Blowing Smoke

Melody Jones got hooked on smoking at 16, in the mid-1970s. The 52-year-old school secretary in the U.S. state of Kentucky quit three times — each time she was pregnant — but always relapsed.

Eight thousand miles away in Kolkata, India, Prateek Singh began smoking at 11 years old, after stealing one of his sister’s cigarettes. Now 12, he’s been smoking without his family’s knowledge for the past year.

Singh’s attitude about smoking is the same as Jones’ was when she was young: While he knows it causes cancer, he doesn’t believe it will affect him for many years to come.

But in the United States, evidence of smoking’s deadly consequences has piled up for decades, and its prevalence in pop culture has slowly vaporized. In India, meanwhile, smoking remains a growing problem, particularly among the young – stoked by continuing advertising and sales pushes targeting youth.

As a result, Indian doctors are treating an increasing number of 20-somethings for tobacco-caused cancers, according to the Mumbai-based Salaam Bombay Foundation, a non-governmental organization that focuses on eradicating smoking among Indian youth.

“In (India), one in every three tobacco users started when they were around 10 years old,” Padmini Somani, executive director and founder of Salaam Bombay told a daily. “This is a major problem as it begins very early."
Singh is one of an estimated five million Indian children who use tobacco, which is slightly more than 14 percent of Indian children.

They look up to an adult population that contains 275 million tobacco users— one in three Indian adults. Each year, tobacco-related illnesses claim roughly 700,000 lives.

They are heading in the same direction as Kentucky – one state where the U.S. downward trend in smoking has not stuck. In this poor, rural state with a long history of tobacco farming, smoking rates are consistently the highest in the nation. Currently, more than 28 percent of adults smoke – and records show the rate of smoking has actually increased by half a percentage point since 1995.

The state also ranks among the highest in the nation for heart disease, respiratory illnesses and other chronic diseases related to smoking.

“Kentucky is a lot like a third-world country in that we are not doing what we need to, to prevent (youth smoking),” said Amy Barkley, regional advocacy director for the Campaign for Tobacco Free Kids. “We know what to do and know that it will work, but we just are not doing it.”

“Smoking is like an addiction to drugs.”

Smoking has been “detrimental” to her health, Jones said before coughing.

Even though she’s reduced her smoking from a pack or more a day to five cigarettes daily, she is still harming her body – and filling it with an increasing number of dangerous chemicals.

According to the latest U.S. Surgeon General’s report on smoking, modern cigarette designs and additives mean she is breathing in more noxious materials and carcinogens, putting her and every other smoker at an alarming risk of cancer.
“(Cigarettes) are not just tobacco rolled up in paper,” Barkley said. “They’re a highly engineered nicotine delivery device.”
And they damage more than just the lungs.

“Smoking has been causally linked to diseases of nearly all organs of the body, to diminished health status, and to harm to the fetus,” the report reads.

It says smoking causes one in three cancer deaths in the United States and has killed more than 20 million Americans who smoked before or at the same time Jones started.

Smoking is the leading cause of preventable deaths in the U.S., according to the U.S. Centers for Disease Control and Prevention, and the third leading cause of health loss in India, according to a study in the Journal of the American Medical Association.

Comparatively, one million cancer cases are diagnosed annually in India — 40 percent attributed directly to tobacco use — a sum that is expected to rise to 1.7 million by 2035, according to a mid-April report published by the medical journal The Lancet Oncology. And of those with cancer in India, more than 70 percent die within five years of their diagnosis.

But tobacco has caused those deaths in a variety of ways, many of which were unknown until recently. According to the surgeon general’s report, smoking can cause:
·        Coronary heart disease;

·        Blindness;

·        Strokes and reproductive effects;

·        Tuberculosis;

·        Orofacial clefts;

·        Diabetes;

·        Ectopic pregnancy;

·        Male erectile dysfunction;

·        Rheumatoid arthritis and other ill effects.

Many users who know of tobacco use’s deadly consequences find it a difficult addiction to shake.

Smrita Pal began smoking in Kolkata at age 16 to help with stress, and now she says she is an insomniac and that smoking helps her sleep at night. But smoking has also prematurely aged her skin, affected her sense of smell and left her with a cough, she says.

Now 23, she thinks about quitting “pretty much every day,” she said. But has not been able to full realize those aspirations.

Not many do.

“Only about four percent to seven percent of people are able to quit smoking on any given attempt without medicines or other help,” according to the American Cancer Society.

