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When Mira Aghi, PhD, was working on a tobacco intervention project in the Indian states of Andhra Pradesh, Gujarat, and Kerala, she asked old men why they smoked. We get bored if we’re not doing anything, they told her. Ah, she said, so if you’re working you don’t need to smoke. No, they countered, you have to smoke to get some rest.

"They can give you any reason," Aghi says. “You smoke when you’re sad to get rid of the sadness. To enjoy happiness, you have to smoke."

Many in India don’t know that tobacco is bad for them. With low literacy rates and a population of 1 billion people, India presents a special challenge for tobacco control. The WHO has estimated that 43 percent of Indian men and 3 percent of women smoke, but smoking rates vary greatly depending on the location within India. “Among adult men, it can vary from about 15 percent to 80 percent in different parts [of India],” says Prakash C. Gupta, ScD ’75, a senior research scientist at the Tata Institute of Fundamental Research. In addition, Indians partake of tobacco in a variety of forms beyond regular cigarettes—another complicating factor for tobacco control projects. Bidis (tiny cigars so cheap that a few cents will get you 40) are smoked throughout the country. While less than 100 billion cigarettes are produced annually in India, 700 billion bidis are made there each year, according to Gupta. Additionally, gutka, a flavored chewing tobacco, has become very popular in recent years. (Gutka’s popularity has led to an epidemic of oral cancers—80,000 new cases per year, according to one estimate.)

Gupta knows the challenges of calculating tobacco’s effects on health in India; he is under-taking a study of 150,000 people in Mumbai. In addition, he is the epidemiologist in charge of India’s portion of IGTC’s multi-country cotinine study. “We know that tar and nicotine levels in Indian cigarettes are high and the manner of smoking could be different,” says Gupta. “It will be illuminating to look at the results.”

While researchers like Gupta and Aghi recognize the severity of the country’s tobacco epidemic, Indian politicians—absorbed by other, more prominent health concerns like AIDS and malnutrition—are just now considering national tobacco control policies. “Tobacco control is not a paid job in India,” Aghi says flatly. “All of us who are in tobacco control are doing some other kind of research jobs. This is more like a passion.” (The U.S. NIH sponsored the tobacco intervention project she worked on in the 1980s.)

The NIH project had a dramatic impact on her and the rural villagers, says Aghi, who co-authored a chapter on smoking initiation in Women and the Tobacco Epidemic , published by IGTC and WHO. “There were things like a woman telling her 2-year-old daughter to light a little cigar for her and the girl would have to puff it to make sure it was well lit,” she recalls. “This is how the habit in the little girls is also there.” By explaining what happens to the body as tobacco is chewed or smoked, Aghi educated people about the dangers and encouraged them to quit. “The job was very difficult but we had great success there, a great reduction in precancerous lesions in the mouth,” she says.

Our Man in Phnom Penh
Working as a sort of advance guard for the Johns Hopkins Institute for Global Tobacco Control (IGTC), Byron Crape has 45 days in Cambodia to aid government agencies and local NGOs in their tobacco control efforts and to get a feel for that country’s tobacco situation. It doesn’t look good.
    “There is a strong awareness that the tobacco industry is coming in fast and hard,” says Crape, a PhD candidate in Epidemiology whose second trip to Cambodia began in January. “They’re building new factories here and throughout Southeast Asia. There is an urgency because they’re increasing production rapidly. With the increased production, they’re also increasing marketing and getting more smokers.”
    With support from the Rockefeller Foundation and a Thai health agency, IGTC sent Crape to work with the Cambodian Ministry of Health and local nonprofits. His goals: train people in research methods, guide them in statistical analyses, assist them in drafting research proposals, and help them set up surveillance of the country’s tobacco industry.
    Long afflicted by war and Pol Pot’s brutal Khmer Rouge regime, Cambodia has begun a social and economic recovery, only to face a new threat to national health posed by smoking. According to The Tobacco Atlas, 66 percent of Cambodian males and 8 percent of women smoke. There is some precedent for successful anti-smoking campaigns in Cambodia; a project to reduce smoking among Buddhist monks succeeded in cutting back their smoking rate by more than 80 percent.
    On this trip Crape has seen small signs of progress and greater coordination among tobacco control groups. “I’ve seen it growing. We’re not an army but a series of different compartments that work together,” he says. —Brian W. Simpson


In the global tobacco control community, there is China… and then the rest of the world. One of every three cigarettes smoked in the world is fired up in China. Still in the early throes of its tobacco epidemic—cigarette sales have increased steadily since 1981—China is just beginning to see the health consequences of cancer and cardiovascular disease. By 2025, 2 million Chinese will die each year from tobacco-related illnesses, according to one study. This in a country whose government is essentially the largest tobacco company in the world; the China National Tobacco Corporation is a state monopoly.

As a UNICEF representative to China in the mid-1980s, Carl Taylor, professor emeritus in International Health, saw ominous portents in the clouds of cigarette smoke at social gatherings and medical meetings in China. A friend of China’s minister of health at the time, Taylor tried to impress on him the seriousness of China’s rising tobacco epidemic. “I kept telling him that by all indications the greatest cause of death in China was smoking, and we ought to do something about it,” recalls Taylor, MD, DrPH, MPH.

Preliminary data convinced government officials that smoking was a health threat, but more data on the extent of smoking in China were needed. So Samet, Karen Becker, MPH ’95, and Taylor collaborated with the Chinese Academy of Preventive Medicine on one of the largest studies ever conducted of one country’s smoking rates: China’s 1996 National Smoking Prevalence Study. The survey of 128,766 Chinese found that 63 percent of men and 3.8 percent of women smoke. Only one-third of those interviewed knew that smoking can cause lung cancer. Samet continues to collaborate with the study’s director, Dr. Gonghuan Yang. And recently, the Institute embarked on another major study with the Chinese Academy of Preventive Medicine. IGTC (with Fogarty support) is studying the effects of secondhand smoke on women and children in Chinese homes.

Patrick Breysse measures nicotine levels in air.

In a way, Hong Kong, where tobacco consumption peaked in the 1980s, can serve as an important bellwether of what’s to come in China, according to Dr. T.H. Lam, chair and professor of the Department of Community Medicine at the University of Hong Kong. “Hong Kong is between the U.S. and China. Hong Kong is 20 years ahead of China and 20 years [behind] the U.S.,” says Lam. “This will be a forewarning of what is very likely to happen in China and the rest of the developing world.”

In a similar fashion, Hong Kong can help predict the success of tobacco control programs in mainland China, says Lam. “The tobacco industry sees Hong Kong as a very important place to fight a battle,” says Lam. “If they win here, they will definitely win on the mainland.” Key issues debated recently in Hong Kong have been cigarette smuggling from the mainland where taxes are much lower than Hong Kong, an increase in tobacco taxes, and a ban on smoking in all restaurants.

A frequent collaborator over the years with Samet and IGTC, Lam joined Samet and Stillman in Thailand to conduct a recent workshop training Southeast Asian colleagues on writing research proposals. He recently enlisted Samet’s advice on a proposed study certain to capture male smokers’ attention. Lam is seeking funds for a randomized, controlled trial of smoking cessation for men with erectile dysfunction, “because it is often said smoking can cause impotence.”

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