If India, Bangladesh and Pakistan’s policies on the use of smokeless tobacco stay as they are now, then more than $23 billion will be spent on healthcare costs across the lifetime of consumers in the three countries, with the biggest health impacts falling on young people who haven’t yet taken up the habit.
These are headline findings from health economists from Brunel University London, UK, who, together with researchers from South Asia and the University of York, ran the first-ever study of the lifetime impact of smokeless tobacco use on the health, quality of life and healthcare costs of South Asians – sorted according to country, age group and sex.
Khaini, gutkha and pan masala are some of the several smokeless tobacco products which deliver an addictive nicotine fix when chewed, snuffed or applied to the teeth and gums. These products are a big hit in South Asia, where the nearly 300 million people who consume smokeless tobacco represent 5 out of every 6 of the whole world’s users.
“Smokeless tobacco is deeply embedded in South Asian culture,” explained Prof Subhash Pokhrel, Professor of Public Health Economics at Brunel, who led the study. “It’s often offered at wedding ceremonies, where it’s polite to accept. Celebrities endorse it through surrogate adverts. And because of looser legislation than for smoked tobacco such as cigarettes, there are less stringent rules around selling smokeless tobacco to minors. It’s a cheap product that is even sold near schools, though laws prohibit it.”
The perception that smokeless tobacco is safer than cigarettes has led to more use, but at a cost to the health of citizens and to national finances. For example, around a quarter of India’s healthcare costs related to tobacco use had previously been estimated to be attributable to the smokeless form alone.
In the new study – funded by the UK’s National Institute for Health and Care Research, and published today in the journal Nicotine & Tobacco Research – the health economists predicted the lifetime costs of treatment of four of the most common diseases for smokeless tobacco users: oral, pharyngeal and oesophageal cancers (which affect the mouth and throat), together with stroke.
The researchers split the current adult populations of India, Bangladesh and Pakistan into five-year age bands, ranging from 15–19 years old up to 70–74. They separated men and women, creating age/sex cohorts for detailed analysis. Within each cohort, the researchers identified how many people were current users of smokeless tobacco, former users or ‘never-users’, based on a range of country-specific data, such as from tobacco consumption surveys and previous research.
The researchers then ran a predictive model throughout the lifetimes of these age/sex cohorts. In any given year, some smokeless tobacco users would quit, some would carry on, and some former users would relapse. Others would take up the habit for the first time, some people would remain never-users, and some people would die. The researchers used best-estimate probabilities of how likely people were, in a year, to switch between or stick to each of these states – for example, how likely a woman in Bangladesh aged 15–19 would become a smokeless tobacco user for the first time. They then factored in how common cancers and stroke would be for each cohort at that point in time, together with the healthcare costs associated with each disease. And then the researchers moved their model year by year.
The analysis meant that the researchers were able to put a monetary value on the lifetime healthcare savings if India, Bangladesh and Pakistan changed and effectively implemented their policies to eliminate smokeless tobacco use, overall and for each cohort. Their model could also predict how much longer someone’s life would be without smokeless tobacco, and how much more of their life would be lived in states of less than full health.
“If there were no changes in the current smokeless tobacco policies and their current levels of implementation, the lifetime healthcare costs attributable to smokeless tobacco would be over $19 billion in India, in US dollar terms, with oral cancer costs the largest contributor,” said Prof Pokhrel. “They would be over $1.5 billion in Bangladesh and over $3 billion in Pakistan.
“These figures are large, but conservative because we have been cautious in selecting the best available estimates to link smokeless tobacco use to diseases that it can cause. So the true figures may end up being higher.”
For all countries, the overall attributable costs are higher for younger cohorts. The greatest costs for men in India were for those currently aged 35–39, in Bangladesh those aged 30–44, and in Pakistan the cohorts aged 20–24 and 30–34.
The financial and health burden is almost double for men compared with women in India and Pakistan. However, in Bangladesh, the burden is generally slightly greater for women compared with men.
The researchers’ most remarkable insight is that the people who will bear the most significant burden in the future are young never-users – young people who haven’t started using smokeless tobacco, but might – if the current inadequate policies and the levels of their implementation to address smokeless tobacco were to stay.
Prof Ravi Mehrotra, a co-author of the study and an Honorary Professor of Health Sciences at Brunel, said: “Positive changes in the current smokeless tobacco policies of India, Bangladesh and Pakistan are needed to avoid young people who are current non-users ending up carrying the most burden, both financially and health-wise, in addition to supporting current users to quit. Strict implementation of the laws is the need of the hour.
“Such changes would also prevent women bearing the increasing burden of smokeless tobacco use.
“If the current usage patterns and policy status quo continue, smokeless tobacco will continue to be and increasingly become responsible for significant mortality and morbidity across the three countries.”
The researchers hope that their detailed analysis will give policymakers a better understanding of the dynamics of the healthcare costs of smokeless tobacco within the countries’ populations. It will also allow for improved targeting of interventions to reduce usage.
“These products are cheap, so just applying more tax without other policies is unlikely to have much of an impact,” said Prof Pokhrel. “Given that they’re culturally embedded and addictive, users will also need cessation support to help them kick the habit.
“We don’t yet know fully what works best to prevent and control smokeless tobacco use at the population level. However, our study suggests that in younger-age cohorts, more may be gained through targeting non-users with interventions aimed at preventing the uptake of smokeless tobacco, whereas in the middle-aged, interventions targeted at cessation support may be most efficient. More research is needed to confirm that.”