Pal says she gets cranky when she craves a cigarette, and in Kentucky, it is a feeling Jones knows well.

“What people don’t understand is that smoking is like an addiction to drugs,” Jones said. “It takes a hold … and you can’t quit.”
Arnab Ray, a 42-year-old general physician in India, said he started smoking in high school and now chain-smokes 30 to 35 Gold Flake cigarettes a day. He admits that he smokes in his chamber, but said he stops if it bothers a patient.

Ray said smoking has affected his health “considerably” and he’s tried to quit using Nicorex gum -- but without success. When asked whether he feels more obliged to quit because he’s a doctor, he said “it’s a personal choice. And I am really just another human being.”
There is no doubt what is responsible for pushing the drug, and health crisis, on the 44 million Americans who smoke and 275 million Indians who use tobacco, the surgeon general’s report says.

“The tobacco epidemic was initiated and has been sustained by the aggressive strategies of the tobacco industry, which has deliberately misled the public on the risks of smoking cigarettes,” it reads.

“A total failure in leadership”

When Jones started smoking 40 years ago, a third of American high school seniors smoked cigarettes. In fact, so many were smoking and attitudes so relaxed that schools often designated areas and times for smoking. It was an easy habit start, especially for someone under peer pressure to start.

“Everyone was smoking,” Jones said. “Everyone.”

For Singh, it was as easy as reaching out and taking a cigarette from his sister’s purse, and it has not been much more difficult to continue.

But many Americans feel a stigma attached to the deadly habit, and many U.S. states — although not Kentucky — have passed laws to prevent smokers from lighting up in public places such as schools. India followed suit in 2008, passing a national law that bans smoking in public.

Although Pal said she only smokes when she is alone, and Jones says there are places she won’t go in Kentucky because she cannot smoke there, stigmas have not yet deterred young smokers like Singh in India from picking up the habit. Nor did it stop Hannah Younger, who began smoking when she 17 and in high school.

She did not tell her family because she knew they would disapprove and worry for her health. On a recent night, Younger, now 25, stepped outside of a Lexington, Ky., bar and asked a man for a smoke.

He was her 23 year-old brother.

“I was very surprised (that it was him),” she said, but added that on second though it is not surprising that he picked up the habit.  “Pretty much all of my friends smoke.”

Experts have said that tobacco will not be leaving Kentucky or India any time soon. And much of its prevalence, especially among youth, is due to the lack of enforcement of current tobacco laws.

Kentucky lawmakers have never passed legislation that would ban public smoking, despite support from Gov. Steve Beshear and growing support from the public. And for the past two fiscal years, Kentucky has only allocated $2.1 million of the $57 million recommended by the CDC for tobacco prevention programs.

“It’s a total failure of leadership because the public supports (that legislation),” Barkley said. “Our people get it, the business community gets it, the medical community gets it but our legislative leaders do not.

“They have not made reducing tobacco use a priority and it shows in our smoking rates. That’s all there is to it.”
In India, much the opposite is happening. Legislators are passing anti-tobacco bills but those laws are laxly being enforced.

“Compared with many countries around the world, India has been proactive in introducing tobacco control legislation since 2003," Geoffrey Fong, a professor of psychology at Canada's University of Waterloo and a co-author of the report told Reuters last year. "However ... the legislation currently in place is not delivering the desired results in terms of dissuading tobacco use and encouraging quitting."

That’s largely because enforcement officials are failing to impose the bans and regulations in place, said Vandana Shah, director of Southeast Asia for the Campaign for Tobacco-Free Kids.

For example, it is illegal for someone under the age of 18 to buy tobacco products in India, but because few young people have IDs it is “really up to the shop keeper” to apply the law, she said. That means Singh could likely find a vendor willing to sell him tobacco whenever he wants without worrying about repercussions.

In Kentucky, Younger was forced to ask friends to illegally buy cigarettes for her and risk getting caught or gamble that a cashier would not ask to see her ID.

Further complicating the problem in both India and Kentucky is the price of tobacco products. A pack of 20 cigarettes can be bought for five dollars (300 rupees) or less in Kentucky, while those seeking the same product in states with the lowest rates of smoking have to pay almost triple that because of high taxes. Kentucky cigarette taxes are 60 cents (36 rupees) a pack while the national average is $1.53 (about 92 rupees.)

