Wednesday, October 29, 2008

Call for a Google doodle for World Diabetes Day on November 14

India is the diabetes capital of the world with estimated 41 million Indians having diabetes.Every fifth diabetic in the world is an Indian.It is believed that about one third of the Diabetic in India do not know they have Diabetes.

You've seen the cool "doodles" that Google has done for Holidays, important moments in history etc etc.

Well the Diabetes Online Community wants Google to do one on November 14Th for World Diabetes Day to increase awareness about Diabetes.
So click here to Petition Google for a World Diabetes day doodle.

Thank you for bringing more awareness to Diabetes!!!

Tuesday, October 28, 2008

How to know when you have a Major Depression

The stimulus for this post are recent blog posts on suicide by Seema and Cris. So I thought I will share some knowledge about Depression and how to tackle it. This is adapted from Psychiatry Text Books and websites

How to find out you or your friend is having a major problem of Depression?

Most people with depression will not have all the symptoms listed below, but most will have at least five or six.


1.Feel unhappy most of the time (but may feel a little better in the evenings)
2.Lose interest in life and can't enjoy anything
3.Find it harder to make decisions
4.Can't cope with things that you used to
5.Feel utterly tired
6.Feel restless and agitated
7.Lose appetite and weight (some people find they do the reverse and put on weight)
8.Take 1-2 hours to get off to sleep, and then wake up earlier than usual
9.Lose interest in sex
10.Lose your self-confidence
11.Feel useless, inadequate and hopeless
12.Avoid other people
13.Feel irritable
14.Feel worse at a particular time each day, usually in the morning
15.Think of suicide.

You may not realise how depressed you are for a while, especially if it has come on gradually. You try to struggle on and may even start to blame yourself for being lazy or lacking willpower. It sometimes takes a friend or a partner to persuade you that there really is a problem which can be helped.

You may start to notice pains, constant headaches or sleeplessness. Physical symptoms like this can be the first sign of depression.

How to help someone who is depressed?

Listen. This can be harder than it sounds. You may have to hear the same thing over and over again. It's usually best not to offer advice unless it's asked for, even if the answer seems perfectly clear to you. If depression has been brought on by a particular problem, you may be able to help find a solution or at least a way of tackling the difficulty.

It's helpful just to spend time with someone who is depressed. You can encourage them, help them to talk, and help them to keep going with some of the things they normally do.

Someone who is depressed will find it hard to believe that they can ever get better. You can reassure them that they will get better, but you may have to repeat this over and over again.

Make sure that they are buying enough food and eating enough.

Help them to stay away from alcohol.

If they are getting worse and start to talk of not wanting to live or even hinting at harming themselves, take them seriously. Make sure that they see their doctor.

Encourage them to accept help. Don't discourage them from taking medication, or seeing a counsellor or psychotherapist. If you have worries about the treatment, then you may be able to discuss them first with the doctor.

Why does a person get depressed?

As with our everyday feelings of low mood, there will sometimes be an obvious reason for becoming depressed, sometimes not. It can be a disappointment, a frustration, or that you have lost something - or someone – important to you. There is often more than one reason, and these will be different for different people. They include:

Things that happen in our lives
It is normal to feel depressed after a distressing event - bereavement, a divorce or losing a job. You may well spend a lot of time over the next few weeks or months thinking and talking about it. After a while you come to terms with what's happened. But you may get stuck in a depressed mood, which doesn't seem to lift.

If you are alone, have no friends around, are stressed, have other worries or are physically run down, you are more likely to become depressed.

Physical Illness
This is true for life-threatening illnesses like cancer and heart disease, and also for illnesses that are long and uncomfortable or painful, like arthritis or bronchitis. Younger people can become depressed after viral infections, like flu or glandular fever.

Some of us seem to be more vulnerable to depression than others. This may be because of our genes, because of experiences early in our life, or both.

Regular heavy drinking makes you more likely to get depressed – and, indeed, to kill yourself.

Women seem to get depressed more often than men. It may be that men are less likely to talk about their feelings and more likely to deal with them by drinking heavily or becoming aggressive. Women are more likely to have the double stress of having to work and look after children.

Depression can run in families. If you have one parent who has become severely depressed, you are about eight times more likely to become depressed yourself.

What about bipolar disorder (manic depression)?
About one in 10 people who suffer from serious depression will also have periods when they are too happy and overactive. This used to be called manic depression, but is now often called Bipolar Disorder. It affects the same number of men and women and tends to run in families (see Help is at Hand leaflet on Bipolar Disorder).

