Tobacco & Alcohol — Epidemiology & Control

Tobacco and alcohol are the two leading modifiable behavioural risk factors for non-communicable disease (NCD) in India and globally. This topic is high-scoring because it is fact-dense and rule-based — COTPA provisions, legal ages, screening questionnaires (CAGE vs AUDIT), attributable mortality fractions and the National Tobacco Control Programme (NTCP) — exactly the kind of recall questions NEET PG loves.

Burden & Epidemiology

Tobacco kills more than 8 million people per year worldwide (WHO), of whom roughly 1.3 million die from second-hand (passive) smoke exposure. In India, tobacco accounts for nearly 1.35 million deaths annually and is the single largest preventable cause of death.

India is unusual because smokeless tobacco (khaini, gutkha, zarda, paan masala) is as important as smoking. Indian survey data come chiefly from GATS (Global Adult Tobacco Survey).

Indicator (GATS-2, India, 2016–17)	Value
Overall tobacco use (adults ≥15 yr)	28.6%
Smokeless tobacco use	21.4%
Smoking	10.7%
Men using any tobacco	~42%
Women using any tobacco	~14%
Decline from GATS-1 (2009–10, 34.6%)	6 percentage-point fall

High-yield: In India smokeless tobacco use (21.4%) is more prevalent than smoking (10.7%) — a reversal of the Western pattern. GATS is the source survey.

Alcohol: per the National Family Health Survey (NFHS-5), alcohol consumption is reported by about 1% of women and 19% of men. Globally alcohol causes ~3 million deaths/year (~5.3% of all deaths) and is a causal factor in >200 disease and injury conditions.

Tobacco — Constituents & Pathophysiology

• Nicotine — the addictive alkaloid; acts on nicotinic acetylcholine receptors → dopamine release in nucleus accumbens (reward). Causes dependence but is not the main carcinogen.
• Tar — contains the carcinogens (polycyclic aromatic hydrocarbons, benzo[a]pyrene, nitrosamines such as NNK).
• Carbon monoxide — binds haemoglobin (forms carboxyhaemoglobin) → tissue hypoxia; contributes to atherosclerosis and IUGR.
• Nitrosamines (TSNA) — chief carcinogens in smokeless tobacco.

Mechanistic chain: Smoking → endothelial dysfunction + oxidative stress + carcinogen-DNA adducts → atherosclerosis, COPD, malignancy.

Diseases causally linked to tobacco

System	Conditions
Respiratory	COPD (most strongly attributable), lung cancer, recurrent infection
Cardiovascular	Coronary artery disease, stroke, peripheral vascular disease (Buerger's = thromboangiitis obliterans)
Cancers	Lung, oral cavity, larynx, pharynx, oesophagus, bladder, pancreas, kidney, cervix, stomach, AML
Reproductive	Low birth weight, IUGR, preterm birth, ↑ ectopic pregnancy
Others	Peptic ulcer, osteoporosis, cataract, delayed wound healing

High-yield: The condition with the highest population-attributable fraction for tobacco is COPD (~80–90% of cases smoking-attributable). For lung cancer, smoking accounts for ~85–90% of cases; relative risk in heavy smokers is ~10–30×.

Smoking-attributable mortality fractions

• Of all lung cancer deaths, ~85–90% are attributable to smoking.
• Of all COPD deaths, ~80%+ are attributable to smoking.
• Roughly half of lifelong smokers die of a tobacco-related disease; a smoker loses on average ~10 years of life.

Passive (second-hand) smoking — health effects

Passive smoke is classified by IARC as a Group 1 (proven human) carcinogen. Effects:

• Adults: lung cancer, ischaemic heart disease, stroke.
• Children: Sudden Infant Death Syndrome (SIDS), lower respiratory infections (bronchiolitis/pneumonia), otitis media (commonest), asthma exacerbation, low birth weight.

High-yield: In children, the commonest consequence of passive smoking is middle-ear disease (otitis media); the most feared is SIDS. Passive smoking is a Group 1 carcinogen.

COTPA 2003 — the core law

The Cigarettes and Other Tobacco Products Act, 2003 (full name: Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution Act) is the backbone of Indian tobacco control. Memorise the four pillars:

Section	Provision
Section 4	Prohibits smoking in public places (smoke-free zones)
Section 5	Prohibits advertisement, promotion and sponsorship of tobacco products
Section 6	(a) Prohibits sale to/by minors and (b) sale within 100 yards of educational institutions
Section 7	Mandatory statutory health warnings on packs (pictorial + text)

Key numbers to lock in:

• Minimum legal age to purchase/sell tobacco: 18 years (Section 6a).
• No sale within 100 yards (≈91 m) of any educational institution.
• Pictorial warnings must cover 85% of both principal display areas of the pack (60% pictorial + 25% text), as per later rules.
• Fine for smoking in a public place: up to ₹200.
• "Public place" exemptions allowing designated smoking areas: airports, hotels with ≥30 rooms, and restaurants seating ≥30 — these may have a separate ventilated smoking room.

