Slamming the Central Government’s decision to delay the deadline of increasing the size of pictorial warnings on tobacco products, healthcare providers, health activists and public health groups put forth arguments and facts to link tobacco consumption with cancer. They also question the government’s commitment to ensure good health for its citizens and recommend the way forward By Raelene Kambli
Last October, the health ministry under the leadership of the then Union Health Minister, Dr Harsh Vardhan issued a notification requiring cigarette manufacturing companies to devote at least 85 per cent of the surface areas of cigarette packets on both sides to graphically and literally represent the statutory warning. According to the notification, every cigarette packet would carry pictorial depiction of throat cancer and a message in English, Hindi or any Indian language on both sides. Originally, the notification was scheduled to kick off on April 1, 2015. However, just few days before the mandate would be effected, the Centre revoked its decision after a parliamentary panel looking into the guidelines for sale of tobacco recommended that the proposal be kept in abeyance until its socio-economic ramifications were evaluated. Some of the members of the panel including BJP MPs, Shyam Charan Gupta, a beedi baron and Dilip Gandhi claimed that there was no Indian scientific evidence that links smoking with cancer and that this move would affect employment prospects of beedi and tobacco industry which employs 1.3 crore people in the country. The health ministry’s inappropriate decision to defer the implementation of a notification for increasing the size of pictorial health warning on cigarette packets and various other tobacco products has triggered an outrage among various healthcare stakeholders. In a letter to the Prime Minister, various tobacco control experts have urged for introduction of new warnings without any further delay.
Facts about tobacco and cancer in India
Dissenting the claims made by the regulatory panel members, experts provide enough evidence that proves the link between tobacco consumption and cancer. Dr Monika Arora, Director, Health promotion and Associate Professor, Public Health Foundation of India, informs that as per the publication 50 years of Cancer Control in India under the National Cancer Control Programme, available on the Ministry of Health and Family Welfare, Government of India website (last updated April 13, 2015) tobacco is the most important identified cause of cancer and is responsible for about 40 to 50 per cent of all cancers in men and about 20 per cent of all cancers in women. These figures have been estimated from the National Cancer Registry Programme of the Ministry of Health and Family Welfare, Government of India”.
“Tobacco is the only legal product that kills more than 50 per cent of consumers who use it the way it is intended. The best public health evidence that has accumulated in the last 50-75 years is with regard to the dangers of tobacco. Tobacco causes not just cancer, but a whole host of cardiac, respiratory and other problems,” reveals Dr Pratima Murthy, Professor of Psychiatry, Centre for Addiction Medicine, NIMHANS, Bangalore.
Giving more statisics from the government’s official reports, Bhavna B Mukhopadhyay, Executive Director, Voluntary Health Association of India says,“The Government of India has published several evidence-based reports which include Report of Tobacco Control in India 2004, Bidi Smoking and Public Health, 2008 and Global Adult Tobacco Survey, India 2010. All these establish the close link between tobacco and cancer as well as other tobacco-related diseases. There are several other studies available in the public domain. Each day 5500 youth initiate tobacco use, 2500 Indians die daily due to tobacco-related diseases and 10 lakh Indians die annually due to diseases caused by tobacco. Economic Burden of Tobacco Related Diseases in India (2014) commissioned by Ministry of Health & Family Welfare states that the total economic costs attributable to tobacco use from all diseases in India in the year 2011 for people aged between 35-69 years amounted to Rs 1, 04,500 crores. The total revenue from all tobacco products in the same year constituted only 17 per cent of the estimated costs of tobacco.”
Experts also point out that not only smoking tobacco causes cancer but also smokeless tobacco has the equivalent risk. Says Dr Sapna Nangia, MD, Radiotherapy, Sr Consultant & Clinical Coordinator, Radiation Oncology, Apollo Cancer Institute, Indraprastha Apollo Hospital, New Delhi, “There are many studies that confirm the strong association between cancer and tobacco. Gajalakshmi et al I ( Asian Pac J Cancer Prev. 2015;16(3):1201-6.) interviewed 80,000 families in Tamil Nadu and found that ever having chewed tobacco increased a person’s risk of dying due to cancer by 50 per cent and of dying early by 30 per cent.”
Binoy Mathew, Media Officer, Voluntary Health Association of India, reveals, “At least 28 chemicals in smokeless tobacco have been found to cause cancer. According to a health report by the Ministry of Health and Family Welfare in consultation with National Institute of Health and Family Welfare on the ill-effects of chewing tobacco, there are over 3095 chemical components in chewing tobacco products (including gutkha), among them 28 are proven carcinogen. The major and most abundant group of carcinogens is the tobacco-specific N-nitrosamines (TSNA). The report reveals that rampant use of chewing tobacco is associated with high prevalence of oral cancer in India, and almost 90 per cent cases are linked to tobacco. India has the highest prevalence of oral cancer globally, with 75,000 to 80, 000 new cases of oral cancers being reported every year.”