Isn't depression just a form of weakness?

Other people may think that you have just 'given in', as if you have a choice in the matter. The fact is there comes a point at which depression is much more like an illness than anything else. It can happen to the most determined of people – even powerful personalities can experience deep depression.

When should a depressed person seek help?
When your feelings of depression are worse than usual and don't seem to get any better.
When your feelings of depression affect your work, interests and feelings towards your family and friends.
If you find yourself feeling that life is not worth living, or that other people would be better off without you.

It may be enough to talk things over with a relative or friend. If this doesn't help, you probably need to talk it over with your family doctor. You may find that your friends and family have noticed a difference in you and have been worried about you.

Helping yourself

Don't keep it to yourself
If you've had some bad news, or a major upset, tell someone close to you - tell them how you feel. You may need to talk (and maybe cry) about it more than once. This is part of the mind's natural way of healing.

Do something
Get out of doors for some exercise, even if only for a walk. This will help you to keep physically fit, and will help you sleep. Even if you can't work, it's good to keep active. This could be housework, do-it-yourself (even as little as changing a light bulb) or any activity that is part of your normal routine.

Eat well
You may not feel like eating - but try to eat regularly. Depression can make you lose weight and run short of vitamins which will only make you feel worse. Fresh fruit and vegetables are particularly helpful.

Beware alcohol!
Try not to drown your sorrows with a drink. Alcohol actually makes depression worse. It may make you feel better for a short while, but it doesn't last. Drinking can stop you dealing with important problems and from getting the right help. It's also bad for your physical health.

If you can't sleep, try not to worry about it. Try listening to the radio or watch some TV while you're lying in bed. Your body will get a chance to rest and, with your mind occupied, you may feel less anxious and find it easier to get some sleep.

Tackle the cause
If you think you know what is behind your depression, it can help to write down the problem and then think of the things you could do to tackle it. Pick the best things to do and try them.

What kind of help is available?
Most people with depression are treated by their family doctor. Depending on your symptoms, the severity of the depression and the circumstances, the doctor may suggest:

self-help as suggested above
counselling treatment
antidepressant tablets

Keep hopeful
Remind yourself that:

Many other people have had depression.
It may be hard to believe, but you will eventually come out of it.
Depression can sometimes be helpful – you may come out of it stronger and better able to cope. It can help you to see situations and relationships more clearly.
You may be able to make important decisions and changes in your life, which you have avoided in the past.

Help site for Depressed in Kerala: Maithry

Friday, October 24, 2008

How I got interested in HIV/AIDS?

In the late 1990s, I was working in a small [Government] Taluk Hopsital. HIV 'Positive' persons I saw in my practise were few and I was happy to refer them to higher centres.

Then I got transferred to a busy District Headquarters Hospital in 2001. There I could not escape dealing with 'positive' persons.
Every week the infectious disease ward will see a new 'positive' patient coming to die.
Most of them by then might have spend a fortune on magical remedies. The most infamous among them was the medicines of Fair Pharma from Kochi. For more detailed information about how one Majeed cheated poor patients and build the costliest house in Kerala click here. Now fortunately the 'medicine' is banned in Kerala by the Court after a longstanding legal battle with 'Positive' people and PUCL.

The patients in my hospital were given symptomatic treatment and left to die. Some come and die alone while the more lucky ones have a wife or mother to be with them during their last days.
I was depressed seeing all these deaths.
What can I do for them? I asked myself.
I had no experience in treating HIV/AIDS patients. In the medical college where I studied in early and mid 1990s, 'positive' persons were rarely seen. I knew a lot from the text books but practical knowledge was nil.
Those days the Government was giving lot of training in HIV/AIDS for doctors and other health care workers, but it was only about prevention.
HIV/AIDS is a death sentence. So train yourself and others how not to get it.
This was the message of such trainings. Nobody mentioned treatment. We were not trained to cope with these dying 'positive' patients.
In the developed world by the year 2000, more than 10 drugs were available effective in treating HIV/AIDS. Few were available in India too at that time. They were expensive and somewhat toxic but still they worked. And they were cheaper than the Fake medicines of Fair Pharma.
More over, HIV/AIDS patients need treatment for opportunistic infections that attack them as their immunity is low.
So when a 'positive' patient is sick, first we have to find out which opportunistic organism or organisms have infected him/her. Then give the proper treatment so that he/she becomes better. Later, ART [anti retro viral therapy] was started. Some time in severely sick patient we may have to start both treatments together.

