Abstract
Tobacco use is a serious concern in India since it is one of the largest producers and consumers of tobacco in the world. With growing evidence of health hazards caused by tobacco, Government of India had enacted various tobacco control legislations. This article provides a critical review of such government interventions. It traces tobacco practices and production trends in India, and proceeds further to provide a detailed account of the history of such interventions to understand the effectiveness of such policies, and stresses on the role of tobacco companies to weaken tobacco control policies in India. This article concludes that though tobacco control has taken a long leap forward with the introduction of various legislative steps to prohibit tobacco use across the country, review of these policies shows their inadequacy not only in enforcement but also in issues related to (a) the interference of the tobacco industry, (b) issues with tobacco taxation and (c) the failure of government to rehabilitate people involved with cultivation, production and distribution of tobacco products.
Introduction: Rationale for Tobacco Control
Tobacco is one of the most easily accessible legally available addictive substances. Use of tobacco has been found to cause long-term sufferings and premature deaths. High morbidity due to tobacco is especially a serious concern for low and middle-income countries with majority of world smokers being residing in those countries (Jha et al., 2011; Singh, Kaushik, & Jain, 2011). It is associated with numerous health problems such as cardiovascular diseases, different types of cancers, numerous respiratory disorders and various reproductive effects as well (Gupta, 2013; Wald & Hickshaw, 1996; Zarocostas, 2011). Studies have found women who smoke are more likely to experience primary and secondary infertility and delayed conception than non-smokers (Baird & Wilcox, 1985). Given these facts, tobacco has emerged as one of the significant public health concerns and the foremost cause of avertable mortality in the world. Death due to tobacco related illness is particularly major issue for the developing countries, given that studies have estimated that about 80 per cent of the smokers in world belong there.
It is estimated that if consumption of tobacco continues at the same rate, by 2030 it will take more than 8 million lives every year, and the majority of these deaths are expected to occur in low and middle-income countries. According to the World Health Organization (WHO), tobacco-related deaths will be approximately around 1 billion in this century. Worldwide, tobacco kills more than 5.4 million people, every year, out of which more than 1.3 million deaths occur in the Southeast Asian region (Singh et al., 2011; WHO, 2009). With the decrease in smoking prevalence in developed countries, the multinational tobacco companies are now moving massive resources to boost sales in developing countries. Apart from smoking, in some developing countries, local tobacco production and consumption present major problems (Mackay & Crofton, 1996). Studies have also found not only direct smoking but also prolonged exposure to second-hand tobacco smoke (SHS) or “passive smoking” causes a similar range of health problems as those of smokers. “Passive smoking” refers to a situation where a non-smoker inhales another person’s smoke either by side-stream or by mainstream exposure to tobacco smoke. There is conclusive evidence which links passive smoking to an increased risk of cardiovascular diseases, cancers, asthma and other respiratory diseases in adults, ear infection and sudden infant death syndrome in children, to name but a few of harmful effects of passive smoking (Singh & Lal, 2011). The health hazards do not stop at its consumers alone. There are high levels of nicotine absorption among labourers engaged in harvesting, processing of tobacco leaf and bidi making in India. Common health problems among workers are weakness, joint pain, asthma, bronchitis and allergies (Gupta & Asma, 2008).
The economic costs associated with such exposure and consumption of tobacco is quite high. The extent of these costs and their public share depends on how widespread is an individual country’s tobacco epidemic and the prevailing system of health care provisions. The public share of these costs will be much larger in countries with national health care systems (Ross & Chaloupka, 2003). According to Government of India, the total economic cost attributable to tobacco use from all diseases in India for persons aged 35–69, amounted to ₹1,045,000 millions in 2011, with direct cost being 16 per cent and 84 per cent being the indirect, respectively (John et al., 2015). While 91 per cent of this burden is borne by the male, rest is by the female. Apart from these costs, government intervention is also essential on other economic grounds as well. Since a tobacco user causes high negative externalities by imposing direct financial and non-financial burdens on those who do not smoke. Second-hand smoking has been linked to numerous health problems, and their treatment imposes high costs. Also, there exists market failure due to insufficient information about the health risks of tobacco use.
