tobacco products bill 2001: an aid to public...
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THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 14, No.3, 2001 131
improve economic performance." Similarly, reliable, independent and transparentdata on mortality is likely to be a powerful twenty-first century information tool toimprove health in countries with a low income. Independence is the key, given thatthere may be incentives for users of data, such as officials of disease controlprogrammes, to over- or under-report the disease of their own interest (for example,until recently, the World Health Organization had three substantially differentestimates of global malaria mortality, with the malaria programme estimates beinghigher than that from other departments). Transparency and access to reliable databy civil society, non-governmental organizations, and researchers can often spurgovernments into public health action.
REFERENCESCaselli G. Health transition and cause-specific mortality. In: Schofield R, Reher D. Bideau A (eds). The decline ofmortality in Europe. Oxford:Clarendon Press, 1991.
2 World Health Organization. Investing in health research and development. Report of the ad hoc committee on healthresearch relating to future intervention options. Document TDRlGen/96.1, 1996.
3 BanthiaJ, Dyson T. Smallpox in 19th century India. Popul Dev Rev 1999;24:649-80.4 Asma S, Jha P. Counting the dead in India in the 21st century: Proceedings of the International Workshop on
Certification on Causes of Death, Mumbai, February 1999. US Centers for Disease Control, 1999.5 Registrar General. Compendium ofIndia's fertility and mortality indicators, 1971-1997. http://www.censusindia.net/
newreldec1999.pdf1999.6 Ruzicka L, Lopez AD. The use of COD statistics for health situation assessment: National and international
experiences. World Health Stat Q 1990;43:249-57.7 Gajalakshmi V, Peto R. Tobacco epidemiology in the state of Tamil Nadu, India. Asian Pacific J Cancer Prev 2000;1
(Suppl):44-<i.8 Gupta PC, Mehta He. Cohort study of all-cause mortality among tobacco users in Mumbai, India Bull World Health
Organ2000;78:877-83.9 Liu BQ, Peto R, Chen ZM, Wang JL, Wang GH, He XZ, et al. Emerging tobacco hazards in China: I. Retrospective
proportional mortality study ofone million deaths. BMJ 1998;317: 1411-22.10 Murray C, Lopez A (eds). The global burden of disease: A comprehensive assessment of mortality and disability
from diseases, injuries, and riskfactors in 1990 and projected to 2020. Cambridge, Massachusetts:Harvard Schoolof Public Health, 1996.
11 Gupta PC, Sankaranarayanan R, Ferlay J. Cancer deaths in India: Is the model-based approach valid? Bull WorldHealth Organ 1994;72:943-4.
12 Dye C, Scheele S, Dolin P, Pathania V, Raviglione MC. Consensus statement. Global burden of tuberculosis:Estimated incidence, prevalence and mortality by country. WHO Global Surveillance and Monitoring Project. JAMA1999;282:677-86.
13 Anonymous. Schools brief: Monopoly power over money. The Economist, 4 Dee 1999.
PRABHATJHA
Senior Health SpecialistWorld Bank
Washington D.C.USA
Tobacco Products Bill 2001:An aid to public health
Smoking causes diseases that could lead to death. The scientific evidence is sooverwhelming that after disputing it for several decades, cigarette companies are nowforced to acknowledge it. To quote from the website of British American Tobacco,'of which the India Tobacco Company (ITC) is a subsidiary: ' ... with ... cigarettesmoking come real risks of serious diseases such as lung cancer, respiratory diseaseand heart disease ... also, for many people, it is difficult to quit smoking.' Similarstatements can be found on the websites of other major cigarette companies.
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Despite having considerable knowledge about various health risks from tobacco,most smokers continue to smoke. Most smokers also confess that they want to stopsmoking, but are unable to do so. Many have tried and succeeded, but only for a shortwhile. This is due to the nicotine in tobacco, which is one of the most addictivesubstances known to mankind.' Nicotine is absorbed into the human body bysmoking (mostly through the lungs) and smokeless use (through the oral mucosa).The only real reason for the use of tobacco by a habituated individual is the ingestionof nicotine.