Training myself in HIV/AIDS management, I started treating these patients in earnest. I procured medicines from drug companies directly and thus was able to give it to patients much below market rates. The stigma of buying such medicines from Drug Store was circumvented as I myself provided the medicines.

The results were dramatic. Patients in death bed about to say their final prayers were able to look after themselves with in months. Those who sticked on to the medication schedule for more than a year began working and earn for themselves.

I lost many patients too, but I tried my level best. Some came to me at a very late stage. Many could not continue the medicines because of the high cost of ART. Many by then had become social outcasts and committed suicide.

I urged other Physicians to take up the challenge of HIV. I conducted lectures in the IMA[Indian Medical Association]. I told them that it was ,we the modern medicine doctors, who are making the 'positive' persons go to Quacks like Majeed [Fair Pharma]. As we are not ready to take care of them, they are helpless. Unscrupulous persons squeeze out the last penny from them giving false hopes.

That made some difference. Few of my colleagues started taking up such cases.

By 2003-2004, things started changing in a positive direction for 'positives'. ART drugs became cheaper. India became one of the biggest manufacturer and exporter of cheap generic HIV drugs. Govt of India started giving ART drugs free of cost at selected centres. Kerala Government followed suit.
The emphasis in training of health care workers shifted from prevention to treatment. From a 'death sentence' HIV/AIDS became projected as a chronic manageable disease needing lifelong medication like Diabetes.

Now a 'Positive' person comes to my clinic every other day. Most of them are old patients coming for follow up. A newly detected 'positive' person is seen once or twice a month. Most of them are taking the free ART drugs from Medical Colleges. Some who can afford [and is afraid of perceived stigma at Govt centres] take medicines from me.
Deaths occur but only rarely.

I cherish the sight of happy faces and healthy bodies of all those positive persons. That sight make my life meaningful.

Monday, October 20, 2008

Primary care Physician versus Sub specialist

After my post graduate training in Internal Medicine [ie MD], I had two options. Either to work as a primary/secondary care General Physician or go for a sub- specialisation [or as it is called in India, Super specialisation,ie DM]. I chose the first option. Why? Do I regret it?

Why I chose not to study more? Primary reason was I had become fed up with studies . I had spent almost 26 years of my life studying by then[including KG].
Also I was married and had just become a proud father. Wanted to earn something for myself and my budding family.
Another factor that made my decision easy was the appointment letter from the Government, posting me as a Physician in a small town not very far from my home.

There was also another big reason. I hated confining myself to one organ or organ system. Internal medicine had all the thrills. The wide variety of illnesses that an internist manage made it an exciting profession.
At that time, I had some noble ideals too [young and romantic?]. I wanted to help as many patients as possible especially the poor. So rather than being a super specialist in a 5 star hospital looking after the cream of the society, I preferred the Govt job as an internist in a small, run down Taluk hospital.
Do I regret it?
Yes, some times.
Especially when patients ask, 'Sir enthinde specialista?'[ in what subject are u specialised in?]or when they ask 'do you feel I should see a specialist?'
Some times it is the relatives who ask the same question.
I reply to them trying to make them feel I am an all rounder, knowing about all diseases.
Also, I regret it some times when I realise that the sub specialist's consultation fee is twice or thrice that of mine.
But most of the time I don't regret it. Looking back I feel my decision was right.

I enjoy my profession. I like the thrill of finding out the cause of fever in a FUO [fever of unknown origin]. I like the satisfaction I get when I correctly diagnose the cause of breathlessness in a poor patient by just patiently listening to the history and using the stethoscope,without ordering any fancy investigations. I like the way people come to me for advise regarding anything related to medicine. I am happy taking disease prevention classes to house wives or school kids or teachers or Taxi drivers or 'Positive'[HIV] people. I feel I am doing something when I console and give hope to a crying man or woman when they first realise they are 'Positive'.
So as of now I am happy being a Generalist who 'know a lot about a lot of illnesses rather than a super-specialist who 'know more and more about less and less'.

Monday, October 13, 2008

Sad News

The Type 1 Diabetic patient in 'Strange Interview' and 'Happy News' called me to tell that she had a spontaneous abortion.
Her recent blood sugars were between 80 and 220mg but her frequency of testing was only about once a day or once in 2 days.
Early foetal loss is most commonly due to congenital defects in foetus caused by high blood sugar during first few weeks.
For a diabetic woman who wants to be pregnant, keeping a very good control over her blood sugar is very important.The first 42 days after conception is the most important period, but in most cases the woman will be aware that she is pregnant only after a missed period, which is about 14 to 21 days after conception.
So planning the pregnancy in advance and keeping a tight control on blood sugar is absolutely essential.
The loss of that foetus was a personal failure for me too. I should raise the standard of my care of care of Diabetes in Pregnancies.
I had emphasised all these to her and I hope she will have a successful pregnancy next time.