With the growing evidence of hazards from tobacco use, the Government of India enacted different tobacco control legislations. While the Cigarettes (Regulation of Production, Supply & Distribution) Act in 1975 was the first such attempt, the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulations of Trade and Commerce Production, Supply and Distribution) Act, 2003 (COTPA), on the other hand, is considered to be the most significant step in this direction. In 2004, the government ratified the WHO Framework Convention on Tobacco Control (WHO FCTC), which lists critical strategies for reduction in demand and supply of tobacco (Kaur & Jain, 2011; Mishra, Pimple, & Shastri, 2012; Panda et al., 2012). Later, to strengthen the implementation of the tobacco control provisions under COTPA and policies of tobacco control mandated under the WHO FCTC, the Government of India launched the National Tobacco Control Programme (NTCP) in 2007–2008. In 2015, amendment of COTPA was also introduced.
Given the above context, this article attempts to traces out details of such anti-tobacco legislations and critically reviews the effectiveness and failures of such government interventions and discusses for the road ahead. The article is divided into five sections. The next section provides a concise description of consumption pattern and production of tobacco in India. The third section details out the various public policies adopted in the country over the time to control tobacco use until present, while the fourth section reviews them critically to point out the accomplishments and deterrents of such efforts. The fifth section concludes the review by tracing the current policy space and possible future directions it can take.
Tobacco Consumption and Production in India: A Brief Description
India is one of the major tobacco-producing countries in the world. Table 1 presents data from six major tobacco-producing countries in the world in the past three years. India features as the country with the third highest production of tobacco in the world after China and closely preceded by Brazil in 2017, and also the second highest area under tobacco cultivation in the world. In 2016, the production of tobacco in India even exceeded Brazil.
Area Under Cultivation and Production of Tobacco in Major Tobacco Producing Countries
In India, use of tobacco is highly prevalent, and statistics show that around 28.6 per cent of the adult population (aged 15 years and above) use tobacco in some form or the other, out of which 10.7 per cent are smokers and 21.4 per cent uses smokeless tobacco. The prevalence of tobacco use among males is found to be higher with 29.6 per cent as compared to 12.8 per cent among females. Apart from the direct use of tobacco, 52 per cent of the adults (rural—58% and urban—39%) were found to be exposed to second-hand smoking (Tata Institute of Social Sciences [TISS], Mumbai, and Ministry, of Health and Family Welfare, 2016).
Tobacco is consumed in myriad forms in India that include both smoking as well as smokeless tobacco (Mathur & Shah, 2011; Rani et al., 2003). In rural areas, bidi is the most popularly prevalent smoking product (Gupta, Yadav, & Anand, 2010; John, 2005), while cigarette is the preferred product in urban areas (2010). Hookah, Chuttas, Dhumti, Chillum, Cigars, Cheroots and Pipes are some other forms of tobacco smoking in different parts of India (Jindal et al., 2006). Some of the commonly used smokeless tobacco products are dry tobacco areca nut preparations, such as paan masala, gutka and mawa are also popular in many parts of India (Gupta, Ray, & Singh, 2012; Rooban et al., 2010). Apart from these, oral tobacco such as mishri, gul and gudakhu are also vastly used as topical applications on teeth and gums (Dobe, Sinha, & Rahman, 2006; Rani et al., 2003). Use of smokeless tobacco is a socially accepted habit especially in eastern, northern and northeastern parts of the country.
In India, varieties of tobacco are produced; however, flue-cured Virginia (FCV) has the highest share of production and also has the most exported variety. Table 2 lists the tobacco varieties discussed above by the major growing states in India. FCV tobacco is grown mostly in districts of Andhra Pradesh such as Eastern and Western Godavari, Nellore and Krishna, and Telangana such as Warangal and Khamma. It is also grown in some parts of Karnataka and smaller part of West Bengal and Orissa. Apart from FCV, bidi, Pikka, Hookah and chewing tobacco, Motihari tobacco, Cigar wrapper, Cheroot, Snuff, Burley, Oriental, Natu tobacco, HDBRG, Lanka are the main types of tobacco grown in the country.
