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COMMENTARY
Year : 2018  |  Volume : 62  |  Issue : 1  |  Page : 55-57  

War against tobacco: Where do we stand?


1 Professor, Department of Community Medicine, IQ City Medical College, Durgapur, India
2 Assistant Professor, Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India

Date of Web Publication6-Mar-2018

Correspondence Address:
Prof. Indranil Saha
P-19, Jadavpur University Employees’ Housing Co.-operative Society Ltd. P.O.: Panchasayar, Kolkata - 700. 094, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_166_17

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   Abstract 


India has launched war against tobacco epidemic for the past few decades but with partial success; hence, challenges are still there which need to be identified and addressed for winning the battle. Targeted approach directed at motivating smoking cessation of female smokers, frequent changing of pictorial warnings depicting variety of health consequences in cigarette packets and devoid of logos and colors in conjunction with plain packaging, and display of toll-free number for quitting are expected to dissuade tobacco consumers to quit and save themselves from the devastating health, social, environmental, and economic consequences of tobacco consumption. Online reporting system for violating legal enforcements can also be implemented easily. Moreover, guidance from success stories of countries/states who have achieved smoke-free status along with concerted efforts such as innovative anti-tobacco campaigns, involvement of religious leaders in anti-tobacco propaganda, strict legislations, and overall strong political commitment would further aid in winning the war.

Keywords: Cigarettes and Other Tobacco Products Act, smoking/prevention and control, tobacco, tobacco products


How to cite this article:
Saha I, Paul B. War against tobacco: Where do we stand?. Indian J Public Health 2018;62:55-7

How to cite this URL:
Saha I, Paul B. War against tobacco: Where do we stand?. Indian J Public Health [serial online] 2018 [cited 2020 Sep 29];62:55-7. Available from: http://www.ijph.in/text.asp?2018/62/1/55/226614




   Introduction Top


Tobacco kills half of its users, with smoking and smokeless tobacco killing nearly 6 million people worldwide. Every 6 s in each year, one death is said to be reported, according to the World Health Organization (WHO).[1] Cigarette smoke contains over 4,800 chemicals, out of which 69 are regarded as carcinogenic. Apart from cancers, smoking is also a major risk factor of coronary heart disease, chronic bronchitis, stroke and other conditions such as delayed healing of wounds, peptic ulcer disease, and infertility.[2]

Although India has witnessed an overall decline in the number of tobacco users in the past 7 years, i.e., around 81 lakhs in recently released Global Adult Tobacco Survey (GATS-2) 2016–2017 report,[3] still the country is the second largest consumer of tobacco products worldwide with more than 275 million adults consuming a wide variety of tobacco products.[4] The prevalence of tobacco use has decreased by 6% from 34.6% in GATS-1 in 2009–2010 to 28.6% in GATS-2 with about 33% relative reduction among the younger population aged 15–24 years. GATS-2 report also reveals encouraging facts of augmented awareness level about ill-effects of tobacco consumption among adults motivated by the warnings displayed on tobacco products, i.e., 61.9%, 53.8%, and 46.2% had thought of quitting cigarettes, bidi, and smokeless tobacco, respectively.[3] Nevertheless, our country is yet to reach the target of “relative reduction in prevalence of current tobacco use by 15% by 2020 and 30% by 2025” as envisaged in the National Health Policy, 2017.[3] With this background, this paper attempts to identify the successful interventions of the past and the remaining challenges ahead needed to win the war against tobacco in our country.


