
1 Assist; Assist the tobacco users in
making a quit.
2 Arrange; Arrange for follow up by
setting the next contact.

18. Approach for a current tobacco
users who is not quitting tobacco
use (5 ‘R’s)
1. Relevance- Explain the relevance of
quitting to the client and harmful
effects of tobacco use.
2. Risks- Highlight the health hazards
that are more relevant to the
individual tobacco user.
3. Rewards- Benefits of quitting all
forms of tobacco use should be
explained
( Health ,financial, approval of family
etc.)

19. 4. Roadblocks- Barriers that the client
may face in his/her quit attempt should
be identified. Withdrawal symptoms,
fears and concern associated with
quitting, depression, lack of social
support, enjoyment of tobacco are some
of barriers that the client may face in
attempt.

20. 5. Repetition- The physician should
assure the client that because of
chronic nature of tobacco
dependence, relapses are common in
the initial phases and multiple
attempts may have to be made before
he/she is able to quit tobacco.

23. WHO INITIATIVE

24. WHO-FCTC
 The World Health Organization
Framework Convention on Tobacco
Control (WHO FCTC) is a treaty adopted by
the 56th World Health Assembly on 21 May
2003. It became the first World Health
Organization treaty adopted under article 19
of the WHO constitution. The treaty came
into force on 27 February 2005.It had been
signed by 168 countries and is legally
binding in 180 ratifying countries.
 It is an evidence based treaty that reaffirms
the right of all people to the highest standard
of health.

27. MPOWER PACKAGE
 MPOWER is a policy package intended to
assist in the country-level implementation of
effective interventions to reduce the demand for
tobacco, as ratified by the World Health
Organization (WHO) Framework Convention on
Tobacco Control .The six evidence-based
components of MPOWER are:
 Monitor tobacco use and prevention policies
 Protect people from tobacco smoke
 Offer help to quit tobacco use
 Warn about the dangers of tobacco
 Enforce bans on tobacco advertising, promotion
and sponsorship
 Raise taxes on tobacco
 Reduce the size of cigarette

28. TOBACCO CONTROL IN INDIA
In order to discourage tobacco use and protect
the youth and masses from harmful effect of
tobacco use and SHS , GOI enacted
COTPA
Cigarettes and Other tobacco products (Prohibition of Advertisement
and Regulation of Trade and Commerce, Production, Supply and
Distribution) Act, 2003
SCOPE OF ACT:
 The Act is applicable to all products containing tobacco in any form i.e.
cigarettes, cigars, cheroots, bidis, gutka, pan masala (containing
tobacco) khaini, mawa, mishri, snuff etc. as detailed in the schedule to
the Act.
 The Act extends to whole of India.

29. MAIN PROVISIONS OF THE
ACT

30. Enforcement agencies and
mechanisms
 Any police officer, not below the rank of Sub-
Inspector
 Any officer of State Food or Drug
Administration
 Any other officer, holding the equivalent rank
being not below the rank of Sub-Inspector of
Police
 Any other Official as authorized by the
Central/State Governments.

31. NATIONAL TOBACCO CONTROL PROGRAMME
The GOI launched NTCP in the 11th five
year plan (2007-12) to implement
Tobacco control Laws and bring about
greater awareness about ill effects of
tobacco, institute a regulatory
mechanism including laboratory facility
for effective monitoring and
implementation of Anti tobacco initiatives
at State/ District level.

32. Main Components
National Level:
Public awareness/ mass media campaigns
for awareness building and for
behavioural change.
Establishment of tobacco products testing
labs, to build regulatory capacity, as
required under COTPA,2003.
Mainstreaming researchs and programme
components as a part of health delivery
mechanism under NHM.

33.  Monitoring and evaluation including
surveillance (GATS/GYTS).
 Dedicate tobacco control cell for
effective implementation and
monitoring of Tobacco control
initiatives at state level.

34. STATE LEVEL
Dedicated tobacco control cell for
effective implementation of Tobacco
Control initiatives at state level.
DISTRICT LEVEL
Dedicated tobacco control cell for
effective implementation of Tobacco
Control initiatives at District level.

35. Training;
Training of school teachers, health
workers, health professionals, law
enforces, NGO’s, Women SHG’s on
tobacco control in the districts.
IEC:
Using local media, Nukkad/street corner
shows, Exhibition, Melas, etc in regional
languages at the grass root level.

36. School Programme:
As part of school health programme of
the state govt. or with the help of NGOs
to train school teachers and sensitize
children on harmful effects of tobacco,
SHS and provisions under the law, 50
schools are covered in each district.
Tobacco Cessation Centres (TCC):
Setting up of Tobacco Cessation
facilities at the District Hospital level.

39. National Tobacco Control Cell
 The NTCC is responsible for overall
policy formulation, planning, monitoring
and evaluation of the different activities
envisaged under the programme.
National cell functions
Joint Sec/Director and technical
support is provided by DGHS( i.e.
DDG/CMO.

40. Organizations (NTCC)

42. Training:
STCC should train multiple stake holders
of tobacco control level advocacy
workshops/senitization programmes.
Efforts should be made to involve all
state government department for
tobacco control. Specific tailors made
trainings should be organised for
academicians, Health
medical/professionals, students, police,
food and drug safety authorities,
judiciary, Media etc.

45. NTCP at District Level
 Every identified district should have
District Tobacco Control Cell (DTCC) in
the District Hospital.
 The DTCC is headed by DNO preferably
CMO/CS on full time basis.
 It is desirable that the DNO under NTCP
is also given the responsibility to look
after the NCD programmes like
NPCDCS, NMHP, NPHCE.Other team
members of this cell include
Psychologist/Counsellor, Social worker
and Data Entry Operator on contractual
basis under NTCP.

46. Target Trainees:
 Doctors, Nurses, Community Health
Workers, ASHAs, Civil society
Organisations, NCC, IMA, IDA,
Teachers, Officials from Enforcement
deptt. Like Police, Food Authorities,
Municipal Officers etc.

49.  Block Level Interventions:
Block level coordination committee;
Block chairperson, members of block
panchayat and gram pradhans (village
Heads), prominenet NGOs, CBOs ,local
MLAs,MPs,
Incharge MO of the Block PHC as convener.
Block level activities; orientation and
senitization of representatives, working
towards tobacco free schools and offices
in block.

50. Village level interventions:
 Village Level committee; village
Pradhan, ASHA,ANM, Anganwadi
worker , the meetings need to be
conevened by the ASHA worker.
 Village level activities; senitization of
village level officials, Gram Panchayat,
CBOs like Farmers clubs, Mothers
froups, SHGs, Youth/ Adolescent club
etc . Special IEC compaign involving
school children on World No Tobacco
Day, and special days.

51. What Further?
 Integration of NTCP with other health
interventions/programmes.
 As we are very well aware that
tobacco is a risk factor for cancer of
various organs,CVS and Pulmonary
diseases, and is strongly assoiciated
with it. Moreover also strong
association with pregnacy n
consequences.

52. Conclusions
 There are numbers of programme for
diseases control ,all efforts must be
made to integrate NTCP activities into
the ongoing National Health
programmes like RNTCP, NMHP.
NPCB, NPDCS, RCH etc.