Will India keep its date with 85 per cent pictorial warnings on 1 April 2016?

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Lawyers insists on pictorial warnings on tobacco products

There is a groundswell of public opinion in favour of pictorial warning covering 85% of the packaging of cigarettes, bidis, chewable tobacco, etc. "We, the Lawyers-Against-Tobacco, urge you to show your golden heart and love for the nation by implementing 85% pictorial warning from 1st April 2016," says a letter written two days ago by Bar Association of Allahabad High Court to Prime Minister Narendra Modi.

"We felt very proud when your Government issued a notification 2 years back to make large pictorial warnings mandatory on every tobacco product. It was the need of the hour in a country where tobacco consumption starts at tender age of 10-12 years. Needless to say that effective pictorial warning will also deter uneducated people from picking up this habit..." says the letter, signed by Advocates Radha Kand Ojha and Ashok Kumar Singh, President and Hon. Secretary of the Bar Association, adding, "Considering the growing menace of tobacco which may ultimately affect our own kids, we have formed a coalition called Lawyers Against Tobacco."

The back story of this debate makes the blood boil with indignation. It is estimated that over 10 lakh Indians die of tobacco-related ailments every year, and the total health expenditure burden of tobacco use exceeds one lakh crore rupees, i.e. 12 per cent more than combined State and Central government expenditure on health (2011-12 statistics). The government's excise duty earning from tobacco barely covers a piffling 17 per cent of the health expenditure! But, ingoring this, the 15-member Parliamentary Committee on Subordinate Legislation, that included the bidi baron Shyama Charan Gupta, evidently feels that the tobacco industry deserves our sympathy and consideration. Just like last year, the introduction of pictorial warnings covering 85 per cent of the principal display area on both sides of all tobacco products hit a roadblock with the committee taking the position that increasing the size of the warning from the current 40 per cent on only one side of the packet to 85 per cent on both sides would be "too harsh" on the tobacco industry. It recommended a marginal increase to just 50 per cent.

Despite the overwhelming percentage of people consuming bidis and chewing tobacco, the committee is intent on diluting the warning on these products by restricting the warning to just one side of the bidi pack; only cigarettes will have the warning on both sides of the packet.

In a weak attempt to paint pictorial warnings as ineffectual, the committee has leaned heavily on the findings of a British American Tobacco company-sponsored study while overlooking a body of evidence gathered by independent researchers, which indicate that thanks to larger, graphic warnings, 58 per cent of smokers in Canada and nearly 54 per cent in Brazil and Thailand changed their opinion about the health consequences of smoking on seeing the warnings.

Source: Times of India

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Big pictorial warnings on tobacco products from 1 April

The government will go ahead with its decision to implement a rule requiring large pictorial warnings on tobacco products, said Amal Pushp, director (tobacco) in the ministry of health and family welfare (MoHFW).

He said that from 1 April, all tobacco products, including cigarettes, beedis and non-smoking tobacco, will have to contain pictorial warning covering 85% of the space on both sides of the packet.

“The ministry has issued a notification in February and we will continue with it,” said the official. Currently only 40% of the packet area is to be covered with pictorial warnings.

Implementation of the new rules came under doubt after a parliamentary committee recommended earlier this month that the size should be increased to only 50%. Even though the committee’s recommendations are not binding on the government, its timing led to uncertainty regarding implementation of new rules.

The ministry had approved new rules in October 2014, but could not implement them due to strong opposition from the tobacco lobby. It was only on 19 February this year that a notification was issued to tobacco manufacturers, distributors and retailers to notify health warnings “covering 85% of the principle display area.”

Doctors for Tobacco Control in India (DFTCI), an umbrella organization of groups advocating bigger pictorial warnings, wrote to health minister J.P. Nadda on 22 March, urging him to look into the matter after the parliamentary committee’s intervention.

“It is hugely disappointing to note that the Committee has repeatedly highlighted the ‘economic significance of tobacco’ in India, even in wake of recent evidence from a MoHFW report that treating tobacco related diseases costs India Rs.104,500 crore rupees, which amounts to a whopping 1.16% of India’s GDP (gross domestic product),” read the letter submitted by DFTCI.

Last week, many international organizations such as the American Cancer Society, the Nossal Institute of Global Health at the University of Melbourne, and World Health Federation, wrote to the health minister with similar requests.