   Various Measures Leading to Reduction of Tobacco Use Top


The remarkable achievement of reduction in current tobacco use prevalence as identified in GATS-2 can be attributed to several interventions in the past decade. Elevated pricing and tax measures to reduce tobacco demand are examples of such successful interventions. Increase in taxation in 2011 had led to reduction in self-reported tobacco sales and consumption at the short-term endpoint, as reflected in GATS-2 report.[5],[6] Environmental protection from tobacco smoke has also been possible due to “the Prohibition of Smoking in Public Places Rules, 2008.”[1],[5] Packaging regulations under the Legal Metrology Act, 2015, has prohibited sale of tobacco products in loose. Restrictions regarding tobacco advertising, promotion, and sponsorship along with demand reduction measures, for example, education, communication, training, and public awareness through mass media, school, and community-based programs together have produced additive effect in the war.[1],[5],[7] India has a comprehensive tobacco control act, “The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act (COTPA 2003),” in place.[8] However, the failure of the act to prevent tobacco sale to minors has been addressed by implementation of Juvenile Justice Act, 2015, with the help of which India has become the only nation in the entire world to impose harsh penalty for selling of/by tobacco to minors.[8],[9] Prohibition of tobacco sale within 100 yards of any educational institute has also been brought into force. Ministry of Health and Family Welfare (MOHFW), in partnership with the WHO and the International Telecommunication Union (ITU), has started another innovative initiative by utilizing mobile technology for tobacco cessation. The WHO-ITU’s “Be Healthy Be Mobile” initiative aims to reach out to tobacco users of all categories who want to quit tobacco use and support them toward successful quitting through constant text messaging on mobile phones. The initiative is fully supported by the Government of India (GOI). GOI had also introduced toll-free number (1800 11 2356/011-22901701) to help for quitting tobacco and helpline 1800-110-456 for reporting of any COPTA violations.[10]


   Challenges Ahead Top


Despite all these herculean efforts directed at winning the war against tobacco, multiple challenges still lay ahead which if successfully addressed will help in winning the rest of the battle. Previous studies have indicated that very few young people from backward community like tribal villages could interpret the warnings as intended.[6] Targeted approach directed at motivating smoking cessation of female smokers is yet to be implemented in our country, for example, specific pictorial health warnings depicting health outcome of smoking on women’s health, for example, adverse pregnancy outcome, conception delay, and infertility.[11] Still, a sizable proportion of shops continue to sell tobacco postrestrictions as usual.[5],[6],[12] After banning advertisement of tobacco at point-of-sale, the only option now available from manufacturer side in India is “on-pack” advertising through attractive imagery such as colors, logos, and brand names which is evidenced from the current packet covers available.[5],[7] COTPA 2003 restricts smoking in public places with exemptions at parking spaces, open market places, parks, roads, private homes, hotels with 30 rooms or more, restaurants or pubs with seating capacity for 30 or more persons, and at airports in designated specified smoking rooms.[13] Subsequently, 2004 and 2008 rules tightened the criteria for providing smoking areas.[14] Nevertheless, achievement of 100% smoke-free status is only possible through blanket ban of smoking at all places which would also prevent the perils of secondhand smoke for nonsmokers in future. This target of making our country smoke free is very much achievable as evidenced by smoke-free status of Chandigarh and Chennai. Chandigarh utilized wider legislation to plug gaps in smoke-free laws[14] while Chennai experience has demonstrated success of government and nongovernment organization coordination coupled with sustained compliance monitoring.[15] Thus, creating smoke-free buildings and public places will eventually lead toward smoke-free homes, smoke-free villages, and even smoke-free generations in future.[16]