The menace of tobacco smoking just doesn’t stop there, it harms even people around. “Passive smoking or environmental tobacco smoke (ETS), is an important risk factor for occurrence of lung cancer among never smokers. A strong association was observed between ETS exposure during childhood and lung cancer. In relation to adult life, the increased risk due to ETS exposure from a smoking spouse was observed only in case of cigarette smoke. Exposure to ETS inside vehicles was also detected to be a risk factor,” points out Dr Pradyut Waghray, Sr Consultant Pulmonologist, MD, Kunal Institute of Medical Specialities. Hyderabad and HOD and Prof of Pulmonary Medicine, SVS Medical College, Mahbubnagar, Telangana.
With several evidences to back our claim that tobacco does cause cancer, what should be the way forward to curb this menace? Do we have proper regulations in place?
The Government of India enacted ‘Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COTPA) to prohibit the consumption of cigarettes and other tobacco products, which are injurious to health. To strengthen the implementation of the tobacco control provisions under COTPA and policies of tobacco control mandated under the WHO Framework Convention on Tobacco Control (FCTC), the Government of the India piloted National Tobacco Control Programme (NTCP) in 2007–2008. In spite of these regulations the number of tobacco users and producers are constantly on the rise. Then, can smoking bans be an option?
To ban or not to ban?
Several countries worldwide have introduced smoking bans public policies that include criminal laws and occupational safety and health regulations, which prohibit tobacco smoking in workplaces and/or other public spaces. In India, a nationwide smoke-free law pertaining to public places came into effect from October 2008. Moreover, as per the rule anybody violating this law will be charged with a fine of Rs 200. The sale of tobacco products within 100 yards of educational institutions is also prohibited. This has been a bit beneficial in some areas.
Dr Kunal Saxena, MD, Rusan Pharma cites an example from a study done by the Ministry of Health and Family Welfare. “A recent study compared air nicotine levels in public places in Ahmedabad, India, before (June 2008) and after (January, 2010) the implementation of a comprehensive smoking ban which was introduced in October 2008. Second-hand smoke, exposure was significantly reduced in public places after the smoke-free legislation came into force. Smokers need to be made aware that passive smoking in their official/personal spaces can cause health risks to their loved ones and should refrain from exposing them to the smoke. It is also a brilliant way to try curbing the urge to smoke which can help reduce ones intake,” he says. However, this particular rule is ineffective in many areas and just by having few smoke free zones we cannot help curb this ill- omen. So can a complete ban on sale and production of tobacco be a solution?
Giving a perspective of the laws associated with tobacco production and use, Dr Arora, informs, “Banning tobacco is not mandated either in WHO FCTC or in COTPA. Both FCTC and COTPA aim to regulate tobacco products. In India ban has only been imposed on gutkha products under Food Safety and Standard Authority of India’s (FSSAI) Act, as one of its provisions prohibits addition of tobacco or nicotine to any food product. The Supreme Court of India had declared, gutkha to be a food product in one of the earlier cases. Some states have expanded the net of this ban to include all smokeless tobacco products (chewable forms), as manufacturers of gutkha had started selling tobacco powder and other gutkha ingredients separately, to circumvent the FSSAI Act that bans use, sale, storage and manufacture of gutkha. It is justified to enforce such a ban, if the law cannot be enforced in its letter and spirit.”
The Indian law may not permit a complete ban, yet there are some industry experts who strongly believe that banning tobacco in India is the solution.
Dr Ranga Rao, Director-Department of Oncology at Max Super Speciality Hospital, Shalimar Bagh, feels, “Very strict implementation would be a problem but possible with strong personal, national, social and political determination. That is undoubtedly the best that can happen to humanity in this world. It will do much good to the society. No single measure would have helped humanity so much. The benefit measured in terms of money is unimaginable and the present world can be “a step nearer to heaven.”
Agreeing to the same, Dr Vedant Kabra, Director, Department of Surgical Oncology Fortis Memorial Research Institute expresses, “It will significantly curb the menace. Some of our politicians claim that a ban on tobacco will lead to loss of employment of a large number of people. I think they are more concerned about their own earnings and not that of these poor people because almost whole of the beedi industry of our country is controlled by politicians. These people can be put to much better use and can contribute in a much more positive way in nation building rather than promoting national destruction.”
There are very few countries in the world that have completely banned the sale and production of tobacco. Bhutan is one of them. However, survey’s show that a complete ban on tobacco sale and production in these countries gave rise to smuggling and illicit production and sale of tobacco products. Moreover, some studies conducted by Cancer Epidemiology Biomakers & Prevention journal on examining the history of the cigarette controversies happening in different countries reveal that tobacco companies fund scientific research that was intended to obfuscate and prolong the debate about smoking and health These studies also point out that today, tobacco companies acknowledge that smoking is a cause of disease, but they have not materially altered the way they do business.
Can such a plot be possible in India? In such circumstances will a complete ban lead to black marketing in India?