 Source: Livemint

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Docs urge PM for new pictorial warnings on tobacco products

As many as 653 doctors and office-bearers of medical societies across the country have urged Prime Minister Narendra Modi to implement the new set of pictorial warning on tobacco product packages from April 1, to save millions of lives.

Doctors, cutting across specialties, in a letter, requested the Prime Minister to step in to prevent "powerful tobacco lobby" from subverting the anti-tobacco measures of the government.

"The country is 136th in the qualitative ranking of the pictorial warning on tobacco products. Large pictorial warning on tobacco packets is the most cost effective strategy to prevent youngsters from initiating use and provokes current users to quit the habit.

"We the doctors of India urge you to reject the recommendations of Committee on Subordinate Legislation (CoSL) that aims to promote tobacco industry rather than save innocent Indians from falling prey to this fatal addiction.

Effective pictorial warnings is all about awareness and it is being wrongfully equated with ban on tobacco," the letter said.

They quoted the Prime Minister's Facebook post on May 31, 2014, "Let's pledge to spread awareness on the risks of tobacco consumption & work to reduce tobacco consumption in India. Tobacco not only affects those consuming it but also people around. By saying no to tobacco, let us lay the foundation of a healthier India."

Dilip Acharya, Chairman of National Cancer Control Committee of Indian Medical Association, said, "In a country where vast majority of users are less literate, effective pictorial warning carries tremendous value.

"It is disheartening to note that the Parliamentary Committee has recommended a reduction in the size of the pictorial health warnings, especially since tobacco is linked to several debilitating and terminal diseases. Large and graphic health warnings, when repeatedly seen by children, will raise awareness about its effects," Acharya said.

Pankaj Chaturvedi, Professor and Surgeon at Tata Memorial Hospital, who has also signed the petition, said, "The FB message of Modi ji shows his personal commitment for this important public health issue. Plethora of medical evidence has proven beyond doubt that tobacco is the only consumer product that has no good use except causing disease, disability and death. We are very hopeful that he will do the best for the health of the nation."

"We now look to the Health Minister to continue his crusade against tobacco and implement the 85 per cent pictorial health warnings on both sides of tobacco packages on April 1, as planned, to save the Indian youth and children from tobacco initiation and addiction," Harit Chaturvedi Chairman, Max Institute Of Oncology and Director, Surgical Oncology at Max Healthcare.

Source: The Tribune

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Large Tobacco Pack Warnings Save Lives

Media statement by Dr Henk Bekedam, WHO Representative to India

23 March 2016

The current debate on reducing size of pack warnings, especially on bidis and smokeless tobacco is worrisome, especially because large and prominent health warnings have shown to be a cost-effective means of increasing public awareness of the health effects of tobacco use and in reducing tobacco consumption.

Tobacco use is a major risk factor contributing to a number of chronic diseases, including cancer, lung diseases, and cardiovascular diseases; it seriously affects the human and fiscal health of the country. In India, nearly a million deaths occur annually due to tobacco and the economic burden attributable every year to tobacco-related diseases is a staggering INR 104 500 crores.

India implemented Article 11 of WHO Framework Convention on Tobacco Control (FCTC) a few years back, but is still not FCTC compliant for this provision as the tobacco pack warnings occupy only 40% of the principal display area only on one side of the pack i.e. 20% of the total display area of the pack.

India is ranked 136 of 198 countries according to the international status report on Cigarette Package Health Warnings, 2014 and countries ranked after 143 do not display pictorial health warnings at all.

Any reduction in size of pack warnings will be a great setback for public health in the Region, as neighboring countries, including Nepal (90%), Thailand (85%), Pakistan (85%), Sri Lanka (80%) and most recently Myanmar (75%) have overcome similar challenges and notified large pictorial warnings.

As per the Global Adult Tobacco Survey-India (GATS 2010) covering the age group 15 years and above, 71% of cigarette smokers noticed health warnings on cigarette packages and 38% thought of quitting because of the warning label; 62% of bidi smokers noticed health warnings on bidi package and 29% thought of quitting because of the warning label, and 63% of users of smokeless tobacco noticed health warnings on smokeless tobacco product package and 34% thought of quitting because of the warning label.

