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India's tobacco war

Oct 01, 2008

As India bans smoking in public places from October 2, communications specialist Deepanjali Bhas argues the war on tobacco has to be fought both on the demand and supply side. WHO estimates 800,000 deaths each year due to tobacco use, expected to rise by another hundred thousand by 2010.

Nearly 800,000 deaths per year in India are attributed to one of the biggest public health issues in the country - tobacco consumption.

Even as Union Minister for Health Anbumani Ramadoss announced early September that, starting October 2, 2008, smoking in offices and private establishments – covering shopping malls, cinema halls, public/private workplaces, hotels, banquet halls, discotheques, canteens, coffee houses, pubs, bars, airport lounges and railway stations - would be banned in line with the revised rules of the Act pertaining to the prohibition of smoking in pubic places, the issue of tobacco consumption still receives minimal attention.

India has some of the strictest laws in place to stem tobacco consumption, but they are rarely implemented. Cigarette manufacturers continue to make money in India, even as they are on the retreat in western nations.

Serious health issue

Young India is a happy playground for advertisers who peddle smoking, with 50% of its population under the age of 24. A study by the University of Texas’ School of Public Health, published in June 2008, titled Associations Between Tobacco Marketing and Use Among Urban Youth In India, says that smoking is becoming increasingly popular among Indian children, some as young as sixth-graders.

Tobacco cuts across the rural-urban divide, with bidis currently accounting for 77% of the smoked tobacco market

India accounts for 12% of the world’s smokers and there are nearly 8 lakh deaths every year on account of tobacco use, according to World Health Organisation estimates. This figure is expected to touch 9.3 lakh by 2010. Lung cancer is assuming epidemic proportions in India, according to the Indian Society of Medical and Paediatric Oncology (ISMPO), while chewing tobacco or gutkha is strongly linked to oral cancer.

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Non-governmental organisations actively fighting in the anti-tobacco domain maintain that tobacco consumption is a serious public health issue. Yet it has never received the recognition it deserves; nor does the average citizen regard the issue with any seriousness.

Even as the smoking population is dropping in developed countries, the numbers in India and China are on the rise. Stringent legislation enacted in India in 2004 has only made cigarette companies more creative; they make their presence felt through lifestyle brands and event sponsorships. That the law itself is barely implemented is another matter.

Tobacco cuts across the rural-urban divide, with bidis currently accounting for 77% of the smoked tobacco market. A recent study by the Centre for Global Health Research at the University of Toronto, Canada, states that 1 million Indians will die from smoking-related illnesses in the next 24 months.

The study (A Nationally Representative Case-Control Study of Smoking and Death in India), done by scientists from India, Canada and the UK, covered nearly 1.1 million homes across India. It found that men who smoke bidis lose six years of their life, women lose eight, and men who smoke cigarettes lose 10 years.

Initiated by the WHO in 2003, the Framework Convention on Tobacco Control  is the only global treaty of its kind to control tobacco consumption

This is a disease burden that cannot be ignored, according to Healis from the Sekhsaria Institute of Public Health, Mumbai, whose research shows a significant causal association between bidi smoking and tuberculosis. An extensive longitudinal study carried out by Healis and an international group of researchers, between 1991 and 2003, among bidi-smoking men, showed that at least 32% of deaths due to tuberculosis could be attributed to bidi smoking.

If consumption of gutkha, which has an overwhelming 90% causal connection with oral cancer, is factored in, hundreds of thousands of lives are in danger.

India: A quick mover in legislation

To its credit, India has always been at the forefront of legislation relating to tobacco control. India has been a prominent player on the international scene too, with the most activity taking place within the last decade, chiefly the last six years.

The Framework Convention on Tobacco Control (FCTC) (www.fctc.org), the only global treaty of its kind to control tobacco consumption, was initiated by the WHO in 2003. India was one of the first countries to become a signatory, and was regional coordinator.

It was stated that once 40 countries signed up, the treaty would become legally binding. Till date, nearly 157 countries have ratified the WHO FCTC says Vineet Gill Munish, National Professional Officer (Tobacco-Free Initiative), WHO India, which implies that member states need to gear up their national legislation. The FCTC was one of the fastest treaties to be adopted in the history of international treaties.

Taxation is one of the most effective measures for tobacco control, forcing consumption levels down over time 

Even before the FCTC, India was one of the first countries to have a national tobacco control law - the Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act 2003 (COTPA). This comprehensive tobacco control legislation came into force on May 1, 2004.