Varieties of Tobacco Grown in the Major States of India
There are only a few players in the Indian tobacco industry, with ITC having the largest market share and around 60 per cent of the total production. The other major companies are: Godfrey Phillips India (GPI) Limited, Vazir Sultan Tobacco (VST) and Golden Tobacco Company (GTC) Limited.
A Brief Chronology of Various Anti-tobacco Litigations and Regulations
It is believed that the first attempt to ban the use of tobacco was by the emperor Jahangir when in 1617 he passed an order to prohibit tobacco smoking (Chattopadhayya, 1995). It is also documented that in 1673, Shivaji used an official order to warn his officers against smoking of tobacco pipes, as the use of tobacco had become widely prevalent among Maratha army (Gode, 1961). During the era of Independence, it is recorded that Mahatma Gandhi repeatedly spoke about its harm and against its use. According to the draft of the constitution in 1948, Article 47 of the Constitution states that “State shall endeavour to bring about prohibition of the consumption, except for medicinal purposes, of intoxicating drinks and drugs which are injurious to health” (Reddy & Gupta, 2004, pp. 43–47).
India’s first legislation as an attempt to prohibit the use of tobacco evolved in 1970; first in this series was The Cigarettes (Regulation of Production, Supply & Distribution) Act 1975, which made a prominent statutory health warning mandatory on all cigarette packets for any sort of trade, distribution or supply of the product. This act also mandated restriction on the advertisement of cigarettes, unless the specified warning is included in such advertisement. Since then several modifications and inclusions have been done in acts related to the issue (Cigarettes Act, 1975). During the 1980s and 1990s, both central and state governments imposed further restrictions on tobacco trade and efforts were initiated to bring forth a comprehensive legislation for tobacco control. Judicial activism has also played a major role in providing a substantial push to implement tobacco control legislation by both directing the government to take necessary steps and creating a climate of public support for such legislative measures. One of such efforts was on July 1999 when Government of Kerala banned public smoking in the state.
In 1990, the Central government issued an executive order prohibiting smoking in certain enclosed public places where huge numbers of people are expected to be present for long periods. These places included educational institutions, conference halls, planes, trains and buses, and each location was required to display billboards indicating that smoking was strictly prohibited. No ashtrays were allowed in these places and the sale of cigarettes was banned. In December 1991, the Central government amended the Cinematograph Act, 1952, to ban scenes that promote and endorse the consumption of tobacco in any form. In 1992, the Central government amended the Drugs and Cosmetics Act, 1940, and thereby banned the manufacture and use of toothpastes and toothpowders containing tobacco (Reddy & Gupta, 2004).
In February 1995, the Parliamentary Committee on Subordinate Legislation (10th Lok Sabha) examined the rules and regulations framed under the Cigarettes (Regulation of Production, Supply and Distribution) Act, 1975. The committee in its 22nd report presented to the Lok Sabha on 22nd December 1995 made a series of observations and recommendations which were examined by a Coordination Committee comprising representatives from the Ministry of Commerce, Agriculture, Labour, Information and Broadcasting, Indian Council of Medical Research and NCERT. While most of the ministries agreed with the recommendations of the committee, the Ministry of Labour was of the view that the adverse impact of such legislation on the livelihood of labour force involved in tobacco production, processing and marketing could not be ignored. The committee reported inadequacy and inefficiency of previous acts in terms of limitations in health warnings and provisions of tobacco advertising. The committee also pointed out the risk of diseases caused by direct inhaling as well as passive smoking, and further suggested to initiate policy decisions for the government to encourage farmers to move to other profitable crops. Deliberations of the committee let to the framing of comprehensive legislation on “Prohibition of Advertising and Regulation of Production, Supply and Distribution of Tobacco Products” and the bill was introduced in the Rajya Sabha on 7 March 2001. Also, in November 2001, the Supreme Court of India directed state governments and union territories to take necessary actions to implement a ban of public smoking across India. Even, National Human Rights Commission of India (NHRC) advocated tobacco control as an essential measure to protect human rights.
