As India waits for proof, 3,500 succumb to tobacco daily

while globally, tobacco control measures are being strengthened and countries are adopting targets to end the tobacco epidemic, India has put its notification on increasing size of pictorial health warnings on tobacco product packages in abeyance.

In 2004, India was one of the first signatories of the World Health Organisation’s Framework Convention on Tobacco Control (FCTC), the only public health treaty that guides countries to adopt evidence-based measures that protect their citizens from dangers of tobacco. Over time, several countries, including our neighboring countries, have overtaken India in implementing stronger tobacco control laws.

On conservative estimates, India loses about 12.7 lakh people to tobacco use every year and spends over Rs 1 lakh crore on tobacco-attributable diseases. Fifty years from the US Surgeon General’s 1964 report, which recognised cigarette smoking as causal risk factor for lung cancer, the evidence base has grown remarkably. Research in India and in other parts of the world has well established that smoking in any form causes different kinds of cancer, heart diseases, respiratory diseases and a pack of other diseases. Tobacco use in any form is harmful and deadly. One billion people are expected to die due to tobacco related diseases by the end of the 21st century and most of these deaths will occur in developing countries like India.

These estimates sound off an alarming siren for increasing awareness on the health risks of tobacco use. Graphic health warnings are recognised globally as effective strategy to warn people against the dangers of tobacco use. These warnings provide strong public health benefit by educating users about the harms of the habit and motivate them to quit.

Every time a tobacco user pulls out a pack, he or she is reminded of its deadly consequences. These warnings also serve to protect adolescents, who are lured by attractive packaging. In short, larger warnings elicit more negative perceptions about the packs and tobacco use, in general.

On April 1, India was scheduled to implement 85 per cent graphic pack warnings on all tobacco products, a move that was lauded globally. However, much like India’s chequered history with pack warnings since their introduction in 2009, the implementation of these strong warnings has yet again been delayed. There is a perception that lobbies connected to the tobacco industry are at work.

A recent international report ranks India at an abysmal 136th position among 198 countries in pack warnings. India’s dismal performance on this report can be attributed to small pictorial health warnings covering only 40 per cent of one side of the pack, with which India is unable to fulfill even its minimum required mandate under the FCTC.

 The delay in implementing the warnings is primarily attributed to a report by a parliamentary committee on sub-ordinate legislation assessing India’s tobacco control law.

The committee presented its views to the Lok Sabha on March 18,2015 based on unfounded apprehensions of tobacco industry stakeholders about the adverse impact of imposing 85 per cent health warning on tobacco product packages.

The committee ‘strongly’ recommended stalling the implementation of these warnings citing its repercussions on livelihood of those involved in tobacco trade. The panel acknowledged receiving copious representations from the bidi industry claiming loss of livelihood of workers, law and order disruptions and a dramatic collapse of the bidi industry. Representations also assert that bidis are a natural product, incomparable with cigarettes and other forms of tobacco.

Bidis, commonly understood as hand-rolled, unfiltered cigarettes, are the most prevalent form of smoked tobacco with over 9 per cent adult Indians using the product. About 15 studies in India have shown that bidi smoking poses a very high risk of cancer and in many cases bidi smokers were at greater risk of oral, stomach and lung cancers as compared to non-smokers. 

Chronic respiratory conditions

On the issue of livelihoods, processing of tobacco leaves for bidi manufacture exposes workers to coarse dust and particulates, causing chronic respiratory conditions, tuberculosis and chromosomal damage. The bidi industry provides seasonal and part-time employment, particularly to women and children and production in unincorporated units helps manufacturers evade government regulations on workers’ welfare, wages and working conditions.

Tribal populations involved in plucking tendu leaves for bidi rolling form the lowest rung of this industry. Under such deplorable circumstances, investing in alternative skills and helping bidi workers’ transition to other sources of employability would reap more dividends.

No tobacco control measure warrants overnight impact. Therefore, sudden loss of livelihoods and collapse of a deep-set industry are far-fetched notions. Countries like Australia, Finland and New Zealand that have reported a decline in prevalence of smoking and reduced uptake among adolescents have achieved this success, after enforcing comprehensive tobacco control policies over several years.

 The parliamentary committee report refers to many other representations which are not evidence based: claims that the current 40 per cent of pack warnings on one side of the pack are sufficiently large and clearly convey the message to consumers.

But research has shown that despite these warnings, the first thing noticed on tobacco packs is branding and not the health warning, thus underscoring the need to enhance effectiveness of Indian health warnings.

 Most importantly, the committee has not referred to earlier reports of parliamentary committees which have recommended that the health ministry needs to devise more proactive strategies to implement the Indian Tobacco Control Act, 2003 (COTPA). In 2013, the Committee on Subordinate Legislation of Rajya Sabha presented its report on COTPA, making observations to strengthen rules by prescribing stronger, effective and field-tested health warnings covering at least 90 per cent of the principal display area.

The parliamentary committee’s observations and leniency towards the tobacco industry stakeholders does not bode well for the health of our nation and public health advocates strongly demand that health warnings should be enforced without any further delay or dilution.

(The writer is Director, Health Promotion Division and Associate Professor, Public Health Foundation of India, Gurgaon)