India went beyond the FCTC in a few respects, says Munish, by prohibiting the sale of tobacco products within 100 yards of educational institutions - a proactive step that few other countries took. Last year’s controversial initiative by Union Health Minister Anbumani Ramadoss to ban smoking scenes in movies (the matter is currently sub-judice in the Delhi High Court), again, is a first.

Despite a national law being put in place in 2004, however, there was no national tobacco control programme. And so the ability to take the legislation forward was stymied. In 2006, a pilot National Tobacco Control Programme was initiated and is now operational in 18 districts of nine states. Experts hope that by the end of this year it will become more active.

Interestingly, during the tenure of the present Union health minister, tobacco control has suddenly become a hot topic in the media. Munish notes however that the media sensitisation, if any, largely penetrates to the urban population and needs to reach the district level.

Almost all anti-tobacco activists believe that the war on tobacco consumption must be fought both on the demand and the supply side - reducing the power of advertising to spur demand and reducing accessibility to tobacco products by increasing taxes and banning the sale of tobacco products in public places and areas accessed by minors.

In September, Ramadoss promised that the Indian government would help tobacco farmers divert area under tobacco to medicinal plants

Taxation is one of the most effective measures for tobacco control, forcing consumption levels down over time especially among price-sensitive sections of the population. But though India has progressively increased taxes on cigarettes, it’s been difficult taxing bidis. While cigarettes are priced at between Rs 50-80 for a pack of 20, a similar pack of bidis costs between Rs 4-5, and chewing tobacco Re 1.

There are some who put forward the livelihood argument that fighting tobacco consumption negatively impacts tobacco farmers. Tobacco farming is lucrative - the Tobacco Institute of India, a tobacco industry magazine, reports in its June 2008 issue that this year production, auction prices and exports of Flue Cured Virginia (FCV) tobacco touched one of its highest levels ever. The editorial notes that the average rate per kilo of FCV tobacco in the Andhra auction climbed to Rs 84 this year as against last year’s Rs 47; farmers earned Rs 585 crore more than last year.

The strong tobacco lobby maintains that there are as yet no viable alternatives to the dependable and lucrative tobacco crop, and adds that any move to push farmers to shift from farming tobacco must be preceded by well-researched and planned identification of a substitute that is as sustainable and profitable as FCV tobacco.

This is a weak argument, according to sector professionals. Food and trade policy analyst Devinder Sharma believes such a shift is possible. He says attempts to identify substitutes have never been serious; in fact, anti-tobacco activists believe that it is the tobacco lobby that has stymied attempts to identify crop alternatives right from the time Narasimha Rao was prime minister, in 1994.

In September, Ramadoss promised that the Indian government would help tobacco farmers divert area under tobacco to medicinal plants. The government would assist tobacco growers in switching to other crops and would use a Rs 6 billion fund to promote medicinal plants. How many farmers take the option remains to be seen.

Even with the best anti-tobacco efforts, tobacco consumption will decrease only by a small percentage. Experiences in developed countries have shown that growth and consumption drop gradually, over a few decades at least. So, experts believe, there is no threat of immediate unemployment.

Spurring demand - the impact of advertising

There has been a lot of talk in recent years about whether advertising really influences people to smoke. As regards the ban on smoking in movies, the argument for creative expression has found favour in many circles. Given India’s twin obsessions of cricket and cinema, there can be no argument in favour of allowing smoking in movies.

Covert advertising and lifestyle brands have replaced the earlier more visible forms of tobacco advertising that were banned in 2004

Munish points out that Indian films have a global impact on audiences; their influence extends to South Asia, even to South East Asia. Study after study has clearly shown that young people are influenced by seeing their favourite stars smoke on screen. The Centre for Global Health Research study also shows a strong connection between exposure and receptivity to tobacco advertising and promotion and tobacco use among young people in India.

The powerful tobacco industry in India has muscled its way out of any move to curtail consumption. Covert advertising and lifestyle brands have replaced the earlier more visible forms of tobacco advertising that were banned in 2004.

NGOs working in this area also point to the political clout of cash-rich tobacco companies. Even our health minister’s commendable efforts to put repulsive and frightening pictures on cigarette packs (notified last year) has been postponed a number of times. Dr Upendra Bhojani, faculty, Institute of Public Health, Bangalore, says that while the pictures initially decided on were those of a dead baby and a cancerous lung, they have been modified to those of a scorpion!