This demonstrates the key role of health warnings as a preventive and public health promotive measure.

Prominent pack warnings also assist in reducing illicit trade and improve tax administration because these products are easy to distinguish from those which do not conform.

On 15 October 2014, the government issued a notification making it mandatory for tobacco companies to display graphic health warning occupying 85% of the principal display area of all tobacco packs. The gazette notification amending Cigarettes and Other Tobacco Products (Packaging and Labelling) Rules, 2008, which was to come into effect from 1 April 2015, is now scheduled to come into force on 1 April 2016.

This implementation will uphold the proud announcement made by the country at Moscow in 2014, during the sixth session of the Conference of the Parties (COP6) to the WHO Framework Convention on Tobacco Control (FCTC).

Along with large graphic pack warning, tobacco taxation is a recognized cost-effective and evidence-based population level strategy to reduce tobacco use. Both these measures are easy to implement, with no cost to the government.

In India, the most commonly used tobacco products are smokeless tobacco and bidis. These forms of tobacco are poorly taxed and therefore remain available at very cheap prices, making them very affordable and accessible.

Tobacco taxation as a fiscal policy is a ‘win-win’ situation. It not only increases revenue generation, it also reduces the consumption of tobacco, especially for the young and poor.

Today, as India stands on the threshold of hosting the seventh session of the Conference of the Parties (COP7) in November 2016, implementation of the 85% pictorial health warnings on both sides of all tobacco packs and the development of a comprehensive tax policy for tobacco products will uphold India’s position as a global leader in health and save precious lives.

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Let larger pictorial warnings stay

Nearly one million tobacco-related deaths take place in India every year, and in 2011, the total health expenditure burden from all diseases due to tobacco use amounted to more than Rs.1,00,000 crore, which is 12 per cent more than the combined State and Central government expenditure on health in 2011-12. The revenue earned through tobacco excise duty during the same period was a paltry 17 per cent of the health burden of tobacco. Yet, the 15-member Parliamentary Committee on Subordinate Legislation, that included the bidi baron Shyama Charan Gupta, has brazenly let commercial interests override public health concerns.

Just like last year, the introduction of pictorial warnings covering 85 per cent of the principal display area on both sides of all tobacco products hit a roadblock with the committee throwing a spanner in the works. It has said that increasing the size of the warning from the current 40 per cent on only one side of the packet to 85 per cent on both sides would be “too harsh” on the tobacco industry. It has instead recommended increasing the size to just 50 per cent.

Cigarette smokers a minority

According to the Global Youth Tobacco Survey, in 2009, of the nearly 15 per cent of children in India in the 13-15 age group who used some form of tobacco, only 4.5 per cent smoked cigarettes; 12.5 per cent used other forms of tobacco such as bidis and chewing tobacco. Similarly, in the case of adults in India, of the nearly 35 per cent tobacco users in 2009-2010, only 5.7 per cent smoked cigarettes, while bidi and chewing tobacco users were 9.2 per cent and nearly 26 per cent, respectively.

Despite the overwhelming percentage of people consuming bidis and chewing tobacco, the committee is intent on diluting the warning on these products by restricting the warning to just one side of the bidi pack; only cigarettes will have the warning on both sides of the packet. This goes against the grain of introducing larger pictorial warnings. Besides being unaware of all the risks associated with tobacco use, a vast majority of consumers in India of bidi and chewing tobacco are poor and less exposed to awareness campaigns. Larger images on both sides of the packet are the most effective and powerful way to communicate health risks to this population, provoke a greater emotional response, decrease tobacco consumption and increase motivation to quit.

India is ranked 136 among 198 countries in terms of prominence of pictorial health warnings on tobacco packaging. At 30 per cent, the only other country on the list with a smaller warning than India is Cayman Islands. Despite having relatively lower tobacco use than India, countries like Thailand (85 per cent front and back), Australia (75 per cent front and 90 per cent back), Uruguay (80 per cent front and back), Brunei (75 per cent front and back), Canada (75 per cent front and back), and Nepal (90 per cent front and back) have large-sized warnings.

A case of absurd arguments

In a weak attempt to paint pictorial warnings as ineffectual, the committee has leaned heavily on the findings of a British American Tobacco company-sponsored study while overlooking a body of evidence gathered by independent researchers. For instance, studies indicate that thanks to larger, graphic warnings, 58 per cent of smokers in Canada and nearly 54 per cent in Brazil and Thailand changed their opinion about the health consequences of smoking on seeing the warnings.

