Ban on Gutka in India: symbolic Victory or actual end-game for smokeless tobacco. Large-scale household survey in Delhi finds out!

Background Smokeless tobacco (ST) use by over 200 million is major public health challenge in India. Gutka and Khaini are most popular products. Beginning in 2012, most states in India banned gutka and pan-masala containing tobacco. Ban on ST seemed like beginning of End-game. Almost 10 studies evaluated implementation or impact of ban. But, suffered from convenience sampling and reporting bias. Through first-of-its-type large-scale household survey in Delhi on Global Adult Tobacco Survey (GATS) model, we assess impact of ban on practices, patterns and quitting of tobacco by gutka users. Methods Male adults in Delhi were interviewed during Mar-Dec, 2016 on tobacco-use currently and before gutka-ban. Changes were made in questionnaire of GATS-India (2010), developed by CDC, WHO and Govt. of India, to accommodate retrospective-cohort study design. 1710 households were sampled using 3-step randomization. Inbuilt mechanisms in standardized questionnaire cross-validated self-report and minimized recall-bias. Data were entered into SPSS and statistically analyzed. Results 95.2% of 1710 household visited agreed to participate. Delhi banned ALL ST products in 2015, but except pre-mixed gutka, all ST products are freely available. Interestingly, 97.5%respondents believed tobacco as very harmful(78.9%) or somewhat harmful(18.6%). However, only 18.84% gutka users attempted quitting after ban. 2.4% successfully quitted. 84.1% of pre-ban gutka-users switched to twin-sachet (pan-masala and chewing-tobacco sold separately to circumvent law). Another major shift is in unit size from single-dose sachets earlier to multi-dose sachet. 10.1% switched to khaini or other ST products. 3.4% shifted to smoking. But 1.4% among them were former dual users. [Impact of gutka-ban on pattern of tobacco use and ] Conclusions If selective ST products are banned, most users switch to another ST product. Though few try quitting, success rate is low. There is minimal tendency to initiate smoking. Hence, apprehension of increased smoking and second-hand smoke exposure isn't true. Only comprehensive ban on ALL SLT products coupled with strong quitting campaign can achieve End Game