Thirty versus Forty -- Part 2

Reading my last post again I realised I was too negative. Is it true that at Forty I have lost everything that was good in me? No It is not true. Let me try to enumerate the positive changes in me.

My ability to communicate with patients have improved over time eventhough time available for each patient is less. My ability to find out the correct cause of the each patient's problem have also increased very much. This have helped my patients from undergoing unnecessary investigations and mental trauma.

I have established a very good practise with a large number of loyal patients. I read [when I get time] journals and Text Books.Still now I am one of the better informed doctor of my age.
I have a very good relationship with all other doctors I work with.
I have done some good work in training other doctors in HIV/AIDS. I have become a much better speaker in front of general public and even in front of doctors.
The quality of care I give to my patients as a whole have improved.
Lastly and not the least I have a blog of my own which I am able to maintain with frequent posts.
So Forty is not bad at all.

Wednesday, October 8, 2008

Thirty versus Forty

This year I turned 40.
A milestone in many aspects.
10 years ago when I turned 30 where was I?
It would be interesting to study the contrast.

At 30, I was out of medical college after my postgraduate degree and had just started my career. I was raring to go and was flushed with the initial success of my practise. As I had only few patients to see,I spent considerable amount of time talking to patients, making them understand the disease and how to cope with it. I wondered why the senior doctors in my area are not communicating well with the patients. I was happy to see patients 24hrs a day.

Each difficult case was a challenge to me and I researched and referred books and net till late hours to find a solution to each diagnostic problem. Each new issue of my favourite medical journal was awaited eagerly. I wanted to practise medicine the way it is given in Text Books. I hated when the patient or the relatives said that they are going to a higher medical centre for further evaluation. I looked down in other doctors who referred cases without any reason. My belief in Science was immense. Also I believed very much in my patients and their relative's loyalty to me. I never could imagine one of them going for a malpractice litigation against me. I was ready to teach the staff nurses the finer points of patient care at any time.

I had umpteen number of dreams about my future. Researching and finding out a new breakthrough methodology of treatment for an important disease was one of them. Presenting papers after papers in National and International conferences and publishing them was another.

At medical conferences, I was the baby among the audience. I was up to date in knowledge and was proud about it. I was bombarded with advise from seniors to do that,to do this, and not to do this etc. I was also an early product of technology generation. So, I was the one who showed the senior doctors how to use the Internet and the possibilities of cell phones.

At 40, I am in the middle of my career in practising clinical medicine.The sight of crowded waiting room in my clinic do not excite me, rather it makes me feel tired. I stick to my working hours. Any patient coming outside it, is shown an angry face. Finishing the patient appointments in time is the priority now. Time given for each patient became limited.

I am slow to accept changes in treatment methods. Text Books and journals pile up untouched.

A difficult case is easily referred. Any wish expressed by the patient to go elsewhere, brings up a reference letter from me in a jiffy. My belief in the unknown increased. Each person who enter my clinic is viewed as a possible litigant.

The dream of researching and presenting papers still remain a dream. At medical conferences, I am somewhat a veteran. Young faces are seen all around. Many come to me for advice. I try not to show youngsters my lack of up to date knowledge.

Still I try to maintain the spirit and my standard of practise, may be for another decade.

Read the next part of Thirty versus Forty here

Follow up

I had narrated about many people/patients in my postings. This is a post which will tell you about where they stand now.[as far as I know]

The 31 year old newly wed wife who preferred Insulin to tablets is now well controlled on a single tablet. She also started working part time and looking forward to get pregnant.

The 50 year old lady who took money from me [as narrated in patient taking money from doctor]for her bus ticket returned the amount promptly next month. But I have not heard from the other guy whom I helped on the same day for getting Government certificate.

The 65 years old Type 2 Diabetes patient who disturbed my sleep by missing her Insulin injections for a few days was hospitalised for 3 more times, all around 2 am, with hypoglycemia.The doctor on duty managed her all the time with out disturbing my sleep.

The patient in Another sad 'positive' story is doing well with anti Tuberculosis treatment.His CD4 count is also low and may need anti HIV medicines too shortly.

