India’s tobacco challenge

India currently holds the dubious distinction of being the second largest producer and the second largest consumer of tobacco in the world. Not a particularly dignified title, considering that tobacco kills half of its dedicated users prematurely in their productive years! According to the Global Adult Tobacco Survey-2010, 47.9% of males and 20.3% of females currently use tobacco in some form in India. Globally, smoking prevalence is declining in developed nations while it is on the rise in developing countries. India is currently on an upward swing both in terms of tobacco use and mortality thereof.

The World Health Assembly recognised the rising global tobacco epidemic and passed nearly 17 resolutions in the 30-year span between 1970 and 1999 exhorting its Member States to initiate action against tobacco use. Nevertheless, these resolutions did not lend a legislative framework that would obligate countries to take action against tobacco, nor could they address the transnational nature of the tobacco problem. Thus, in May 1999, Member States of World Health Organization (WHO) passed a resolution mandating negotiation of an international treaty to address the tobacco challenge. Four years and six gruelling rounds of negotiations later, WHO Member states agreed upon the Framework Convention on Tobacco Control (FCTC), the world’s first legally-binding international public health treaty under the WHO. India played a constructive, leadership role right through the negotiations and ratified the treaty in 2004. 

The Supreme Court of India in 1998 ordered a national smoking ban and called on the Government to legislate on tobacco control. The Cigarettes and Other Tobacco Products (Prohibition of Advertising, Regulation of Trade, Commerce, Production, Supply and Distribution) Act (COTPA) was thus enacted in April 2003. In addition to providing a national, legislative framework for action on tobacco control, this law spells hope for regulatory action on other consumer products with health consequences that are aggressively promoted, but largely unregulated.

The COTPA has been in existence for nearly a decade now. It is therefore a good time to assess its implementation and take stock of policy requirements to match the challenges of the coming decades. Slowly but steadily, a handful of Indian states are beginning to implement the tobacco control law, largely due to political leadership, administrative actions and civil society advocacy at the State level. In recent times some states have banned smokeless tobacco, some have enhanced regulation of retailers such as through licensing, others have extended smoke free public areas to include parks and streets and still others are increasing tobacco taxes. These state-level actions, if adequately defended, mobilised and extended, could in turn ignite the next generation of national-level policies to tame the still-escalating tobacco epidemic in the country. 
A less spoken of, but important, feat by the Government of India involves the ban on Foreign Direct Investments (FDI) in cigarettes, cigars and cigarillos. Over the last one decade, when the Government went on an FDI overdrive opening up sectors that were so far preciously guarded, the Ministry of Health managed to defend the cigarette sector from being opened up to multi-national rush. This comes at a time when several other Asian countries from Sri Lanka to Indonesia and Philippines have allowed transnational tobacco companies to run shops in their backyards. Foreign and domestic companies do harm public health. Therefore the policy could at best be viewed as aiming to minimise damage in terms of reducing the number of players, promotions, brands and hopefully lesser volumes of cigarettes to be dealt with.
While COTPA provided an early step towards meeting India’s FCTC obligations, the country falls short of several of the treaty requirements. For instance, while FCTC requires health warnings on tobacco packs to occupy minimally 30% of the principal display areas, Indian warnings average to only 20% of the principal display areas of cigarette packs. Similarly, FCTC, as well as COTPA, requires a comprehensive ban on direct and indirect tobacco advertising. But conflicting and ambiguous policies by different Ministries have led to surrogate advertising being the order of the day. 

India has also witnessed some well-intended tobacco control policy initiatives failing to reach their logical end. India was the first country in the world to prohibit the use and display of tobacco products in movies and television in 2005. Legal challenges and opposition by certain interest groups have since watered it down and continue to delay the implementation of even the diluted rules. Similarly, industry and political meddling has led the health warnings originally proposed for tobacco packs to be reduced in size and impact. Tobacco taxes wax and wane from one year to another, with no clear policy in place on tobacco economics. 

A fundamental reason for the unintended fate of these well-intended policies is the lack of a planned approach by policy-makers. Policies often spring up spontaneously and as sporadic efforts, with sparse strategy and preparation in place to withstand potential industry challenges. It is notable that Australia spent nearly 2 years in identifying potential challenges, developing counter strategies, research and legal defence before announcing its plain packaging policy last year which is working to its benefit. India needs to urgently develop, through a consultative process, a national road map and strategy with clear policy goals for tobacco control in the country for the next 20-30 years. The National Tobacco Control Programme (NTCP) is a good place to start this forward thinking. 