Some of the recommendations of the 2001 bill include making pictorial depictions of health warnings mandatory and required nicotine and tar contents and their maximum permissible limits to be printed on cartons and packages of all tobacco products. It was also recommended that special smoking areas should be provided in hotels, restaurants and airports, penalties for noncompliant producers, dealers and sellers of tobacco products should be standardised across the country, and sale of cigarettes and tobacco products should be completely banned within a radius of 500 yards of educational institutions. This proposed bill eventually became an act of parliament “COTPA, 2003”, notified on 18 May 2003.
COTPA enactment was also a partial fulfilment of the treaty obligation with the WHO on the proposed international FCTC. India was among the first few countries to sign and ratify this treaty. WHO FCTC is regarded as the first international treaty adopted under Article 19 of the WHO constitution. This was negotiated during the 56th World Health Assembly held in Geneva, Switzerland on 21 May 2003. The treaty came into existence on 27 February 2005. It had been signed by 168 countries that legally bounds 180 ratifying countries, including India. This treaty is a supranational agreement that seeks: “To protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke”. The provisions of the treaty requires implementation of strategies to reduce the demand for tobacco through tax and other price, non-price measures; also it mandates legislative measures to be adopted for protection from exposure to tobacco smoke; regulation of the contents of tobacco products; regulation of tobacco product disclosures; packaging and labelling of tobacco products; education, communication, training and public awareness; comprehensive ban on advertising, promotion and sponsorship of tobacco products; and disseminate demand reduction measures concerning tobacco dependence and cessation.
With the ratification of this treaty, COTPA was an act implemented to prohibit the advertisement, and to provide for the regulation of trade and commerce in, and production, supply and distribution of cigarettes and other tobacco products and for matters connected therewith. This act applies to the whole of India and covers all types of tobacco products. It came into force in May 2004. Salient features of the law includes: prohibitions on direct and indirect advertisement of tobacco products, ban on sponsoring of any sport or cultural events by cigarette and other tobacco product companies, ban on smoking at public places, ban on sale of tobacco products to any person below the age of 18 years, ban of sale of tobacco products within 100 yards of educational institutions, pictorial warnings to be displayed on all tobacco products, and provision for restriction of the trade and commerce in, and production, supply and distribution of all tobacco products, and ban on trade by any person in any tobacco products including imported products unless the specified warnings, nicotine, and tar contents are indicated (COTPA, 2003).
Prohibition of the direct and indirect advertisement was in all forms of audio, visual, outdoor and print media. This also included prohibiting promotion of tobacco products through sponsorships of any events such as sporting or cultural ban on smoking in public places was supposed to be implemented using “no smoking” banner and the board with people to approach in case of violations. List of public places where smoking was prohibited was extensive which includes enclosed spaces, restaurants, cinemas, shopping malls, clubs, workplaces and even semi-open spaces such as stadiums, railway stations and bus stops. Provision of laws of prohibiting the selling of tobacco products to a person below 18 years and within 100 yards of an educational institution is to deter youth and students from tobacco use. A health warning on tobacco products having legible and prominent text with a conspicuous size and colour picture was made compulsory under this law. Also, this law made it mandatory to test and display nicotine and tar content on any tobacco products which were produced, supplied or distributed (COTPA, 2003).
