Dear Editor, Looking at the oral cancer situation in India, a 2020–2022 study by Asmin et al. 1 reflected the widespread nature of the disease, as per the distribution of oral cancer cases in South India’s oncology institutes, and specifically pointed to a massive increase in the occurrence of tongue and buccal mucosa cancers. India has the highest global burden of lip and oral cavity cancer, with tobacco being the number one cause behind. 2 The prevalent consumption of smokeless tobacco products, including gutka (a blend of tobacco, areca nut, flavorings, and spices), khaini (dried or fermented tobacco leaves), and paan masala, is a primary driver of lip and oral cavity cancer (LOC) becoming the most frequently diagnosed cancer among men and the second leading cause of cancer-related deaths nationwide. As you move through the country, the rate of lip and oral cavity cancers is higher within the northeast and center of India. Especially Meghalaya, Assam, Madhya Pradesh, Gujarat, and Delhi, are the hotspots. 3, 4 Looking at the future of oral cancer in India, the numbers are daunting. According to global cancer observatory (GLOBOCAN) estimates, the number of new cases of oral cancer in the country is set to rise by a chilling 69. 1%, from 143, 759 cases in 2022 to 243, 150 cases in 2045. 2 This crisis affects not just the individual, but also has a colossal economic toll on families and the nation. The study by Tata Memorial Hospital stated that productivity loss resulting from premature deaths due to oral cancer in India was found to cost approximately 5. 6 billion annually. 4 Tobacco consumption causes more than 80% of the cases of oral cancer in India. 5 Despite this decline, the tobacco industry is thriving and using legal tricks and aggressive advertising to ensnare new young customers. The Indian Tobacco Industry is never shrinking, with the IMARC Group forecasting it to grow even further in 2024 to an approximate 804. 8 thousand tons and has the potential to increase up to almost a million ton by 2033. With cultural tolerance for tobacco and increasing disposable incomes of the people, along with persuasive marketing techniques, some that include promotion by leading film celebrities of the Indian film industry, increasing demand for tobacco further threatens to increase the burden in India. 6 These are not only extending and diversifying the market base but also implying the normalization of smoking among different population groups. India is therefore confronted with an enormous public health challenge. The nation is now experiencing the highest prevalence of lip and oral cancers in South Asia, primarily due to extensive consumption of smokeless tobacco and areca nut. India recorded as many as a whopping 83, 400 of these global cases out of the total 120, 200 reported in 2022 so far, as against a mere 9, 700 by Bangladesh, just short of 8, 900 for Pakistan, and around 1, 300 for Sri Lanka. 7 The fact that one in every three individuals living in India, not to mention 3% of children, consumes tobacco, emphasizes the pressing requirement for renewed tobacco law regulation. 8 The tobacco industry, quite rapidly, is turning into a great economic power house and the one that needs to be addressed. WHAT CAN BE DONE! Programs like National Tobacco Control Programme and school-based sensitization and awareness initiatives of Tatas Cancer Care Foundation have achieved some success but are not enough to stem the tide. A total ban on tobacco is a utopian concept, India being such an important place for tobacco growing. Tobacco production is a major source of employment and national income; hence, an absolute ban is not feasible. An alternative and more effective strategy is a substantial increase in tobacco taxation Figure 1. 9 Currently, tax hikes remain minimal, with only ₹2–₹3 per piece increases, which do little to deter consumers. The Budget 2023 hiked excise duty on cigarettes, marginally rising their prices by 1–3%. The 2024 Budget left taxes alone, and the price levels were held steady. In 2025, the Goods and Services Tax (GST) Council hiked the tax rate for tobacco products from 28% to 40%, which could potentially lead to an increase in price by about 5–6%. The cigarette sticks that used to cost around ₹19 would now cost about ₹21. The World Health Organization (WHO) identifies higher taxation as the most effective measure to curb tobacco use, recommending that at least 70% of a cigarette’s retail price be taxed. India’s 2017 GST reform placed tobacco products in the highest tax slab (28%) with an additional cess. However, in some states, the new system resulted in lower taxes compared to the previous Value Added Tax (VAT) regime. 10 Additionally, beedis (hand-rolled tobacco wrapped in specific tendu leaves), classified as a cottage industry, remain largely untaxed, and exemptions exist for small manufacturers (companies with <20 employees) and farmers as well. To align with WHO recommendations, India should introduce uniform taxation, eliminating exemptions and imposing at least a 70–80% tax at the retail price on all tobacco products. Raising tobacco taxes would achieve two key objectives: making tobacco products less affordable, particularly for young users, and ensuring significant government revenue even from limited consumption. Global examples demonstrate the efficacy of high tobacco taxation. Australia’s tobacco tax, at 68% of retail price, reduced smoking prevalence from 15. 1% in 2010 to 11. 6% in 2019, with illicit trade remaining below 10% due to strict enforcement. 11 In the Philippines, a 29% increase in cigarette prices was estimated to prevent about 1, 961 tobacco-related deaths and save 34, 571 disability-adjusted life years (DALYs). The resulting reduction in hospitalizations and additional excise revenue generated around USD 367 million in savings, rising to USD 415 million when productivity gains were included. In total, the public payer saved USD 10, 612 per DALY thanks to the reform. 12 Such tax increases generate a substantial amount of revenue that can be diverted to public health initiatives. Figure 1: Countries’ overall cigarette tax scores and per-capita cigarette consumption, 2014-2020 9 Figure 1 tracks trends in 97 countries from 2014 to 2020, showing that as the average cigarette tax score climbed from 2. 23 to 2. 53, per-capita cigarette consumption simultaneously dropped from over 1, 060 sticks to 880 sticks. In a broader perspective, other smokeless forms of tobacco consumption such as gutka, khaini, and Zarda are predominant in India besides cigarettes. More than one in five adults in India uses some form of tobacco. General policies against these products, tax uniformity, effective bans on flavored and packaged smokeless forms, and media campaigns in rural areas are all needed to limit the risk of developing oral squamous cell carcinoma. 8 The tobacco companies often assert that raising taxes will lead to smuggling. Yet the international experience indicates that strong enforcement measures can help to effectively reduce these risks. Countries that have implemented high tobacco taxes have successfully maintained low levels of illicit trade through rigorous supervision. India must take a similar approach by bearing higher taxes and creating tough regulations and sturdy enforcement. CONCLUSION The escalating oral cancer crisis in India demands immediate, decisive action. We must put the health of our citizens before the profits of any industry. Tackling this will require a focused strategy: tougher policies, stronger enforcement, and widespread public education. This integrated approach is the only way we can dramatically cut down the cancer cases linked to tobacco and protect our children and future generations from its devastating effects. Author contributions All authors read and approved the final manuscript. All authors made equal contributions in designing, writing, reading, and approving the final manuscript. Ethics statement The author (s) did not have any external funding. Financial support and sponsorship The author (s) received no financial support for the research, authorship, and/or publication of this article. Conflicts of interest The author (s) indicate that they do not have any conflicts of interest.
Nagar et al. (Fri,) studied this question.