Jammu and Kashmir is among the four Indian states with the highest prevalence of chronic obstructive pulmonary disease. The state recorded tobacco sales worth Rs 5,530 crore over seven years up to 2017-’18, according to state sales tax data accessed by IndiaSpend. This is the equivalent of the funds needed to construct four state-of-the-art hospitals along the lines of the All India Institute of Medical Sciences in Jammu.

Chronic obstructive pulmonary disease, typified by coughing, wheezing and breathlessness, is the second-most-frequent killer among diseases in India. It was responsible for the death of almost 10 lakh Indians in 2017, IndiaSpend reported in March 2018, citing the Global Burden of Disease study by the University of Washington. Caused by the inflammation of the lung’s airways, it destroys the air sacs that extract oxygen and expel carbon dioxide.

Air pollution and smoking have been established as the primary reasons for the occurrence of chronic obstructive pulmonary disease in India, according to a 2018 study published in The Lancet.

Jammu and Kashmir witnesses widespread burning of biomass fuel for cooking and heating, as well as widespread smoking, which together cause a 16% to 18% prevalence rate of chronic obstructive pulmonary disease in the state. The national average is between 5% and 7%, said Sundeep Salvi, director of the Pune-based Chest Research Foundation in an interview to IndiaSpend in March.

Jammu and Kashmir, Himachal Pradesh, Uttarakhand and Haryana report chronic obstructive pulmonary disease figures equal to or greater than 4,750 per 100,000 population – the highest across India.

In Jammu and Kashmir, acute exacerbation of chronic obstructive pulmonary disease in about 470,000 chronic patients annually costs around Rs 210 crore, enough to set up four maternity hospitals, one study has estimated.

“Jammu and Kashmir is fast emerging as the ‘smoking capital’ of the north,” The Economic Times reported in February 2015, citing sources at the Voluntary Health Association of India, a nonprofit organisation.

One in five, or 20.8%, of Jammu and Kashmir’s citizens smoke, against the national average of 10.7%, according to the Global Tobacco Survey 2016-’17. The state ranks the sixth highest among Indian states by smoking habits, behind Meghalaya, Tripura, Arunachal Pradesh, Manipur and Mizoram, as per the survey.

To understand how widespread the use of tobacco and tobacco products – including cigarettes and bidis – is in Jammu and Kashmir, IndiaSpend accessed data over seven years to 2017-’18 on sales taxes collected in the state on these items.

We found that tobacco and tobacco products fetched the state’s sales tax department its highest revenue among more than 70 commodities, including automobiles and electronic gadgets.

Total consumption of tobacco and tobacco products is IndiaSpend's analysis of the data. Source: Jammu and Kashmir sales tax department

Users in the state consumed tobacco products worth Rs 5,530 crore over the seven years to 2017-’18, according to IndiaSpend’s estimates, based on the 40% sales tax imposed on these items by the government. IndiaSpend took into account that after the implementation of the Goods and Services Tax regime in the state in 2018-’19, the tax rate is now down to 28%. Annually, the state consumes tobacco products worth an average Rs 800 crore, our analysis revealed.

Year-wise data from these sales figures suggested that the consumption of tobacco products is rising in the state. The only decline was in 2017-’18.

Prevalence among smokers

“Our studies have revealed that there is a very high prevalence of biomass burning and smoking in Kashmir,” said Parvaiz Koul, head of the general medicine department at the Sher-e-Kashmir Institute of Medical Sciences in Srinagar. “Both of them are responsible for causing chronic obstructive pulmonary disease. Smoking itself is a form of biomass burning.”

Smoking is also responsible for reduced lung function among those living in Kashmir, concluded a study carried out by Koul and others and published in the International Journal of Tuberculosis and Lung Disease in October 2016. The team measured the incidence of chronic airflow limitation, which reduces pulmonary functioning.

“Most patients we receive in all seasons suffer from chronic obstructive pulmonary disease,” said Naveed Nazir Shah, senior consultant at the Chest Diseases Hospital, Srinagar. “And we have observed that most of them have a history of tobacco use.”

Yet another September 2018 study concluded that there is a high prevalence of chronic obstructive pulmonary disease in Kashmir and this is associated with smoking.

Chronic obstructive pulmonary disease prevalence was 2.7% among non-smokers, 22% among ex-smokers and 28.2% among current smokers as per the study. Also, 59.5% of chronic obstructive pulmonary disease subjects had a history of tobacco exposure.

Low awareness of hazards

Tobacco use, especially cigarette smoking, is socially acceptable in Kashmir because of the lack of awareness and inadequate advocacy, said Arshad Hussain, a senior psychiatrist and professor at the Government Medical College in Srinagar.

“What is aiding this huge prevalence of tobacco use enormously, especially smoking, is the fact that Kashmir has become a highly stressful zone where people are facing not only challenges associated with daily life, but also those posed by the turbulent security and political situation,” Hussain said. “When people experience anxiety and stress, they tend to manage the unpleasant feelings by resorting to the use of substances such as tobacco.”

Up to 45% of the state’s population experiences mental distress, a survey on mental health in Kashmir, published by Medicines Sans Frontiers or Doctors without Borders, the international medical humanitarian organisation, in May 2016, revealed. “Nearly 18 lakh adults [45% of the population] in the Kashmir Valley show symptoms of significant mental distress,” the report said.

Hussain pointed to the lack of aggressive public campaigning against smoking in the region. “For example, some time back, an order was issued that incidents of smoking in offices or public places be reported – but it has been taken lightly and people continue to smoke in offices and public places,” he said.

The growing prevalence of smoking, Arshad observed, is not only one of the major causes of respiratory diseases but also a gateway to drug abuse among the youth. “The authorities should focus on how to involve youth in activities like sports which can potentially help avoid this situation,” the psychiatrist said.

The fresh waves of armed and political conflict in the region are pushing tobacco use, said Malik Roshan Ara, who teaches psychology at Srinagar’s Institute of Advanced Studies in Education. “The repeated incidents of violence and political unrest often confine people to their homes that too in a state of anxiety,” she said. “So people must be using tobacco as a stress-buster especially when the use of tobacco is considered acceptable in our culture.”

Cost of the disease

A recent study published in the Annals of Global Health in January analysed data on out-of-pocket costs of hospitalisation and missed work-days of patients and their attendants.

“Our study estimated the costs of acute exacerbations of chronic obstructive pulmonary disease in India to be Rs 44,390 per admission and mostly [71%] related to direct hospital costs,” the study said. “Importantly, about 30% of the total costs were related to transportation, medications and diagnostic tests and out-of-pocket expenses. These results suggest that acute exacerbations of chronic obstructive pulmonary disease generate substantial costs that could be a major economic burden to patients and their families.”

The study calculated the financial burden of the disease thus: the state’s population, as per the 2011 census, is close to 1.2 crore. Given the expected prevalence of 19% of chronic obstructive pulmonary disease in individuals over 40 years of age, there are an estimated 470,000 patients with the disease in the state.

“Assuming that at least half of chronic obstructive pulmonary disease patients will have two exacerbations per year, we can estimate that approximately Rs 210 crores are spent on acute exacerbations of chronic obstructive pulmonary disease in Jammu and Kashmir,” the report concluded.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.