High-yield: Minimum age for tobacco purchase under COTPA = 18 years; no sale within 100 yards of schools; pictorial warning covers 85% of the pack. These three are the most frequently asked single-fact recalls.

High-yield: COTPA Section 4 = smoke-free public places; Section 5 = advertising ban; Section 6 = minors/100-yard rule; Section 7 = health warnings. Mnemonic: "Public-Ads-Minors-Warnings" (4-5-6-7) in ascending order.

National Tobacco Control Programme (NTCP)

Launched 2007–08 under the Ministry of Health & Family Welfare. Structure: National → State → District Tobacco Control Cells. Activities include training, IEC, school programmes, COTPA enforcement, monitoring, and setting up Tobacco Cessation Centres.

Related schemes/initiatives:

• mCessation (Quit Tobacco) — mobile-based cessation via the National Tobacco Quitline (toll-free 1800-11-2356).
• Prohibition of Electronic Cigarettes Act, 2019 — complete ban on production, sale, import and advertisement of e-cigarettes/ENDS in India.
• India is a party to the WHO Framework Convention on Tobacco Control (FCTC, 2003) — the first global public-health treaty. WHO's demand-reduction package is MPOWER.

MPOWER mnemonic (WHO):

• M — Monitor tobacco use and prevention policies
• P — Protect from tobacco smoke (smoke-free laws)
• O — Offer help to quit
• W — Warn about dangers (pack warnings, mass media)
• E — Enforce bans on advertising/promotion/sponsorship
• R — Raise taxes on tobacco

Tobacco cessation — the 5 A's & pharmacotherapy

Behavioural counselling follows the 5 A's: Ask → Advise → Assess → Assist → Arrange (follow-up). For those unwilling to quit, use the 5 R's (Relevance, Risks, Rewards, Roadblocks, Repetition).

Nicotine Replacement Therapy (NRT) and drugs

Drug	Notes
NRT (patch, gum, lozenge, inhaler, nasal spray)	First-line; patch = steady level, gum/spray = acute craving. Doubles quit rates. Caution in recent MI/arrhythmia
Varenicline (Champix)	Partial agonist at α4β2 nicotinic receptor; most effective monotherapy. Watch for neuropsychiatric/sleep effects
Bupropion (Zyban)	Atypical antidepressant; lowers seizure threshold (avoid in epilepsy, eating disorders)
Clonidine, Nortriptyline	Second-line

High-yield: Varenicline = α4β2 nicotinic receptor partial agonist — the single most effective pharmacological agent for cessation. NRT roughly doubles quit rates. Start NRT on the quit date; patches give a baseline, gum manages breakthrough craving.

Alcohol — pharmacology, metabolism & disease

Ethanol is metabolised: Ethanol →(alcohol dehydrogenase)→ Acetaldehyde →(aldehyde dehydrogenase, ALDH)→ Acetate. Disulfiram blocks ALDH → acetaldehyde accumulation → flushing, nausea (aversion therapy). Many East-Asians have ALDH2 deficiency → flushing reaction.

Standard drink (India/WHO): contains ~10 g of pure ethanol. Categories of harmful use are graded by AUDIT (below).

Alcohol-related disease

System	Conditions
Hepatic	Fatty liver → alcoholic hepatitis → cirrhosis
Neuro	Wernicke's encephalopathy (thiamine deficiency: confusion + ophthalmoplegia + ataxia), Korsakoff psychosis, peripheral neuropathy, seizures
GI	Gastritis, pancreatitis, oesophageal varices, Mallory–Weiss tear
CVS	Cardiomyopathy, hypertension, arrhythmia ("holiday heart")
Cancers	Oral, oesophageal, liver, breast, colorectal
Withdrawal	Tremor, seizures, delirium tremens (treat with benzodiazepines + thiamine)
Fetal	Fetal Alcohol Syndrome — growth restriction, facial dysmorphism, CNS deficits

High-yield: Acute alcohol-withdrawal/delirium tremens → manage with benzodiazepines (chlordiazepoxide/diazepam); always give thiamine before glucose to prevent precipitating Wernicke's encephalopathy.

Screening: CAGE vs AUDIT (most-tested distinction)

CAGE questionnaire

A 4-item rapid screen for alcohol dependence/lifetime problem drinking:

• C — felt you should Cut down?
• A — people Annoyed you by criticising your drinking?
• G — felt Guilty about drinking?
• E — had a morning Eye-opener drink?

Scoring: 1 point each. ≥2 = clinically significant, warrants further assessment. Quick but not good for hazardous/early drinking and not quantity-based.

AUDIT (Alcohol Use Disorders Identification Test)

Developed by the WHO; 10 items covering consumption, dependence and harm; each scored 0–4 (max 40).