The committee’s naivety again stands exposed when it attempts to justify the reduction in pictorial warning size by arguing that tobacco consumption in India has increased and not declined after pictorial warnings were introduced in 2009. Tobacco companies too claim that there is no evidence whatsoever to suggest that large, graphic health warnings reduce consumption. If these are indeed true, why is the committee afraid that the proposed health warnings would have the “potential to severely affect” farmers and tobacco companies? The pictorial warnings clearly cannot cut both ways.

The committee’s claim that pictorial warnings would encourage illicit trade is at best hollow. According to a 2015 paper in the journal Tobacco Control, a national cross-sectional survey undertaken in Australia after plain packaging was introduced found “no increase” in the use of illicit unbranded tobacco, contraband cigarettes or purchase from informal sellers. If plain packaging does not lead to increased illicit sales, there is no reason to believe that pictorial warnings would. Needless to say, sale of illicit tobacco products is more likely to be linked to cost of tobacco products than larger pictorial warnings.

Curbing illicit sales of tobacco products, if they really exist, should be a high priority for the government and the companies; there are several well-proven methods that India can adopt to fight this menace. For instance, Brazil and California use a digital tax stamp using invisible ink to keep illicit trade under check, while the European Union uses barcodes and Malaysia uses a security mark with a visible and an invisible feature.

While a comprehensive approach that includes education and awareness generation should be adopted, there is no evidence to back the committee’s claim that education and awareness generation are “more effective” than other methods. California spent millions of dollars to attain the level of awareness that Canada achieved through pictorial warnings at little or no cost to the government, notes a May 2010 study in Tobacco Control.

Unlike other measures, excise duty hike and bigger, graphic pictorial warnings are easy to enforce and have the highest impact on tobacco consumption. Considering the huge public health benefits, it is imperative that the Health Ministry ignore the recommendations of the committee and enforce pictorial warnings that cover 85 per cent of the principal display area on both sides of all tobacco products from April 1. Any dilution in the size of warning would entail a delay of several months and cost thousands of lives. The country can ill afford it.

Source: The Hindu

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Oral mucosal lesions highly present among Kerala migrant workers

Oral mucosal lesions are highly prevalent in the users of chewing tobacco among migrant workers in Kerala, a study revealed.

Oral mucosal lesions (OML) were seen in 36.3 percent of the participants and among chewing or smokeless tobacco users, 44.6 percent had lesions.

The study led by O.P. Aslesh from the Academy of Medical Sciences, Kannur began in 2013. It was carried out among male migrant workers, most of them under 30 years of age working in factories in parts of Kannur district. 

The study showed that the prevalence of use of chewing tobacco product was 71.7 percent among the male migrant workers in the area, which was over five times more than among all the entire male population of Kerala as shown in the global adult tobacco use survey in 2010.

The sale of chewing tobacco has been banned in the state since May 2012. However, the study revealed that in spite of the ban, the use was high among male migrants.

Oral mucosal lesions like leukoplakia, erythroplakia and sub-mucous fibrosis are considered as precancerous lesions associated with the use of tobacco. This known fact has again been found true in the study.

According to the Kerala government's estimates, there are around 2.5 million migrant workers mostly from North Indian states, West Bengal and the northeast.

Aslesh's team found out that the prevalence of current use of smoked tobacco, chewing tobacco and alcohol use were respectively41.8 percent, 71.7 percent and 56.6 percent among migrants.

Oral cancer is the second most common cancer among males in India and the main cause attributed to this is the use of chewing tobacco besides alcohol consumption.

Among the current smokers, 90.2 percent use cigarettes only, 4.5 percent use beedi only and 5.4 percent use both.

Among the current users of chewing tobacco, 37.7 percent were using products containing plain tobacco leaves. Khaini was used by 26.9 percent, pan masala by 28 percent, zarda by 6.1 percent and gutka by 2.9 percent. These are chemically treated areca nut products with or without tobacco.

The practice of chewing tobacco was seen in 77.9 per cent of migrants from Uttar Pradesh and 70.1 percent from Bihar.