To reinforce implementation of the tobacco control provisions under COTPA and policies of tobacco control mandated under the WHO FCTC, the Government of India launched “National Tobacco Control Programme” (NTCP) in 2007–2008. The prime objective of the programme was to increase awareness of health issues related to tobacco use, monitoring of the implementation of anti-tobacco initiatives at state as well as district level and also enabling regulatory mechanisms such as set up of tar-testing laboratories. Initially, it was introduced for 9 states and 12 districts, which was later expanded to cover 12 more states and 24 districts by 2008–2009. The implementation of NTCP was a major step forward for India and for the first time, funds were allocated specifically to implement tobacco control strategies at the central, state and sub-state levels (Kaur, 2012). By 2013, the coverage of NTCP has been upscaled from 42 districts of 21 states to 53 districts of 29 states.
The major components of NTCP at a national level can be summarized broadly as: (a) An intensive national level health campaigns to raise greater awareness of tobacco use. This was when for the first time, under this programme, anti-tobacco messages (TV/radio), specifically targeting tobacco products used in the country, were developed, field-tested and translated into 18 languages for the national campaign. Since 2008, at least three campaigns on television, radio and print have been conducted each year, with a considerable government commitment to media buying; (b) Initiate laboratory facility for tobacco product testing for better regulation. Although COTPA mandated testing of all tobacco products for their tar and nicotine content and displaying the levels on tobacco product packages, it could not be implemented successfully; (c) Research and training on alternative crops and livelihood, to reduce the supply of tobacco in the long run. With India being the second largest producer of tobacco, the government is bound to address supply-side issues of tobacco control, as the need to rehabilitate millions of tobacco growers, farm workers, bidi rollers, sellers and retailers are equally essential for successful implementation of the tobacco control strategies; and (d) Monitoring and surveillance through Global Adult Tobacco Survey (GATS). This is the first ever-dedicated household survey to study the prevalence of tobacco use among adults. Also, under the National Health Mission (NHM), flexi-pool for non-communicable diseases (NCDs), “National Consultation on Tobacco Economics” has also been organised, which dwelt on three issues of economics of tobacco (a) health cost of tobacco use, (b) alternative livelihood to tobacco farmers and bidi rollers and (c) tobacco taxation. At the state level, the NTCP intended to establish tobacco control cells to build trained manpower and facilitate resources to implement and monitor effective anti-tobacco laws. At the district level, NTCP mandates to train health workers, NGO workers and teachers regarding tobacco control strategies, setting up tobacco cessation facilities, design tobacco control programme for schools and monitor the implementation of tobacco control laws. The establishment of District Tobacco Control Cells also provided an opportunity to integrate tobacco control with other national health programmes and National Rural Health Mission (NRHM).
From 2 October 2012, the Government of India began screening two major anti-tobacco advertisements tagged “Sponge” and “Mukesh” in movie theatres and also on television. These advertisements were specially designed to create awareness about the amount of tobacco tar produced by cigarettes and bidis and to feature a case study on ill effects of tobacco use. In October 2013, the “Sponge” and “Mukesh” advertisements were replaced by new advertisements titled “Child” and “Dhuan”. “Child” focuses on the health risks of smoking and second-hand smoke, while “Dhuan” portrays the behaviour expected of various segments of people such as business managers, advocates, enforcement officials, smokers and non-smokers to enforce smoke-ban in public space. Also, during the period 2011–2013, many states had started banning the sale, manufacture and distribution of gutka and paan masala. Although by 2013, about 24 states and 3 union territories had banned gutka, illegal sale of gutka continued to thrive.
To strengthen the ban of gutka, in September 2016, the Supreme Court of India ruled against selling any chewable tobacco products including paan masala, Khaini, Zarda and so on. Also, on 15 October 2014, the government introduced new larger warnings that increased the warning size from 40 per cent of one side of tobacco product packaging to 85 per cent of both sides of tobacco packaging. Although the rules announced were supposed to have gone into effect on 1 April 2015, 1 April 2016 became the implementation date of the new warnings. Recently in September 2017, government has proposed that every tobacco selling shop needs to get registered with local civic body, and also they cannot sell candies, biscuits, chips and so on to discourage non-users especially children and younger adults to get attracted to tobacco products.