The guy in Craze for specialist consultation was diagnosed to have Hepatitis B. He went to a Gastro-enterologist for better care, but was unhappy with the lack of communication of that particular specialist.He came back to me again and has now recovered well.He is back in Bangalore working.
The 12 year old girl with Diabetes in Type 1 or Type 2 did not keep her follow up appointments. I hope she is getting treatment and monitoring from some where else, may be from Government run clinics as the family was very poor.

Sunday, October 5, 2008

Chronic severe Joint pain of Chikungunya

The rainy season due to the South West Monsoon over the Indian sub continent is over.Epidemic of acute severe joint pain and swellings associated with fever due to Chikungunya infection has also subsided.Now I am seeing more and more patients with Chronic severe joint pain of varying duration, a sequel of Chikungunya infection.

Let me tell you a little more about this virus and the illness it causes in humans.

Chikungunya is a re-emerging, mosquito-borne viral infection causing fever, rash and acute or sudden severe joint pains of several joints.Chikungunya (Chick’-en-GUN-yah) in Swahili an African language meaning “that which contorts or bends up” refers to the contorted (stooped) posture of patients who are afflicted with severe joint pains (arthralgia) the most common feature of the disease.
Chikungunya virus is a single-stranded RNA Alphavirus, from the family Togaviridae. Other Alphaviruses also causing fever, rash and arthralgia, include O’nyong-nyong, Mayaro,Barmah Forest, Ross River and Sindbis viruses. Chikungunya virus is most closely related to O’nyong-nyong, but remains genetically distinct.

The disease was first described by Marion Robinson and W.H.R. Lumsden, following an outbreak along the border between Tanzania(erstwhile Tanganyika) and Mozambique, in1952. Since 1953, the virus has caused outbreaks in Africa and South Eastern Asia, including India, Sri Lanka, Myanmar, Thailand, Indonesia, the Philippines and Malaysia, which are well documented. There is historical evidence that Chikungunya virus originated in Africa and subsequently spread to Asia. Phylogenetic studies support this theory, with Chikungunya virus strains falling into three distinct genotypes based on origin from West Africa, Central/East Africa or Asia.

Chikungunya is transmitted by the bite of the infected Aedes mosquito from an infected person to a healthy person. The disease does not get transmitted directly from human to human (i.e. it is not a contagious disease). In a pregnant woman with Chikungunya there is risk of transmitting the disease to her foetus.
The fever starts usually about 2 to 3 days after the entry of virus into the human body. There will be severe chills and shaking of the body at the onset of fever.At the same time the joint pain and swelling starts.The patient will not be able to move with in minutes of onset of illness.The joints of hands mainly the metacarpo phalangeal and proximal inter phalangeal joints become warm swollen and very painful.Wrist and elbow are also affected to a lesser extend.The joints of ankle,feet and to a lesser extend hip are all affected.
Itchy reddish raised rash is typically seen[70%] when the fever subsides, which in most of my patients was by 3 days.Many patients and Physicians confuse it with drug rash due to allergy to the medicines the patient took for fever and joint pain.
Rash is typically seen on the cheeks, nose and outer part of ears.The ear lobe is typically painful to touch. The rash is also seen over the trunk and limbs with severe itching which lasts for only 2 days. There will be painful swelling of ankle and shin with dark red discoloration. Painful oral ulcers are also seen during this time.Last year I had few patients with enlarged cervical lymph nodes, which disappeared in few days.

Although rare, the infection can result in meningo-encephalitis, especially in newborns and those with pre-existing medical conditions. Pregnant women can pass the infection to their foetus. Severe cases of Chikungunya can occur in the elderly, in very young ones (newborns) and in those who are immuno-compromised.

Chikungunya outbreaks typically result in several hundreds or thousands of cases but deaths are rarely encountered.
Differential diagnosis of Chikungunya includes Dengue and Dengue Haemorrhagic Fever,
O’nyong-nyong virus infection and Sindbis virus infection.
It has been reported that attack rates in susceptible populations may be as high as 40-85 per cent and the ratio of symptomatic to asymptomatic patients is about 1.2:1.

Children are less likely to experience joint pain, but may have other features such as febrile fits, vomiting, abdominal pain and constipation.