The use of tobacco imposes major health consequences. Globally, an estimated4 million deaths are caused by tobacco every year-3 million in the industrializedcountries and 1 million in the developing world. There is a lag period of severaldecades between the initiation of tobacco use and the appearance of health effects.Therefore, the current mortality is the result of the use of tobacco several decadesearlier. On the basis of the current use of tobacco, it is projected that by 2030, some10 million deaths every year will be caused by tobacco, about 4 million in theindustrialized and 6 million in developing countries. While most industrializedcountries have made major strides in their tobacco control efforts, in many developingcountries the use of tobacco is still increasing. These statistics emphasize the needto place tobacco control high on the public health agendas of developing countries?
Controlling, containing and reducing the use of tobacco in the population areextremely important, high-priority strategies for improving public health. TheTobacco Control Bill proposed by the Government of India, therefore, ought to beseen in this context. Will the measures proposed therein help in reducing the use oftobacco? The salient features of the Bill are:
1. Prohibit the advertisement of all tobacco products;2. Prohibit smoking in public places;3. Prohibit the selling of tobacco products to persons below 18 years of age;4. Indicate nicotine and tar contents on the packets;5. Have warnings of adverse health effects on tobacco product packages in English
as well as in Indian languages; and6. Place a total ban on sponsoring of any sports/cultural events by cigarette and other
tobacco product companies.
Banning the advertisement of tobacco products has been identified as the mostimportant prerequisite for tobacco control. Although there are numerous studies toshow that this is effective in reducing tobacco consumption, a ban on tobaccoadvertisement is necessary even otherwise: a product that causes addiction, seriousdiseases and death ought not to be allowed to be associated with sexy, glamorous andmacho images. Such associations are meant only to mislead the public.
In 1975, Norway was the first country to impose a total ban on tobaccoadvertisement and a long term evaluation showed that the ban was effective inreducing consumption. None of the dire consequences of the ban forecast by tobaccocompanies materialized."
Sponsorship of sports and cultural events is simply a form of advertising for atargeted market segment. A study from India demonstrated that cricket sponsorshipby tobacco companies, by creating false associations between smoking and sports,increased the likelihood of children experimenting with tobacco.' Therefore, a banon sponsorship of such events is a necessary part of a ban on advertisement.
However, the proposed regulation allows surrogate advertising-advertising of abrand of tobacco products is permitted as long as it is associated with a non-tobaccoproduct or service. Tobacco companies are already preparing to exploit this loopholethrough surrogate advertisements, for example, on adventure gear and braveryawards. With the passage of the proposed Bill, such advertisements would increasefurther.
The issue of warning labels should be seen in the context of consumer information.Tobacco products are highly dangerous and every existing or potential consumerought to be adequately informed about the risks. The proposed labelling requirements
THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 14, NO.3, 2001 133
are an appropriate beginning, although several countries have moved far ahead. Forexample, Canada already requires coloured pictorial warnings depicting mouthcancer or diseased lungs." The disclosure of the correct tar and nicotine levels shouldalso be seen in this context even though it does little for tobacco control andsometimes may actually be harmful by providing false assurances.
A ban on smoking in public places is based on the premise of protecting non-smokers from tobacco smoke and is not just an annoyance or nuisance. There are datato demonstrate that involuntary exposure to tobacco smoke may cause lung cancerand heart diseases.' Children are most vulnerable as they are unable to voice anyobjection and suffer from many ill-effects-middle ear infection and exacerbation ofasthma attacks.' Tobacco companies have not yet accepted the fact that tobaccosmoke is harmful to non-smokers just as they did not accept that smoking washarmful for smokers. Public health policies, however, need to rely on science ratherthan acceptance by tobacco companies.
A ban on the sale of tobacco to children is an emotive and politically correct policywhich, as a public posture, is supported even by tobacco companies. In terms oftobacco control, it is one of the least effective policies and is rather difficult to enforce,especially in India. Even in countries where good enforcement has been possible, theeffectiveness has been low-most often, children can get whatever they want.
Unlike most countries where tobacco control is synonymous with cigarettecontrol, in India it implies controlling a wide range of smoking and smokelesstobacco products. Therefore, policies are needed to control the entire range of tobaccoproducts. In the Indian system, State and Central Governments have jurisdiction overdifferent areas. While the Central Government can make laws regarding the use ofcigarettes, state governments will need to adapt these laws for bidi and smokelesstobacco products. Some states have been more progressive. Goa enacted its tobaccocontrol legislation before the Central Government did much in the matter andPunjab, Uttar Pradesh and West Bengal have already accepted Parliament's authorityin this regard.