The most popular form of smoked tobacco in India, the beedi, accounts for more than half of all Indian tobacco consumption, according to the U.S. Food and Agriculture Organization. It is extremely cheap and often not subject to taxation all.
Shah describes the beedi as the “poor man’s cigarette.” The products are small, hand-rolled and often tied together with a string, and can often cost as little as 5 rupees (11 U.S. cents) for a pack of 20.
These low prices are largely responsible for the rates of smoking in India and Kentucky, especially among the poor and young, according to Shah and Barkley.

Not only do young smokers tend to buy what is cheap; they also tend to stick with that brand. Jones and Younger still smoke what was cheapest and available for them when they were younger and Singh smokes the brand he can steal from his sister and buy the cheapest.

“Smoking and being poor and uneducated go together,” said Barkley.

Nearly half of poor Indian men smoke, compared with 20 percent of rich Indian men, according to a survey conducted by the World Health Organization.
And nearly four in ten people smoke in one of the poorer counties in Kentucky, which ranks 47th out of 50 states in household income.
“The single most effective way to keep kids from smoking is to raise the prices,” Barkley said.
That’s not happening in Kentucky or India. Tobacco excise taxes in both places are well below the 70 percent mark recommended by the WHO.

The U.S. Congressional Budget Office estimates that a 10 percent increase in cigarette taxes will lead to a five to a 15 percent reduction in smoking among minors and a 3 to 7 percent reduction among adults, while the WHO estimates that a similar rise in beedi prices would reduce rate by 9.2 percent in rural India and 8.5 in urban India.
“The bottom line is we know what works to reduce smoking,” said Barkley. “But we’re not doing it.”

“We are totally outgunned”

“We rarely see tobacco ads (in the U.S.) today, so a lot of people think the problem is solved,” Barkley said. “But it’s not.”
The tobacco industry spent $8.4 billion in 2011 on cigarette advertising in the U.S., $7 billion of which went toward price discounts, according to the CDC. Barkley’s organization estimates that $271.1 million is spent annually in Kentucky alone.
Barkley and Shah said most advertisements come at the point of purchase, such as at gas stations; in magazines that anyone can buy; and in subscriptions that everyone who says they are 18 years of age on the Internet can access. These ad campaigns are aggressive, target youth and are highly successful, Barkley said.

“They wouldn’t be spending billions of dollars on marketing their products if it wasn’t working,” she said.
Data is harder to find about tobacco advertisement spending in India, but Shah said in addition to point-of-purchase advertising, tobacco companies in India do a lot of “brand stretching” where they sell non-tobacco products — like cigarette lighters, clothes and even perfumes, hair and skin care products — under the same logo as their tobacco. She notes that this “is a direct violation of the law” but happens anyway. She said that was typical of other anti-advertising laws too.

“The tobacco companies have gotten more diabolical in how they avert regulations,” Barkley said. “All the things that the government, society and medical community are trying to do just … don’t match up to the tobacco companies.”
Tobacco companies were amongst the biggest spenders in the 2014 Kentucky General Assembly, spending a total of $188,380 hoping to influence legislation. Bills that would have enacted a statewide ban died as a result of this pressure, according to one of the bill’s sponsors.
“We are totally outgunned,” Barkley said.

But where India has had success in banning tobacco ads is on the big screen. India is home to the world’s largest film industry, and for years tobacco companies exploited it by offering actors and directors to feature their products in film.
But the Indian government recently cracked down, and now all films shown in India with tobacco use will “include strong anti-tobacco warnings at the beginning and at the end of the movie, as well as scrolling messages along the foot of the screen during every scene containing tobacco use,” according to the WHO.
But that success is very limited.

A farmer’s view: “Until you make it illegal, we’re going to keep growing it”

By Judah Taylor

Kentucky’s cultural and economical heritage was sown with tobacco seeds, and for many it as a life-giving crop, not a life-taking one.
“I worked in tobacco since I was old enough to pull a little red wagon … picking up leaves in the field and went from there,” said tobacco farmer Allan Bryant, 48, whose family has farmed tobacco in Kentucky for more than two centuries. “Tobacco put me though (university), bought me my first car and my first farm, and now it provides for my family … it has given us opportunities where otherwise we would not have anything.”

Both India and Kentucky rely heavily on agriculture, especially tobacco.

Half of all U.S. tobacco farms are located in Kentucky and nearly India 38 million Indians work in the industry at some point — 75 percent in the agricultural sector — making the South-Asian country the world’s third largest tobacco producer and the Southern American state the second largest producer in the United States.