Civil society groups are now actively pursuing recognition of tobacco consumption as a public health issue. Meanwhile, the Bill and Melinda Gates Foundation and New York Mayor Michael Bloomberg announced a joint commitment in July 2008 to invest $ 500 million towards anti-smoking efforts in developing countries like India and China.

Crisis of implementation

Civil society advocacy has been effective in many respects. The most noticeable impact is tax levies, which are translated immediately into action and which, according to the FCTC, is one of the best measures for tobacco control. However, a quick look at any Indian city or town shows that this is perhaps the only aspect that has been put in place.

The government has formulated a National Tobacco Control Programme, which is in its pilot stage

Implementation with regard to prohibiting smoking in public places and selling tobacco products to minors is absent; many small shops sell tobacco products near schools and people smoke with alacrity in restaurants and on the streets.

The designated enforcement authorities under the law are inspectors of the Food and Drug Administration, police officers not below the rank of sub-inspector, and any officer authorised by the central and state government. But, as Dr Bhojani puts it, there is no implementation mechanism in place to enforce legislation.

He adds: “Very few government officials are even aware of this legislation as it was just communicated as a written order. Some senior police officers I have spoken to say they know about it but don’t see it as a priority!” He points out that as long as there is social acceptance of tobacco use, such laws will not work.

The Indian Railways and Indian Airlines were one of the first organisations in the world to ban smoking in trains and on flights (before 2004) through a department notification. But one still sees cigarettes and bidis being sold on trains because the travelling public does not oppose it, he says.

The government has formulated a vertical programme - the National Tobacco Control Programme (NTCP) - which is in its pilot stage. B K Prasad, Joint Secretary, National Tobacco Control Cell, says a plan has been drafted to boost implementation of anti-tobacco advertising and sales; it will start rolling out in pilot districts where the programme has been initiated. Prasad adds that it will be some time before the results start to show.

Then there are socially contributing factors such as the freedom with which young people smoke in front of their parents or elders today - something that was rarely done a few decades ago. More women too are smoking.

The way forward

The need of the hour is to take the anti-tobacco movement to the grassroots. The role of the NTCP and its district cells is critical in this regard. Today, only a few civil society groups are focused on the issue.

More taxation would be a disincentive to users, making cigarettes painfully expensive for price-sensitive people.

The need of the hour is to take the anti-tobacco movement to the grassroots

A packet of gutkha though is less than Re 1 and given that its consumption cuts across socio-economic strata and is especially prevalent in rural areas, the battle against this carcinogenic substance will need to be taken up even more vigorously.

However, higher taxation coupled with an inefficient and corrupt law-enforcing machinery will only lead to an increase in the illegal, low-priced regular-size filter cigarettes that are being produced by small manufacturing units and currently account for 7% of the market. This sector is growing fast and the price of these cigarettes is reportedly even lower than the applicable VAT/excise duties, notes TII.

Bans on smoking in public places, while necessary, cannot be seen as the only solution. As a stand-alone intervention, its efficacy is questionable mainly due to the addictive nature of nicotine and chewing tobacco.

A survey by the Federal Health Office in Switzerland said, in May this year (swissinfo.ch), that smoking bans in public places appear to have little impact on the number of smokers, with three out of 10 respondents saying they still smoked. The number of smokers remained unchanged compared with 2006. What’s interesting is that the number of those wanting to quit in Switzerland rose marginally to 54%, perhaps pointing to the success of anti-smoking campaigns.

Educating and generating awareness is vital. Bhojani believes that simple education about the ill-effects of tobacco consumption should become part of the primary school curriculum and continue right through high school and college. Anti-tobacco organisations believe that the anti-tobacco programme must be taken up in ‘campaign mode’ in India.

It’s evident that there are no quick fixes. Munish explains that tobacco has existed in India for centuries; there are nearly 100 different forms of tobacco use here, from smoking it to chewing it, with each state having its own variant.

Anti-tobacco organisations believe that the anti-tobacco programme must be taken up in ‘campaign mode’ 

Then there’s the cultural dimension: in states like Assam, for instance, tobacco products are offered as a welcome gift to visitors.

When the US started its moves to curtail smoking by regulating advertising in the 1960s, it took a few decades to see a decline in smoking levels. India started on this front nearly three decades later. International studies have shown that even if comprehensive tobacco control measures are in place it takes over a decade to see a marginal drop in prevalence.

Clearly, the road ahead is a long one but it’s one that has to be traversed with purpose. As Bhojani concludes: “Tobacco consumption is not an issue where there can be two stands.”

Deepanjali Bhas is a development communications specialist. She was previously a journalist with The Times of India.

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