The most commonly used tobacco product in India is the bidi. It is necessary tocontrol bidi smoking because bidis are no different from cigarettes in terms of healthconsequences. Bidis have similar levels of tar and nicotine as cigarettes do. Bidis alsocause the same diseases as cigarettes with similar levels of risks." A recent study fromMumbai reports that the age-adjusted relative risk of overall mortality in a largecohort after a 5-year follow up was 1.78 among bidi smokers and 1.39 amongcigarette smokers, with a strong dose-response effect. 10
Smokeless tobacco is another highly popular form of tobacco use in India with ahigh prevalence among men as well as women." Smokeless tobacco use causes oralcancer as well as other oral mucosal and dental diseases." The overall mortality hasalso been reported to be significantly higher among smokeless tobacco userscompared to non-users of tobacco, the age-adjusted relative risk being 1.22 amongmen and 1.35 among women. 10
Commercially manufactured smokeless tobacco products are comparatively newitems in the country and have caused serious public health problems. These productsare heavily advertised and promoted by manufacturers resulting in a high degree ofuse, especially by youngsters. As a result, an epidemic of oral submucous fibrosis, adebilitating precancerous condition, has already spread in the country" and there isstrong evidence of an increasing incidence of oral cancer among young people."
Smokeless tobacco items are manufactured with the sole intention of putting andretaining them in the mouth. Since they satisfy all the criteria of being food items,they should be governed by the laws that apply to food items. Legally it is not possibleto manufacture and sell food products that cause cancer. The Rajasthan High Courthad ordered the Central Government several years ago to find out whether smokelesstobacco products were hazardous. The government entrusted the inquiry to itsCentral Committee on Food Safety and received a report that these products wereindeed hazardous. The government is thus duty bound to ban these products but ischoosing to proceed very slowly.
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The proposed Bill needs to be placed in both houses of Parliament and passedbefore it becomes a law. Hopefully, this will happen although there have beeninstances in the past when proposed tobacco control policies did not complete thelegal process. After becoming law, the proposed Bill would be seen as a newbeginning for tobacco control efforts and improvement of public health in India.
REFERENCESI Broughton M. What we believe. http://www.bat.comlbatlhomepage.nsflfsHPG_WWBfs!OpenFrameSet.2 US Department of Health and Human Services. The health consequences of smoking: Nicotine addiction. A Report
of the Surgeon General. Rockville:Office on Smoking and Health, 1988.Jha P. Curbing the epidemic: Governance and the economics of tobacco control. Washington D.C.:The WorldBank,1999.
4 Bjartveit K, Lund KE. The Norwegian ban on advertising of tobacco products-Has it worked? Oslo:NorwegianCancer Society, 1998.
5 Vaidya SG, Naik UD, Vaidya JS. Effect of sports sponsorship by tobacco companies on children's experimentationwith tobacco. BM] 1996;313:400.
6 Cunningham R. Canada: Warnings with colour pictures required. Tob ControI2000;9:359.7 US Department of Health and Human Services. Health effects of exposure to environmental tobacco smoke.
Smoking and Tobacco Control Monograph 10. Bethesda:National Institutes of Health, 1999.8 International Consultation on Environmental Tobacco Smoke (ETS) and Child Health. https/Ztobacco.who.int/en/
health/int-consult. html.9 Sanghvi LD, Notani P (eds). Tobacco and health-The Indian scene. Bombay: UICC- Tata Memorial Centre, 1989.
10 Gupta PC, Mehta He. A cohort study of all-cause mortality among tobacco users in Mumbai, India. Bull World HealthOrgan 2000;78:877-83.
II Gupta PC, Hamner JE, Murti PRo Control of tobacco-related cancers and other diseases. Proceedings of anInternational Symposium; 15-19 January 1990; Tala Institute of Fundamental Research. Bombay:Oxford UniversityPress, 1992.
12 US Department of Health and Human Services. Smokeless tobacco or health-An international perspective.Smoking and Tobacco Control Monograph 2. Bethesda:National Institutes of Health, 1992.
13 Gupta PC, Sinor PN, Bhonsle RB, Pawar VS, Mehta HC. Oral submucous fibrosis in India: A new epidemic? NatlMed] India 1998;11:113-16.
14 Gupta PC. Mouth cancerin India-A new epidemic?] Indian MedAssoc 1999;97:370-3.
PRAKASH C. GUPTA
Epidemiology Research UnitTata Institute of Fundamental Research
MumbaiMaharashtra
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