Says, Dr Lancelot Pinto, Consultant Respirologist, P. D. Hinduja National Hospital and Medical Research Centre, “Prohibition has historically been proven time and again to be an ineffective means of curbing a social problem. It moves the market underground, thereby making it even more unregulated and dangerous, besides creating a whole new avenue for criminals to generate a tax-free revenue. I do not think a ban can solve the problem.”
“No ban has worked 100 per cent in India or anywhere else. In fact, an outright ban may turn out to be counterproductive and result in illegitimate consumption of tobacco. So what is required is restricted access and educating the masses on the ill-effects of the tobacco consumption. People should be made aware of the ill-effects of tobacco at an early age so that they know the risks beforehand before getting themselves acquainted to the habit of smoking,” Dr Anil Heroor, Consultant Oncosurgeon, Fortis Hospitals, Mumbai.
Speaking about a possibility of black marketing of tobacco and tobacco-products Dr Achal Bhagat – Senior Consultant, Psychiatrist and Psychotherapist, Indraprastha Apollo Hospitals, Delhi, states, “While a ban might be reassuring at one level, it only generates a secondary market. Access becomes slightly difficult but not impossible. It is important for government to inform people and decrease access to products that could be detrimental to their health. Tobacco dependence is a cluster of behavioural, cognitive and physiological phenomena. Very few tobacco users can successfully quit the habit in their first attempt. But the evidence is strong that it can be done. From quit smoking helplines, mobile applications to counselling to prescription medicines, there are numerous effective ways to make people quit. In my opinion, a scientific way of controlling any drug use is decreasing the source of supply and creating effective strategies to reduce the demand.”
Dr Vikram Kekatpure, Senior Consultant and Head of the Department of Head and Neck Oncology and Reconstructive Surgery, Narayana Health City, Bangalore chips in saying, “It should be adequately taxed and access to tobacco products should be restricted.”
Role of social advertisements and pictorial warnings
Well, if banning is not an option and the current regulations are not enough, will there be another solution?
Dr Arora has an answer. Citing examples from different countries, she urges India to take lessons from these solutions. “India needs to note that FCTC provides only the floor (bare minimum) that should be achieved by countries to protect their citizens from dangers of tobacco, and not the ceiling. Realising the public health benefits of larger warnings, countries like Australia, Thailand and many others, have gone beyond the minimum prescribed size of pictorial health warnings (PHW) in FCTC. Article 11 of FCTC on packaging and labelling prescribes that PHWs should be 50 per cent or more of the principal display areas but shall be no less than 30 per cent of the principal display areas. Indian Tobacco Control Law- COTPA 2003 is on the lines of FCTC for most of the articles, however, falls short in certain areas, such small size of PHW. India’s current 40 per cent on one side of the pack, translates to 20 per cent on both sides and India does not meet the minimum prescribed size for these warnings. Originally, India ranks 136th in the world due to small warnings on one side of the pack only, while other countries like Brazil have 100 per cent of one side of the the principal display area devoted to PHW. This policy intervention in India has not been able to make full impact and is a lost opportunity for providing health education to consumers and youth in particular, who can be dissuaded from experimenting by putting effective warnings on tobacco product packages,” she avers.
“India demonstrated global leadership when it announced its new 85 per cent pictorial health warnings in October 2014. Following the Oct 15, 2014 notification on 85 per cent pictorial warnings on both sides of tobacco products, India’s position jumped to second from 136 (of 198 countries). Taking the cue from India, countries like Nepal, Pakistan, Sri Lanka, dramatically increased the size of their pictorial warnings to 90, 85 and 80 per cent respectively. India has received immense support for implementation of 85 per cent pack warnings from victims of tobacco use, doctors, cancer hospitals, national and state levels health organisations, well-known public health experts, beedi workers unions, women and youth groups and 50,000 signed petitions from general public. Some eminent MPs from across different political parties such as Supriya Sule, Rajeev Chandrasekhar, PK Sreemathy, Baijayant Jay Panda, Prahlad Joshi, among others, have also written to the Health Minister, JP Nadda in favour of 85 per cent larger pack warnings in public interest,” reckons Mukhopadhyay.
Further on Arora says, “Apart from PHW, India needs ban on loose sale of cigarettes, as the whole purpose of PHW on packs is lost, if cigarettes are sold loose. PHW are only on pack and not on individual cigarettes, thus sale in pack is essential to target messages to the consumers. Similarly, surrogate advertising, brand stretching, point of sale advertising and on-pack advertising are areas that still need to be strictly regulated under comprehensive ban on advertising. Tobacco taxes need to be substantially raised, across all tobacco products to be able to influence demand and thus see any public health benefit of this tobacco control strategy in India.”
Lastly…
In a country like India, where more tobacco users are coming on board, larger pictorial warnings is the need of the hour. It is not right to put a billion lives at stake in order to save the occupation of those employed by the tobacco industry. The government if really bothered of these poor people can certainly provide them with an alternate occupation. It is time that all stakeholders of public health raise their voice and join in the war against tobacco.
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