Recent times have seen much discussion and some efforts to combat the emerging wave of Non communicable diseases (NCDs). Tobacco use is the single major risk factor for four of the major NCDs. NCDs account for over half (53%) of the total mortality in the country. The NCD Plan under the country’s 12th Five Year Plan is a potential opportunity to create synergies between the various national programmes addressing NCDs in the country and integrate tobacco control into its implementation. The NTCP for the next plan cycle is expected to integrate tobacco control into the national NCD package. The programme needs to put the nuts and bolts for this to happen in reality. 

Secondly, tobacco has been hitherto viewed as a health challenge in the country, and rightly so. However, there is a growing body of evidence that throws light on the socio-economic implications of tobacco use and supply. It is now known that tobacco affects the poor in the country more adversely-- be it in terms of misplaced expenditure, lost opportunities, productivity challenges and treatment costs. India stands to lose USD 237 billion between 2004-2015 from cumulative increase in losses from premature deaths due to NCDs. Tobacco is therefore very much a challenge to the country’s development, and its efforts to achieve its development goals.

At the UN High Level Meeting on Non communicable Diseases in September last year, India’s Minster of Health and Family Welfare had said,  “Non   Communicable Diseases (implicitly its risk factors including tobacco) are   not   only   a   health   issue   but   also   a   development   issue,   as   they   impact   productivity   and   also   impoverish the society due to  high  health  expenditures”. Given the rising burden of tobacco use and NCDs and the multifarious developmental challenges facing India, it is imperative that the Government of India follows up on its recognition of the problem and takes urgent and serious steps in integrating tobacco control and FCTC implementation into its national development plans. India’s next development planning cycle would commence in 2013 and the poverty reduction strategy revision is due in 2014. The forthcoming review of these key national strategies offers key opportunities to push for the integration of tobacco control via FCTC implementation into the plans and programming. Internationally, India is a key leader in the development discussions. Nevertheless, India’s ability to lead from the pole position at the international development fora and in the development assistance arena would be determined and influenced largely by the results of its actions on FCTC and development on the domestic front. 

On the supply side, the tobacco industry has often successfully paraded tobacco and areca nut growers, farm workers and bidi rollers to thwart tobacco control policies. In a country with sizeable tobacco production and related employments, it is pertinent that the Government identifies the systemic, socio-cultural and industry-abetted factors that create and sustain dependency on tobacco-related employment and also explore factors that would facilitate those interested to explore alternatives. Another supply side aspect that needs consideration is strengthening policies to control illicit tobacco trade, in line with the Protocol on Illicit Tobacco Trade that India has helped to develop and agree last month. 

Last but not the least it is critical that India tackles the increasing tobacco industry interference in its tobacco control policy-making. Article 5.3 of the FCTC requires Parties to the treaty to protect their tobacco control polices from the influence of the tobacco industry. India is among the early ratifiers of the treaty. But the Government is yet to formulate policies to meet this treaty obligation. Incidentally, the theme for this year’s World No Tobacco Day (31 May) is “Tobacco Industry Interference” and presents a great political opportunity to launch a code of practice regulating interactions between public offices and the tobacco industry. 

Dr. Gro Harlem Brundtland, former Director General of the World Health Organization who propelled the FCTC negotiations reminded world leaders at a gathering in Kobe way back in 1999“ …if we do not act decisively today, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.” 

The question is: are we doing enough, doing it right and engaging all the means at our disposal, for the generations of the 2030s and beyond to be protected from tobacco’s avoidable death, disease and under development? 

Ms. Shoba John
(Shoba John is based in India and is the Programme Director of HealthBridge which works to advance public health policies in developing countries. Ms. John also works closely with the Governments and NGOs in Asia and beyond to advance tobacco control policies. She has been involved in the negotiations for FCTC and its smuggling protocol since the beginning. She is also the Immediate Past Chair of the Framework Convention Alliance and continues to serve as a Director on its Board, representing the South East Asia Region.)

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