The discoloration of the nose usually lasts for months.I call it the seal of Chikugunya as I can identify a person who had Chikungunya in the recent past seeing that seal.
Some patients may remain feverish for some more days. The joint pain become less in few days. In about 60 percent of the patients the ilness including the joint pains last only about a week.They become completly all right with only a little bit of tiredness remaining.
But in about 40% of patients joint pain increases or persists.The chronic joint pain of Chikungunya resembles that of Rheumatoid arthritis. The joints commonly involved are the wrists and the knees.The ankle and smaller joints of feet and hands are also involved.Stiffness of these joints in the morning lasting more than 30 mts is typical. The patient feels better as he/she continues to move the joints.
The joint stiffness and pain lasts for about 3 months in about 30% of patients in my practise. But in an unfortunate 10% it may last indefinitely.

Lab Diagnosis of Chikungunya fever

Virus isolation and PCR techniques are costly and is available in very few centres. Serological diagnosis is possible only after a week of onset by detecting antibodies. As the treatment is mostly symptom specefic diagnosis will not alter patient management much. So the typical triad of fever, acute onset joint pains and rash along with a low white cell count in blood sample is sufficient enough to diagnose Chikungunya fever

Treatment of Chikungunya fever

Paracetamol 10 to 15mg per kg body weight given 3 to 4 times a day reduces the fever.It is needed only in the first 2 to 3 days of illness.

Non Steroidal anti inflammatory agents have to be given liberally to reduce the pain and swelling. This may have to be continued for few weeks in some patients with persistent joint pain. Renal and Gastric safety have to ensured while taking such medicines.
Short course of steroids like Prednisolone also helps in resistant cases.
Other analgesics like Tramadol are also useful.
Disease modifying anti rheumatic agents like Chloroquine have been found useful in some studies.Personally I feel Chloroquine is not of much help as it is a slow acting drug taking almost 3 months to be fully effective.

Most of the patients who turned to alternative systems of medicine for relief came back to me saying there is no relief to pain.Many had to take NSAIDs along with their Ayurvedic and Homeopathic medicines which proved that other systems have nothing much to offer.

In short Chikungunya fever is easy to diagnose but not that easy to treat, but to those who suffer it is pure hell.

Friday, October 3, 2008

Smoking banned in public places from today

India on Thursday once again imposed a countrywide ban on smoking in public spaces in its fight against tobacco use, four years after a largely ignored earlier prohibition saw people continue to puff away in restaurants, clubs and bars.The ban, aimed at the country's 120 million smokers, has received a good response from people across the country,Health Minister Anbumani Ramadoss asserted.
"It is a continuous process, ... and the message will go across through repeated awareness campaigns by the government and the media," Ramadoss, a tireless anti-smoking campaigner, told reporters.

The new order bars smoking in hotels, eateries, cafes, pubs, bars, discotheques, offices, airports, railway stations, bus stops, shopping malls and parks. People can continue to smoke in private homes and open spaces.The new ban has directed establishments to appoint anti-smoking officers who will be liable if people smoke.

Britain, France, Ireland and Thailand are among the countries that already have similar bans in place.
The fine for violating India's order is 200 rupees (4.29 dollars), but health authorities said higher fines of up to 25 dollars were being contemplated.
The new Smoking in Public Places Rules 2008 came into force on the anniversary of the birth of Mahatma Gandhi the Father of Nation, who was known for his ascetic habits.
Citing a survey that found that 52 per cent of children took up smoking after watching film stars lighting up on the screen, Ramadoss appealed to Bollywood celebrities not to encourage smoking.
"People look up to celebrities and follow them," the minister said. "Our popular film star Rajnikanth has stopped smoking in movies. Other stars should also set an example."
Besides the police, government officers; inspectors of central excise, sales tax, transport and health departments; and principals of schools have been given powers to fine violators on their respective premises.
Officials acknowledged that enforcement might not be easy.

India is the third-largest tobacco producer and consumer in the world after China and the United States.
According to a Health Ministry release, more than 2,200 Indians die every day from tobacco use. They are at risk from cardiovascular diseases like heart attacks, strokes and cancer.
A recent study by a team of doctors showed that tobacco smoking would kill 1 million people annually beginning in 2010.
Saying India is in the midst of a "catastrophic epidemic of smoking deaths," the doctors warned that nearly 70 per cent of the million deaths would take place among smokers in their prime.

In this large, nationally representative case–control study, it was found that in both rural and urban India, among men between the ages of 30 and 69 years, the rate of death from any medical cause in smokers was 1.7 times that in nonsmokers of similar age, educational level, and alcohol status (use or nonuse). Among female smokers, mortality from any medical cause was double that among their nonsmoking counterparts.
If you are still not convinced about quitting smoking read this and decide.