In the annual budget of 2017, excise on various lengths of cigarettes has been increased by 2.5 per cent to 6 per cent, while for paan masala, it has been increased from 6 per cent to 9 per cent and for unmanufactured tobacco from 4.2 per cent to 8.3 per cent. For other tobacco products such as chewing tobacco, Zarda-scented tobacco and gutka, there has been a proposition to double the excise from 6 per cent to 12 per cent. For handmade bidis, the finance minister proposed to hike basic excise duty from ₹21 per 1,000 to ₹28 per 1,000, and for machine-made bidi, basic excise duty was from ₹21 per 1,000 to ₹78 per 1,000.
The Ministry of Health and Family Welfare, Government of India, has notified new sets of specified health warnings for all tobacco product packs by making an amendment in the Cigarettes and Other Tobacco Products (Packaging and Labelling) Rules, 2008, vide GSR 331(E) dated 3 April 2018 “Cigarettes and other Tobacco Products (Packaging and Labelling) Second Amendment Rules, 2018”. The amended rule is applicable from 1 September 2018.
Achievements and Deterrents of Tobacco Control Measures: A Discussion
Tobacco control has taken a long leap forward with the introduction of various legislative steps to prohibit tobacco use across the country, however a uniform inadequacy could be seen in terms of dissemination of the laws and enactment of provisions under them. Although all the notified sections in COTPA had been intended to be implemented in the entire country, however, there has been no uniformity in implementation across the states, and also there has been negligence in enforcement of few particular provisions of the act (Gupta, Cecily, & Singh, 2012). One of the reasons for such negligence can be attributed to the fact that implementation was left to be the state subject and long-drawn litigation conflicts and lobbying by the tobacco industry. Although the law prohibits indirect advertisements, it is not specific. As a result, it was hardly being controlled and brazen especially in case of paan masala, and surrogate advertising by tobacco brands continued (Sushma & Sharang, 2005). Tobacco companies continued to sponsor sports and cultural events in spite of the prohibition. Provisions of “no selling or buying by minors” and “no selling of tobacco products within 100 yards of an educational institution” remained highly ineffective. According to Global Youth Tobacco Survey (GYTS) in 2006, 72 per cent minor were not refused while buying tobacco product purchase (Sinha, Gupta, & Mukhopadhyay, 2008). Apart from this, tobacco industry had been successfully able to dilute and postpone the enforcement of enhanced pictorial warnings.
NTCP had been conceived in-line with the provisions under COTPA to make the tobacco control strategies more effective. NTCP was first launched in 21 states and 42 districts for Phase I; however for the second phase in 2013, it had been expanded to 53 districts and 29 states. Reviews suggest that despite inadequacies in the implication of certain areas of the programme, it has been broadly able to serve as an important platform for enforcing provisions of tobacco control strategies successfully. The GATS, to understand the prevalence of tobacco use among adults, was first time successfully undertaken in 2010. Since 2008, nationwide anti-tobacco campaigns were launched with strong anti-tobacco messages directed specifically towards products used in the country. These campaigns were filed tested and translated into 18 languages. Under this programme, there have been initiatives directed by Ministry of Health and Tobacco Board of India to understand the feasibility of rehabilitating millions of tobacco sellers, growers, retailers, farm workers and bidi workers towards alternative livelihoods. Projects were also taken up to find economically viable alternative crops in place of various varieties of tobacco crops, to reduce the area under tobacco cultivation, as mandated by the WHO FCTC treaty. Since the conception NTCP, there also has been a noticeable rise in prices of various tobacco products across India. Many states increased VAT substantially, and there has also been an effort to bring bidi and paan-masala under its purview.