But there is “lots of uncertainty on where the industry is headed,” University of Kentucky tobacco expert Dr. William Snell said.

Yet that is nothing new.

When Melody Jones began smoking in the early 1970s, there were more than 70,000 Kentucky tobacco farmers. By the early ‘90s, that number was down to 60,000. Now Snell suspects it is closer to 5,000.

Though that trend is largely the result of agriculture regulation changes in the U.S., tobacco farmers rely on a market that is often in flux.
For decades, tobacco’s use in the U.S. has been declining, but doubled in the developing world between 1970 and 2000, mostly because of its popularity in heavily-populated nations like China and India, which each have more than a billion people, according to the United Nations.

That’s where many tobacco companies are targeting youth, and that’s where Bryant’s tobacco is consumed.

He contract sells his harvest to Philip Morris International, who sells Marlboro cigarettes in India and all across the globe and developing world — where more than three quarters of the world’s smokers live — and where tobacco companies are in constant legal disputes over advertising and other trade agreements.

These legal disputes, along with a constantly-changing market, could mean that the industry is in jeopardy – at least in Kentucky. But that hasn’t stopped Bryant, who built a new barn after his was destroyed by a tornado a few years back — something that would prompt many farmers to quit.

“Look, I wouldn’t suggest smoking to anyone,” Bryant said, noting that he would never smoke. “And if you want to make it illegal, that’s fine … but until you make it illegal, we’re going to keep growing it.”
 

E-cigarettes: Helpful or harmful?
By Judah Taylor

Melody Jones has tried using nicotine patches, gums and candies to quit smoking in the past, but nothing has worked.

“I want to quit,” she said. “I’ve been seriously trying for the last couple of years, and it wasn’t until I found electronic cigarettes that I found an alternative.”

E-cigarettes are battery-powered devices designed to emulate smoking. When the smoker puffs on a tube, which is usually made of metal, it vaporizes a liquid solution called “e-liquid” that often contains nicotine and flavorings.

For Jones and many others, these devices represent a new hope of escaping tobacco addiction.

But they are controversial. The World Health Organization warns against their use until they can be scientifically evaluated and regulated. And health advocates wonder if they will help people like Jones get off tobacco completely, or if they will serve as a gateway for tobacco for young people by getting them hooked on nicotine.

‘‘Right now, for … e-cigarettes, there are far more questions than answers,’’ Mitch Zeller, director of the U.S. Food and Drug Administration’s Center for Tobacco Products told USA Today.

That uncertainty of the booming multi-billion dollar e-cigarette business can be seen in both India and Kentucky.

Two Indian states  — Maharashtra and Punjab — have banned e-cigarette sales, while Air India defies the Indian Ministry of Health and Family Welfare by continuing to sell e-cigarettes aboard flights after the ministry told the air line that e-cigarette sales were a violation of the 2003 Cigarettes and Other Tobacco Products Act.
Meanwhile, Kentucky is among five U.S. states to explicitly say e-cigarettes are not tobacco products, although Gov. Steve Beshear recently signed a bill into law that made Kentucky the 26th U.S. state to prohibit anyone under the age of 18 from buying them.

And last month, the U.S. Food and Drug Administration proposed sweeping new rules that would extend its authority to e-cigarettes and regulate the ingredients put in to them for the first time.

Some experts are disappointed, saying that regulating the ingredients and not the vapor is like examining the health effects of tobacco leaves and not cigarette smoke. But the FDA has left the door open to future regulations as well.

Still, e-cigs are hard to regulate. Having been sold in the U.S. and India for less than a decade, there has not been enough time to gather long-term data on the effects of the products. What data has been gathered is quickly outdated, as new models of e-cigarettes are made and new recipes for e-liquid developed.

“We’re waiting for more studies,” said Amy Barkley of the Campaign for Tobacco-Free Kids. “They probably are less harmful than regular cigarettes, but the question is: Are they going to reduce smoking of regular cigarettes or not?”

Whatever the studies find, Barkley said people all across the world should put in place policies proven to reduce smoking: raising taxes on tobacco products, maintaining smoke-free laws, monitoring the sale of tobacco products around educational institutions, keeping tobacco companies compliant with advertising laws and limiting the sale of single cigarettes in India.

When it comes to smoking, she said an old adage holds true: “An ounce of prevention is better than a pound of cure.”