India: Light at the end of the tunnel
August 04, 2017
No doubt, the tobacco industry has proved the greatest stumbling block in promoting healthy lifestyles. But tobacco use is nevertheless falling
Tobacco is a major preventable cause of death and disease globally. It is a threat to development, environment, society and economy. Many countries have strengthened their tobacco control legislation, guided by the World Health Organisation’s (WHO) Framework Convention on Tobacco Control (FCTC).
The tobacco industry’s influence has been a major roadblock, subverting the implementation of public health policies across the world including India. The industry’s tactics involve sophisticated strategies, including litigation, interfering in policy development, circumventing law, discrediting science and constructing a positive social image through corporate social responsibility (CSR) initiatives. Tobacco control policies in India have witnessed these influences for every strong policy measure notified and enforced ever since the Cigarettes and Other Tobacco Products Act (COTPA) was enforced in 2004. Despite these challenges, India has emerged as a global tobacco control leader, with the third largest graphic warning labels in the world and recent evidence of a 17% relative reduction in tobacco use prevalence in the country.
Litigations as important roadblocks
Several litigations have been filed by the industry allies against the ministry of health and family welfare (MOHFW) challenging COTPA and its notified rules.
While the industry loses most of these lawsuits that challenge government’s tobacco control measures, more than 100 cases are still pending in various courts in the country. The intent of these litigations is to delay enforcement of strong tobacco control measures. A recent review of internal documents of Philip Morris from 2014 mentions “Roadblocks are as important as solutions”. In India, the tobacco industry and its allies challenged issues, ranging from prohibition of smoking in public places to larger health warnings and the advertising ban – the most recent challenge being the hosting of the WHO Conference of Parties (COP7) in India.
Information received under the Right to Information (RTI) Act revealed that the tobacco industry repeatedly sent representations to the health ministry to withdraw the notification mandating large-sized pictorial health warnings (PHW) on tobacco product packages in 2014. Subsequently, a parliamentary committee on subordinate legislation debated and delayed this notification for almost two years. Public health experts deposed before this committee to present scientific evidence on the causal association between tobacco and cancer. Despite these interferences and litigations from the tobacco industry, MOHFW enforced 85% pictorial warning on tobacco packages from April 1, 2016. Media also investigated the issue of conflict of interest in case of some members of the committee. India currently does not have any specific law on implementing Article 5.3 of FCTC, which states that parties to the WHO FCTC in setting and implementing their public health policies with respect to tobacco control shall act to protect these polices from commercial and other vested interests of the tobacco industry, in accordance with national law. Draft guidelines to implement Article 5.3 exist at the centre and is being reviewed in various government departments. Some states like Himachal Pradesh, Bihar, Punjab and Mizoram have already progressed and adopted the guidelines on Article 5.3.
Farmers’ associations and other front groups
The COP7 meeting in India witnessed 500 members of farmers association, protesting outside the conference venue and financing an outdoor advertising campaign, demanding their recognition and participation in COP7 as important stakeholders. The Federation of All India Farmers Association (FAIFA) is now actively filing PILs to challenge the government and is becoming an intervener in existing litigations.
The tobacco industry’s age-old practice of circumventing law is prevalent in India too. Violation of the advertisement ban is rampant, especially at points of sale, as revealed in many monitoring exercises and raids conducted by state enforcement squads. The recent expose of Philip Morris’s promotional tactics in India brought to the fore key marketing activities, including Legal Age Meeting Points (LAMPs) strategy being employed, to hand out packs of Marlboro cigarettes to Indian youth. In spite of a comprehensive advertising ban in India, aggressive and innovative marketing strategies continue to target youth. Local companies resort to surrogate advertising to entice and recruit youth. Another internal document of Philip Morris says “India remains a high potential market with huge upside with cigarette market still in infancy.”
Success against challenges
Against these odds, India’s National Tobacco Control Programme (NTCP), which emphasises on effective enforcement of COTPA, 2003, has shown success. COTPA has many provisions that are in sync with FCTC, though a few go beyond FCTC, for example, ban on gutka and smokeless tobacco, which is a local policy solution. India’s tobacco-free movie rules are also listed as a global best practice. Recently released Global Adult Tobacco Survey (GATS)-2 2016-17 by MOHFW and WHO reported a 6% decline in tobacco use prevalence from GATS-1 (2009-10). Decline in prevalence from 38.4% to 28.6% in absolute numbers means reduction in 8.1 million tobacco users in India, in the past seven years. Noteworthy is the marked relative reduction of 54% and 28%, respectively, in prevalence of tobacco use among minors aged between 15 and 17 years and adolescents aged between 18 and 24. This can be attributed to vibrant and innovative youth engagement interventions such as HRIDAY (Health Related Information Dissemination Amongst Youth) – SHAN (Student Health Action Network), which guided the inclusion of a school health component of NTCP in 2007. Pictorial health warnings have turned out to be extremely helpful in motivating adults to quit after seeing health warnings from 38%, 29% and 34% in GATS-1 to 62%, 54% and 46% in GATS-2 for cigarettes, bidis and smokeless tobacco respectively.
What needs to be done
With every fifth adult still using smokeless tobacco and every 10th adult smoking tobacco in India, the war is far from over. GATS-2 highlighted gaps like loose sale of tobacco products. This is another industry practice to thwart effective tobacco control measures such as price increase and 85% warnings on packages. Those buying single cigarettes or beedis will never get to see and benefit from graphic warnings on packages. Also, loose sale of tobacco products makes the product affordable, thus negating the protective effect of price rise. GATS-2 also revealed that there was no decrease in second-hand smoke (SHS) exposure in workplaces.
• Certain provisions in COTPA now need to be updated with new scientific evidences highlighting protection is effective with only 100% smoke free environments. Designated smoking areas allowed under COTPA need to be amended.
• Effective enforcement of laws to prohibit sale of loose cigarettes and bidis.
• Article 5.3 guidelines need to be prioritised and implemented to safeguard public health policies and the policymaking process from clandestine tobacco industry interference.
• The GST Council has recently imposed a 28% tax for cigarettes with additional cess that will generate revenue of Rs 5,000 crores per annum. Increasing tobacco taxes is an important demand reduction strategy but it is crucial to study impact of GST across tobacco products in India.
• Awareness campaigns in India hitherto have focused only on cancer as an outcome of tobacco use. There is an urgent need to focus on other health effects such as cardiovascular diseases, reproductive and respiratory health effects, etc.
• Implementing stringent policy action to curb introduction of any new nicotine products for example, e-cigarettes and e-hookahs, which entices youth.
• Supply side action has to go hand in hand with demand reduction measures. Alternate employment for beedi rollers, is an urgent need of the hour. Beedi workers have been exploited and continued to live in dismal conditions and receive wages which have kept them below the poverty line for years.
India’s tobacco control journey has been an uphill task with industry being greatest deterrent but reduced prevalence has shown a light at the end of this dark tunnel. This will motivate government, WHO and public health community to continue this rugged ride of saving lives.