Source: Madhyamam

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Chew on This: Tobacco in Your Mouth Can Make You Blind

If you need another reason for not consuming tobacco in any form, here is one: a study by a reputed eye hospital in Chennai has found that chewing tobacco regularly could cause partial blindness.

“While there have been studies in the West that have found smoking to be a risk factor for early and late Age Related Maculopathy (ARM), an eye-condition that affects the central-vision of the eye in the Western population, this is the first study in India that shows that even chewing tobacco carries risks that can affect eyesight,” said Dr Rajiv Raman, senior consultant, Sankara Nethralaya, one of the members of the research team.

In Age Related Maculopathy, the macula, a part of the eye near the centre of the retina the clarity of vision straight ahead, is affected.

The three-year study titled Rural-Urban Age-related Macular Degeneration by the Vision Research Centre of Sankara Nethralaya that was published last week in ‘Eye’, a science journal in the UK, was conducted to report the age and gender adjusted prevalence rates of early and late ARM.

The study identified two independent modifiable risk factors for ARM - hypertension and chewing of tobacco in any form. This was noticed more in rural parts of the country than the urban centres, the study noted, adding that early Age Related Maculopathy was more prevalent in those individuals in the higher socioeconomic groups in the urban population.

The study led by Dr Tarun Sharma, director of Vitreoretinal Services of Sankara Nethralaya was conducted during the period 2009 and 2011, with a sample size of 6,617 - 3,904 (60 per cent) rural and 2,713 (40 per cent) urban.

For the rural population, 16 villages in Kancheepuram and Thiruvallur districts were chosen.

The study found that the prevalence of smokeless tobacco was almost two times in the rural population when compared with urban population (27.9 per cent vs 13.7 per cent), and this could be the probable reason for higher prevalence of early  Age Related Maculopathy  in the rural areas (21 per cent as opposed to 16 per cent). The prevalence of late  Age Related Maculopathy  was two per cent in both rural and urban populations.

“It is estimated that nearly 275 million people in India are users of tobacco. It is known that along with genetics and environmental reasons, smoking is one of the risk factors of Age-related Macular Degeneration among the Western population. However, this is the first Indian study to show smokeless tobacco will cause AMD in Indian Population,” said Dr Raman added.

“Aging population is at a risk of developing ARM, hence every effort must be taken for prevention and early diagnosis so as to minimise visual morbidity. Good control of blood pressure and stopping tobacco intake, and creating awareness on tobacco use are the only prevention methods,” noted Dr Raman.

Source: The New Indian Express

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App Maps Tobacco Vendors Near Schools

Ever thought that a 13-year-old could help shut down a cigarette shop near his school? Thanks to the Android app ‘Children Against Tobacco’, this is a distinct possibility in the future. The brainchild of S Cyril Alexander, State Convenor, Tamil Nadu People’s Forum for Tobacco Control, the app will help map tobacco vendors within 100 metres of an educational institution.

Free for public download, all you need to do is register your name, mobile number and email address, and also fill out details of the vendor. “Once a member of the public alerts us about a tobacco-selling vendor within this proximity, we will collect further evidence with photos and so on, as well as details of other such vendors in the area and then file a comprehensive complaint with the State Tobacco Control Cell,” Cyril explained.

This is in accordance with the Cigarettes and Other Tobacco Products Act 2003, which includes in its provisions: ‘Tobacco products cannot be sold to a person below the age of 18 years, and in places within a 100 metres radius from the outer boundary of an institution of education’. Although their focus is on schools at the moment, “The Act covers all educational institutions. So that means colleges and even tuition centres that provide signage are recognised establishments of study,” said Cyril, who has roped in assistance from his NGO Mary Anne Charity Trust.

How does it work?

• Download the app ‘Children Against Tobacco’
• Fill form with name of school, address, vendor name, type (tea shop, newsmart, provisional store)
• Once alerted, volunteers will gather info and photo evidence to lodge a plaint wi-th State Tobacco Control Cell

A volunteer said that over 40 city schools have been mapped so far, with plans to expand. “Next, we will start mapping vendors around schools in districts like Pudukottai, Tirunelveli, Tirupur and Dindigul,” she added. Plans are also afoot to sensitise school principals and train them to take action against perpetrators.

Source: The New Indian Express

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