Let larger pictorial warnings stay

Oral cancer. - Photo Dr. Pankaj Chaturvedi, Tata Memorial Hospital-Optimized

According to the 2009-2010 Global Adult Tobacco Survery, 170 million Indians chewed tobacco and 120 million smoked. Nearly 80 percent of smokers used bidi. – Photo: Dr. Pankaj Chaturvedi

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. And nearly 67 per cent of smokers in Brazil and New Zealand and 44 per cent in the case of Canada and Thailand wanted to quit smoking as a result of graphic pictorial 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 2006 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.

Published in The Hindu on March 18, 2016