“Sutta breaks” are common in India. A glass of tea and a cigarette constitute the popular “chai-sutta.” Sandeep, a young marketing executive, says, “It’s time to take a break from work stress and make connections. The chai-sutta break is where ideas flow as freely as the smoke.” Not surprisingly, workplaces are common settings where non-smokers are involuntarily exposed to second-hand smoke.
Tobacco use in India: a growing concern
According to GATS2 data, nearly 42% of men and 14% of women in India use tobacco. Home to 70% of the world’s smokeless tobacco (SLT) users, SLT is preferred over smoked tobacco. In smoked tobacco, the bidi is favored over cigarettes, especially in rural and low-income groups. Despite the preference for bidis, India has seen the largest increase in the market share of cigarettes globally.
Rajesh, a shopkeeper in Mulshi, a village near Pune, commented, “Bidis are what people here can afford. Cigarettes are for the city folks. But now even in villages, people want to try cigarettes because they think it’s modern.”
Both SLT and smoked tobacco drastically increase cancer risk, particularly for lung, head, neck, stomach, and pancreatic cancers. “My uncle chewed tobacco for years,” said Sunita, a homemaker from Maharashtra. “He passed away from mouth cancer, and we didn’t realise how dangerous it was until it was too late.”
India ranks first globally in male cancer incidence and mortality rates. Among tobacco-related cancers in males, lung cancer leads globally, while in India, lip and oral cancers top the list, followed by lung cancer. “Every time I see someone with a gutkha pouch in their pocket, I feel like warning them,” said Manish, a college student whose father succumbed to oral cancer. Clearly, the ban on gutkha in India has been unsuccessful.
Economic costs of tobacco use
Along with the health burden, tobacco use imposed an economic cost of ₹1.77 lakh crore (1.04% of India’s GDP) in 2017-2018. Smoking accounted for 74% of these costs, while SLT use made up 26%. With tobacco use on the rise, both health and economic costs are projected to increase.
Rajiv, a father of three who quit smoking after a lung cancer scare, said: “I never realised the financial toll until I saw the hospital bills. Smoking doesn’t just cost you money — it costs you your life and the lives of those who depend on you.”
India faces a dual challenge of significant health and economic burdens from tobacco-related cancers and the complexities of lung cancer screening in a TB-endemic country. This underscores the urgent need for evidence-based anti-tobacco policies as a primary prevention strategy. However, the tobacco industry’s influence—through policy interference, pricing tactics to maintain affordability, targeted marketing, dense tobacco shop networks, and a lack of political will—ensures widespread tobacco accessibility.
“The fact that a bidi costs less than a cup of tea is a tragedy,” said Ashok, a retired clerk. “When I was younger, I didn’t think twice about buying a bidi. Now I see how cheap tobacco ruins lives.”
Taxation remains a critical yet underutilised tool in reducing tobacco use. Despite the proposed GST increase to 35%, it falls short of the World Health Organization’s recommendation of taxing tobacco at 75% of its MRP to effectively deter use. Even with the steep increase in tobacco tax, its impact decreases if consumers’ income increases significantly.
Unlike in other countries where higher prices have deterred smoking, rising disposable incomes in India, particularly among the 450 million middle class have outpaced tax increases. With increased purchasing power, tobacco products continue to be affordable. The unchanged tobacco prices in the 2024 Union Budget further exacerbated this issue, enabling tactics like “undershifting,” where manufacturers absorb tax hikes to expand markets.
A key factor in tobacco affordability is its unit pricing. A pack of bidis has a median price of ₹12 but can be found for as little as ₹5. Similarly, smokeless tobacco products have a median price of ₹5, with some being sold for as low as ₹1. Shankar, a daily wage labourer and cancer patient said he could afford to buy a few packs every day.
While cigarette packs have a median price of ₹95, cheaper options are available for as cheap as ₹5. Sonia, a college student, observed, “Cigarettes are so cheap that they’re easy to buy. The government needs to make it harder for people like us to afford them.”
To enhance affordability, cigarettes are often sold as single sticks – a practice banned in 88 countries but not in India. Priced at approximately ₹15, single sticks become easily affordable and bypass graphic health warnings. Research shows that 87% of Indian cigarette vendors sell single sticks, frequently operating near tea stalls, reinforcing the widespread “chai-sutta” culture.
In India where a significant proportion of the population earns ₹170-180 per day (exchange rate $1 = ₹85), along with the addictive potential of tobacco, makes the current tobacco pricing affordable to fulfill their cravings.
Outlook: the way forward
Tobacco affordability undermines the WHO’s MPOWER framework and weakens tobacco control, hindering efforts to reduce tobacco-related cancers. Reducing tobacco use is vital for cutting cancer incidence. However, to make early detection and treatment accessible, health systems must be strengthened.
Meanwhile, implementing robust anti-tobacco policies can be effective in curbing tobacco use. To achieve this, several key adjustments are crucial.
Firstly, regular tax hikes that outpace income growth can make tobacco products unaffordable, discouraging their use. Additionally, banning single-stick sales can reinforce health warnings and curb impulse purchases. Furthermore, allocating tobacco tax revenue towards public health initiatives, such as cancer screenings in underserved areas, can have a significant impact.
Enforcing plain packaging with prominent health warnings can also reduce tobacco’s appeal, while restricting sales near tea stalls can help break the ‘chai-sutta’ association. Robust enforcement, through regular inspections and penalties, is essential to uphold these regulations. Moreover, prioritising cancer screening, tobacco-cessation programmes, and research can further bolster tobacco control efforts, ultimately creating a comprehensive approach to tackle tobacco use.”
As Shalini, a widower – her husband and bread-earner of the family – died of lung cancer and now single mother of two, put it, “It’s not just about saving lives today—it’s about creating a future where my kids don’t grow up thinking chai-sutta is a normal part of life.”
(Dr. Vid Karmarkar is a social entrepreneur, researcher, writer and advocate of advancing equitable cancer care and global health. He is also the founder of the Canseva Foundation, a registered nonprofit organisation. Email: [email protected])
Published – May 30, 2025 07:00 am IST