AUDIT score	Interpretation / Action
0–7	Low risk
8–15	Hazardous (risky) drinking → simple advice
16–19	Harmful drinking → brief counselling + monitoring
20–40	Possible dependence → refer for diagnostic evaluation/treatment

A 3-item short form AUDIT-C (consumption questions only, max 12) is used for rapid screening.

High-yield: CAGE = 4 questions, cut-off ≥2, screens dependence. AUDIT = WHO, 10 questions, score 0–40, ≥8 = hazardous drinking. Examiners commonly ask which questionnaire WHO developed (AUDIT) and the AUDIT cut-off (8).

Quick comparison

Feature	CAGE	AUDIT
Items	4	10
Developer	Ewing (1984)	WHO
Max score	4	40
Cut-off	≥2	≥8
Detects early/hazardous use	Poor	Good
Quantifies consumption	No	Yes

Diagnosis / Investigation of choice

• Biomarkers of recent alcohol use / relapse: CDT (carbohydrate-deficient transferrin) is the most specific; GGT is the most commonly used and sensitive but less specific; MCV raised in chronic use; AST:ALT ratio >2:1 suggests alcoholic liver disease.
• Tobacco exposure biomarker: cotinine (nicotine metabolite, longer half-life) in urine/saliva/blood is the investigation of choice to objectively confirm smoking/passive-smoke exposure; exhaled CO is a quick bedside marker.

High-yield: Cotinine = best biomarker of tobacco/nicotine exposure. CDT = most specific alcohol biomarker; GGT = most sensitive routine marker.

Stepwise approach (flow)

Screen with AUDIT/CAGE (alcohol) or smoking history (tobacco) → Assess severity/dependence → Brief intervention (advise quit) → Offer pharmacotherapy (NRT/varenicline for tobacco; naltrexone/acamprosate/disulfiram for alcohol) → Refer to cessation centre/de-addiction → Arrange follow-up & relapse prevention.

For alcohol dependence maintenance: Naltrexone (opioid antagonist, reduces craving), Acamprosate (modulates glutamate/GABA), Disulfiram (aversive, ALDH inhibitor).

Complications & social impact

• Tobacco: COPD, lung & oral cancer, IHD, stroke, household poverty, second-hand harm to family.
• Alcohol: cirrhosis, road-traffic accidents, domestic violence, suicide, productivity loss, fetal alcohol syndrome.
• Both impose a major economic burden through health costs and lost productivity, disproportionately affecting the poor.

Key differentials / look-alike facts

• Group 1 carcinogens (IARC) in this topic: tobacco smoke, smokeless tobacco, second-hand smoke, alcohol/ethanol, areca nut.
• Distinguish NTCP (2007–08) from the NPCDCS (NCD programme) — tobacco control is a distinct vertical though integrated under NCD.
• E-cigarettes are completely banned (2019), unlike conventional cigarettes which are regulated under COTPA.

Recently asked / exam angle

• Minimum legal age for tobacco purchase under COTPA = 18 years. (single-fact recall)
• Which section of COTPA prohibits smoking in public places? → Section 4.
• No sale of tobacco within how many yards of a school? → 100 yards.
• Pictorial warning covers what % of the pack? → 85%.
• WHO developed which alcohol screening tool? → AUDIT (10 items, cut-off 8). CAGE has 4 items, cut-off 2.
• Mechanism of varenicline? → α4β2 nicotinic partial agonist.
• Best survey for tobacco prevalence in India? → GATS. Smokeless > smoking in India.
• WHO demand-reduction package? → MPOWER.
• Most specific alcohol biomarker? → CDT; most sensitive routine marker → GGT.
• Commonest passive-smoking effect in children? → otitis media; most feared → SIDS.

Rapid revision

1. COTPA 2003 sections: 4 = smoke-free; 5 = ad ban; 6 = minors + 100-yard rule; 7 = health warnings.
2. Minimum legal age for tobacco = 18 years; no sale within 100 yards of schools.
3. Pictorial warning = 85% of pack display area.
4. India: smokeless tobacco (21.4%) > smoking (10.7%), total 28.6% (GATS-2).
5. NTCP launched 2007–08; structure National–State–District cells; Quitline 1800-11-2356.
6. E-cigarettes completely banned (2019). WHO package = MPOWER; treaty = FCTC.
7. CAGE = 4 items, cut-off ≥2, screens dependence (Eye-opener = morning drink).
8. AUDIT = WHO, 10 items, 0–40, ≥8 hazardous, ≥20 dependence; AUDIT-C = 3 items.
9. Varenicline = α4β2 partial agonist (best drug); NRT doubles quit rates; bupropion lowers seizure threshold.
10. Cotinine = best tobacco biomarker; CDT most specific & GGT most sensitive for alcohol.
11. Passive smoke = IARC Group 1; children → otitis media (commonest), SIDS (feared).
12. Alcohol withdrawal/DT → benzodiazepines + thiamine (before glucose); maintenance → naltrexone/acamprosate/disulfiram (ALDH inhibitor).