   Display of Health Warnings Top


As directed in COTPA, health warning has to be displayed mandatorily in the cigarette packet to reduce its attractiveness where the graphic picture and text warning would cover 60% and 25% of the package, respectively. In compliance with this, MOHFW of India has implemented introduction of new graphic health warnings covering 85% of the principal display area on all tobacco product packages on both sides from April 1, 2016.[9] Studies indicate that the impact of health warning on an individual’s mindset depends on the picture size and design, i.e., obscure text-only warnings appear to have little impact whereas pictorial health warnings that elicit strong emotional reactions are significantly more effective.[17] According to the Canadian Cancer Society report regarding size of their health warnings, India was ranked 3rd in 2016 after Nepal and Vanuatu, with several countries implementing stronger warnings. Other Asian countries are also at par in this regard, with warnings covering 85% of the package on both sides in Thailand, 80% in Sri Lanka, and 90% in Nepal.[18] However, recent strategic change in this regard is promotion of plain packaging (also known as standardized/generic packaging) to further reduce its attractiveness and thus restricting use of tobacco packaging as a form of advertisement and promotion as well as limiting misleading packaging and labeling. On May 31, 2016, the slogan for World No Tobacco Day was “Get ready for plain packaging.” Australia became the first country to fully implement plain packaging in December 2012. Later on, Ireland, Britain, Northern Ireland, and France passed laws to implement plain packaging. Similarly, a number of countries are in advanced stages of considering adoption of plain-packaging laws,[19] but standpoint of our country in this issue has not come into light yet. Setting up flying squads for monitoring legal enforcement, inclusion of anti-tobacco educational materials in the school curriculum, raising awareness of civil society to report violations, and user friendly online reporting system are urgently needed.[12] Tobacco counseling centers should be expanded in the rural areas so that it becomes more accessible and acceptable for the users to quit tobacco. Tobacco control measures as per the Framework Convention on Tobacco Control (FCTC) guidelines and innovative measures beyond FCTC are needed to be implemented and introduced in our country to end the tobacco epidemic.


   Display of Second Image of Health Warning Top


As per notification issued by MOHFW, GOI dated March 24, 2017; all tobacco products manufactured on or after April 1, 2017, shall display the second image of specified health warning in the packs, and violation of this is a punishable offence with imprisonment or fine as prescribed in Section 20 of COTPA 2003.[20] This is another welcome move, but the authors believe that 12-month rotation period for only depicting pictures of throat and neck cancer is too long and grossly inadequate. There should be more variations in the picture encompassing all the possible serious life-threatening complications beyond throat and neck cancer including graphic warnings specific for female smokers. Moreover, the pictorial warnings as well as the text messages need to be changed time to time and more frequently in all types of tobacco products; otherwise, it will not serve its own purpose to create a negative impact about tobacco consumption within the user’s mind. Printing the toll-free number for quitting in the packages in noticeable size and color will also be excellent.


   Evidences from Other Countries Top


Experiences and evidences from countries which have achieved or in line to achieve smoke-free status would be another step ahead to win the battle against tobacco epidemic. Strong political commitment, strict legislations, and most uniquely significant influence of religious leaders in anti-tobacco propaganda mark the success story of Bhutan.[21] Finland’s plan to be tobacco free includes making the country smoker free by imposing ban on even milder products such as e-cigarettes and snuff, increasing the product price and cost for the vendors selling the products enormously, not allowing residents to smoke in private cars in the presence of minors aged 15 years or less and other stringent enforcements.[22]

Till date, 28 countries have comprehensive policy ban, i.e. ban on smoking in all (no designated smoking rooms allowed) enclosed public places and workplaces, including bars, restaurants, and public transportation policies in place with California taking the lead in this regard in 1998.[23]


   Conclusion Top


Tobacco control is relatively inexpensive to implement, and the return is enormous. On a final note, the authors reiterate that war against tobacco is a winnable battle in our country provided; there is a concerted effort on the part of every citizen to achieve 100% smoke-free environment, innovative anti-tobacco campaigns, involvement of religious leaders in anti-tobacco propaganda, strict legislations, and overall strong political commitment. By continuing to make tobacco control a top priority, we can build on our successes and create a tobacco-free country.



 
   References Top

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WHO Smoke-free City Case Study. Towards Breathing Clean Air in Chennai a Smoke-free City Case Study. Geneva: World Health Organization; 2011. Available from: http://www.who.int/kobe_centre/interventions/smoke_free/chennai_web_final.pdf. [Last accessed on 2017 Oct 03].  Back to cited text no. 15
    
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Senthilingam M. What Finland’s Plan to be Tobacco-free can teach the World; 26 January, 2017. Available from: http://www.edition.cnn.com/2017/01/26/health/finland-tobacco-free-plan/index.html. [Last accessed on 2017 Oct 03].  Back to cited text no. 22
    
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