December 9, 2004
Dana-Farber researcher probes tobacco use - and prevention options - in India
In Jodhpur, Sorensen poses with an Indian child. (William Bonney photo)
As the United States continues to struggle with the practice of smoking and its links to cancer and other illnesses, less-developed nations are facing even more staggering challenges around tobacco use.
In middle- and low-income countries like India, for instance, between 68,000 and 84,000 children take up smoking every day, compared to roughly 14,000 a day in high-income countries, researchers note. More than 80 percent of the world's 1.1 billion smokers live in low- and middle-income nations, where tobacco consumption is on the rise.
These and other alarming statistics helped inspire Dana-Farber's Glorian Sorensen, PhD, MPH, to spend five sabbatical months in India this past year studying tobacco use among teachers and workers. Supported by a Fulbright Award, she lived in Mumbai (formerly Bombay) and collaborated with colleagues at the Tata Institute of Fundamental Research, the Tata Memorial Hospital, and other organizations.
What emerged were three papers, pending publication in two journals, which underscore the need for tobacco-use prevention and cessation in this Southeast Asian country of more than 1 billion. India counts an estimated 250 million tobacco users and more than 800,000 related premature deaths each year, according to a recent release from the World Health Organization Representative to India.
"Working with Prakash Gupta [DSc], and others at Tata was a delight," says Sorensen, director of Dana-Farber's Center for Community-Based Research, which has studied the effectiveness of anti-smoking programs among U.S. workers in an effort to reduce cancer risk. "Prakash is an internationally known epidemiologist and a leader in the emerging tobacco-control movement in India."
Addressing the topic in India is complicated by regional differences in usage and the multitude of tobacco products available there, ranging from cigarettes, cigars, and bidis (traditional leaf-wrapped unfiltered cigarettes) to smokeless tobacco options that are inhaled, chewed, or placed against the gums.
One study Sorensen co-led looked at educational and occupational variations in tobacco use in a large sample of residents, collected in the 1990s, in Mumbai, a city of 10 million. The team's analysis, slated to be published in the American Journal of Public Health, indicates that tobacco consumption in India, as in the West, is more common among low-income and less-educated populations.
This problem puts an especially big strain on unemployed and homeless individuals in India, according to Sorensen. "People who have very limited incomes and are addicted to tobacco are making choices to buy it to feed their addiction, rather than feed themselves and their children."
Glorian Sorensen, PhD, MPH
Studying teachers
In another project, Sorensen examined tobacco use from the perspective of teachers. Tapping data from two major international surveys (the Global School Personnel Survey and the Global Youth Tobacco Survey), she and colleagues compared consumption patterns and prevention efforts among educators in two Indian states: Bihar, where 78 percent of teachers consume it, and Maharashtra, where 31 percent do.
In Bihar schools, they learned, tobacco-control policies were virtually nonexistent, and few teachers taught students about avoidance. Nearly 60 percent of all students in Bihar — located in the northeast of India, just south of Nepal — who were polled in 2000 used tobacco products, and their use is "deeply embedded in the social fabric of the community," the paper states.
By contrast, in Maharashtra, the west-coast state containing Mumbai, about 13 percent of students said they were users. More than one-fourth of teachers said tobacco use was prohibited at school, and instruction around health risks and prevention was much more common than in Bihar, a poorer and more rural state. Such teaching was strongly linked with having tobacco-control policies for staff and students and with teachers' own habits.
The findings, the researchers note, underscore the importance of developing and enforcing such policies and programs. "Given that the majority of tobacco users take up use in their teens and that the risks of tobacco use are highest among those who start smoking early and continue for prolonged periods, it is of paramount importance that successful prevention efforts are implemented in these regions," Sorensen co-wrote in an article to be published in Preventive Medicine.
To complement the data analysis, Sorensen and colleagues conducted focus groups in a dozen rural and urban schools in the two states. They asked teachers (in either English or Indian languages) why some consume tobacco, what they teach in the classroom, and what they know about related health hazards. Some participants described the social pressures to smoke or chew — and the lack of support available for stopping.
Looking ahead, Sorensen hopes to advance this work and is seeking funding with DFCI colleague Vish Viswanath, PhD, to examine the effectiveness of tobacco policies and programs in Bihar classrooms.
"Teachers are leaders in the community there," notes Sorensen, who was heartened by the warm reception she received in the schools during her visit, from November 2003 to March 2004. "So if we can begin to move them in the direction of not using tobacco, I think we can begin to have a broader effect on the population overall."