However, tobacco taxation in India is a particularly complex issue given the Indian tobacco market is flooded with abundant tobacco products in smoking as well as smokeless forms (Sinha et al., 2012). Tobacco taxation in India also has been subjected to corporate influences, lobbying, and exemptions in some cases. Also, such a tax system is discriminatory as it covers only some extent of organized sector and it can also be termed unfair to the poor. In spite of the recent rise in taxes, the current tax structure allows easy access of cheaper cigarettes, bidi and other inexpensive non-cigarette products due to much lower, disproportionate or negligible tax (Jhanjee, 2011). Total tax burden, including excise tax and VAT, was found to be only 20 per cent of retail prices in case of bidi and 59 per cent in case of cigarettes in 2013. Also in case of cigarette, excise alone was only 36.8 per cent, much below than recommended 70 per cent by the WHO, and in case of bidi, it was only 5.3 per cent. VAT also varied across states as low as 31 per cent and 39 per cent in Punjab and Haryana, respectively, to 81 per cent in Rajasthan (Institute for Studies in Industrial Development and Public Health Foundation of India, 2014).
Apart from the tax, one of the major drawbacks of tobacco control programme remains: the Enforcement of the ban on sale of tobacco products to minors and its sale within 100 yards of educational institution remains mostly ineffective and hardly any states (only 8) have taken actions for violating this provision. Enforcement of smoke-free rules and fine collection for violating such rules has been limited to very few states. Although out of 21 states, 16 (76%) could establish mechanisms for enforcement of smoke-free rules, but only 10 (47.6%) states were successful in collecting fines for violations. Also, it is a fact that only four states (19%) had collected fines for violating pictorial health warnings (Kaur, 2012). Another issue with the implementation of the programme is that even though the centre has the power to enact laws, again such obligations are mostly left with state government’s priority on public health which has brought in certain laxity in the situation. The states have failed to effectively utilize the dedicated funds provided for tobacco control activities under NTCP in a proper phased manner. Non-recruitment of staff by almost half of the states has resulted in delay and non-implementation of various components of the programme. West Bengal, Maharashtra and Jharkhand failed to make progress regarding recruitment of any staff until the last year of the 11th Five Year Plan, which caused tobacco control activities under NTCP to suffer a major setback in these three states. States are also sluggish in the timely submission of progress reports hindering effective monitoring (Kaur & Jain, 2011).
Almost no progress on the establishment of tobacco testing labs in the country hinders, regulation of contents and emissions of a large number of tobacco products marketed in the country. Also, tobacco cessation facilities have not progressed very much. Although 29 out of 42 districts have such facilities available at the district hospitals under the programme, unfortunately such clinical settings are too few with a fewer trained professional. Availability and affordability of medication required for cessation is also a severe constraint. The fact that the tobacco problem in India is quite complex due to the varied nature of tobacco use, cessation in Indian settings needs a multi-sectoral approach. It must include preventive, curative and rehabilitative care. This limited number of tobacco cessation centres coupled with no establishment of tobacco testing labs in the country has dampened the spirit of progress of the tobacco control programme (Kaur & Jain, 2011).
In the context of these failures, it is important to ponder regarding the existence of the fundamental and irreconcilable conflict of interests between the tobacco industry and public health policy. Interference by the tobacco industry continues to be one of the primary deterrents to the implementation of tobacco control policies. Globally, the tactics used by the tobacco industry includes conducting public relations campaigns, buying scientific and other expertise to create controversy about established facts, funding political parties, hiring lobbyists to influence policy, using front groups and allied industries to oppose tobacco control measures, pre-empting strong legislation by pressing for the adoption of voluntary codes or weaker laws, and corrupting public officials (Saloojee & Dagil, 2000). In India, the industry constantly manoeuvres to hijack the political and legislative processes (Oswal, Pednekar, & Gupta, 2010). Getting access to government officials, funding political campaigns, intervene with every proposed legislation aimed at tobacco control and negotiating participation in forums during policy-making processes are some commonly used strategies. One of the main reasons behind the lack of effective enactment of COTPA could be attributed to long-drawn litigations government’s embroilment with the tobacco industry and industry interference at the policy level (Kaur, 2012).
