Protecting people from tobacco is a public health imperative

Pritha Roy Choudhury, CNS Correspondent, India
A chance meeting with Rosalina Diengdoh (name changed), a 50 year old woman  from the north eastern state of Meghalaya in India, who is in Delhi for the treatment of her son, reaffirmed my doubts regarding the impact of pictorial warnings on packed tobacco products to dissuade people from using the same. It was in April 2016, after a two year battle, that the Indian government  finally acceded to quadruple in size the graphic health warnings on tobacco packaging.

Harrowing images of the health consequences of tobacco use must now be displayed across 85% of the surface area of all tobacco packets -- a measure proven to help users quit and prevent others taking up the habit. I met Rosalina, outside the All India Institute for Medical Sciences (AIIMS). Even though I live in Delhi, I was born and brought up in Shillong—A North eastern state of India. Seeing a lady in front of me, who was dressed in the traditional attire of that state, instilled an interest in me the desire to talk to her. After an initial tete-a-tete, I asked her the reason for visiting AIIMS. She  told me that she was accompanying her 35 year old son who is suffering from oral cancer. She also said in the same breath that her son was addicted to chewing tobacco in its raw form. Larger and stronger pack warnings are proven to be more effective for communicating the harms of tobacco use, raising risk awareness and educating people, including populations with low literacy, prompting tobacco users to quit and discouraging initiation of new users. And yet, there could be aberrations here too.

Many locals, in a state like Meghalaya, chew the tobacco leaf in its raw form. Rubbed with lime, a small piece is handed over to a friend or an acquaintance one meets across the streets or when there is a visitor at home. I was surprised that something, which I was often witness to, as a child, still continues. I asked Rosaline about the pictorial warnings on packed tobacco products and if that had brought down the consumption of tobacco to some extent. She said that most people there still eat the raw form of the leaf and they do not prefer the packed product. While tobacco activists may pat their backs for having succeeded in getting more effective pictorial health warnings occupying larger areas of the packs, how does one warn/educate the users of unpacked tobacco leaves? Even as steps are taken by the government to deter people from using tobacco, there is a constant tussle between the policy makers and tobacco producers. There needs to be some kind of policy for those tobacco users who are yet not educated on the health hazards of the product and/or have no access to any kind of media outreach for their understanding.

Policy formulation towards curbing tobacco usage in India should be customized according to the geography, culture and economic conditions of the population of an area. It cannot be a one- size- fits- all approach. India is the third largest producer of tobacco across the globe, and the demand and usage of tobacco varies across different regions within the country as people come from diverse backgrounds. The policies till now have targeted that sector of the population who can afford to buy packed tobacco products, by showing pictorial warnings in the packaging of the cigars, cigarettes and other such products. But the irony is that a large number of people cannot afford these and so resort to taking the tobacco leaf in the raw form or, at the best, rolled in the form of bidis. Targeting those people who do not have the knowhow of the health problems associated with the consumption of tobacco products in any form, is the need of the hour. The government must come up with measures to educate the greater masses on health related issues of the direct as well as indirect use of this lethal product.

The conflict between the tobacco industry’s influence and public health policy interests continues to interfere and jeopardize the health making policies. It often results in a failure to reach those who are actually in need to benefit from the government’s various tobacco control measures in accordance with the WHO Framework Convention on Tobacco Control (WHO FCTC), to reduce the usage of tobacco and exposure to second hand smoke and hence control the diseases and deaths attributed to tobacco consumption and  exposure. The health hazards due to tobacco are many, including cardio vascular diseases (CVDs) and cancers of various kinds. CVDs account for 29.8% of all deaths in India. According to the World Heart Federation, at least 80% of the premature deaths due to CVDs can be prevented by controlling four main risk factors - unhealthy diet, usage of tobacco, lack of physical activity and excessive consumption of alcohol. A healthy balanced diet, at least 30 minutes of vigorous exercise, moderation in alcohol consumption and complete abstinence from smoking/tobacco use are key to curbing CVD.

57% of all men and 11% of women between 15–49 years of age use some form of tobacco in India. Another problem is the use of betel quid (paan), which is made of pieces of areca nut, processed or unprocessed tobacco, aqueous calcium hydroxide (slaked lime), and some spices wrapped in a leaf of betel vine. Gutka, zarda, kharra, mawa, and khaini are different forms of dry mixtures of lime, areca nut flakes and powdered tobacco, custom mixed together and offered for sale. Bidis— small hand-rolled cigarettes— produce three times more carbon monoxide and five times more tar than conventional cigarettes. Those who smoke bidis have a three-fold higher risk of oral cancer compared with nonsmokers, and are also at increased risk of lung, stomach and esophageal cancer. It is high time that the policy makers think about framing policies for reaching the remotely placed people who are yet to be reached. Further, hand rolled bidis and sale of the leaf in the raw form should be banned from immediate effect, apart from raising the taxes drastically on the processed tobacco products.

Pritha Roy Choudhury, Citizen News Service - CNS
October 17, 2016