The major issue with tobacco legislation in India is the intertwining links between tobacco companies, government and leading political parties. The government has a direct shareholding in leading tobacco companies, and the Indian Tobacco Board (ITB) sponsors various welfare schemes, subsidies and loans for tobacco growers and sets minimum support price for its sales. Also, leading politicians and members have represented tobacco companies in the Supreme Court and some of them even have direct stakes in the tobacco industry. All of these direct and indirect linkages with tobacco companies and growers lead to the conflict of interest in terms of implementing anti-tobacco policies (Bhojani, Venkataraman, & Mangnawar, 2011). Apart from these, tobacco companies every time vehemently opposed enhancement and implementation of stronger graphical warnings. After enactment of COTPA, the depiction of pictorial warning (skull and bone) took three years of legal battle to enforce those provisions due to multiple litigations filed by the tobacco industry. In fact, in September 2007, a spokesman for the All India Bidi Federation, which represented the large bidi manufacturers, told the magazine, Economic Times, “the skull and bones” warning is typically a sign of poison and the government should not equate tobacco products with poison. The implementation of new graphic warnings in 2009 was not only delayed but also weakened the warning requirement as advised by FCTC due to the lobbying of the tobacco industry (Arora & Yadav, 2010; Sankaran, Hiilamo, & Glantz, 2014). The recent enhancement of pictorial warning to 85 per cent was also met with several protests by major tobacco companies. The implementation of new graphic warnings was successfully delayed and was much weakened than the warning requirement as advised by FCTC due to the lobbying of the tobacco industry. Although the enhancement of the warning size was notified in 2014 to be implemented in the first of April of 2015, the government delayed implementation for a year. A prominent BJP Lok Sabha member who directly owns a bidi company strongly protested against the increase in the size of pictorial warnings and stated: “Bidi doesn’t cause cancer”.
Another common tactic played by the tobacco industry is exaggerating the economic significance of itself (Peruga, 2013). Apart from this, manipulating public opinion to gain the appearance of respectability through CSR initiatives is another common alternative strategy adopted by the tobacco companies. There are many instances where funds are invested in anti-smoking campaigns for the youth, disaster relief, educational, health and developmental programmes to improve its image and infiltrate into sectors such as agriculture and education (Kyaing, 2013). Bhojani et al. (2011) rightly point out that the government needs to resolve the inherent conflict of interest by abolishing the pro-tobacco mandate of the ITB. There is an imminent need to regulate government dealings with the tobacco industry.
Concluding Remarks and Way Forward
Some of the measures to curb tobacco use have proven to be effective such as taxation and media awareness of health risks associated with tobacco. TISS, Mumbai, and Ministry, of Health and Family Welfare (2016) reports falling in the percentage of tobacco use among adults from 34.6 per cent in 2010 to 28.6 per cent in 2016. However, still the implementation and dissemination of laws and policies have not been even and adequate. Hence, a way forward to a successful regime for the prohibition of tobacco use in India would first and foremost require strengthening the provisions under the existing legislations for better implementation, which in turn hinges on policies to regulate government dealings with the tobacco industry. This also entails an imminent need to bring in a stable and consistent tax system with accordance to the consumption pattern, which would be uniform and non-discriminatory and the taxes collected should be used to support health promotion and tobacco control programmes. Tobacco problem in India is particularly complex given the consumption of a myriad variety of tobacco products both smoking and smokeless and because of socio-cultural diversity. Hence, there is a need for health campaigns for awareness to be well focused and able to reach out to different segments of the population.
Apart from the demand side aspects, one needs to consider the supply side as well given the fact that in our country, millions of people are involved in the production, manufacture and distribution of tobacco and its product. Although the government has taken several policies and legislative steps in this direction, few studies claim that such efforts have done very little to improve the working conditions or livelihood of people associated with this industry (Sinha & Ramakrishnan, 2012). Hence, in this regard, periodically reviewing the feasibility and efficacy of such initiatives to rehabilitate workers and farmers associated with the tobacco industry remains vital.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.