Swati Srivastava (Research Associate Public Health Foundation of India, currently studying at ITM)
Last month, India hosted the International Conference on Public Health Priorities in the 21st Century: the Endgame for Tobacco, which deliberated upon policy issues for promoting public health by reducing the consumption of tobacco. The conference was also reflective of recent changes in the international tobacco control discourse, with the debate around tobacco shifting from discussions on tobacco-related harms in terms of mortality and morbidity, to one focused on hard, time-bound targets to eradicate tobacco. The conference resolutions called for countries to espouse composite strategies … to reduce … tobacco use to less than 5%, which is a tipping point of de-normalisation, at which countries are enabled to further completely eliminate all forms of tobacco consumption.” Strategies needed for this include: adoption of national action plans to meet “Endgame” targets; sustained government commitment; ratification and full implementation of the World Health Organization Framework Convention on Tobacco Control; increasing tobacco taxes to deter use, and earmarking of their revenue for financing public health (and not limited to tobacco control); mandating plain packaging for all tobacco products (as Australia has done); licensing policies for the entire tobacco manufacturing chain, including cultivation, manufacture, distribution and sale; alternate cropping and livelihood options for tobacco farmers to phase out production; and global ratification and implementation of the first protocol to eliminate illicit tobacco trade, among others. Some other (perhaps even more idealistic, but no doubt important) goals included the addition of tobacco control targets in the post-2015 development goals; ensuring that multi- and bi- lateral trade agreements do not infringe upon tobacco control; devising means for funding global tobacco control efforts; and adoption of policies to prohibit tobacco sales to all persons born after 2000 (as already proposed by Tasmania and Singapore, with similar plans in Ireland and Finland).
Many of these strategies are both timely and revolutionary, and are reflective of the massive change in tobacco control efforts required to engage and counter the pervasiveness of tobacco. In India, the Global Adult Tobacco Survey 2010 showed that more than a third (274.9 million persons) of the country’s adult population used tobacco: 21 percent smokeless users, 9 percent smokers, and 5 percent dual users. Nearly a third of Indian children want to smoke once they grow up. Considering that one in five Indian adults consume smokeless tobacco, the judgment of the Indian Supreme Court in 2011 to ban gutkha (a form of smokeless tobacco) under the Food Safety and Standards Act of 2011, was far-reaching. The act stipulates provisions to ban any food product (as gutkha is classified) which contains harmful adulterants, such as tobacco and nicotine. Many tobacco manufacturers have challenged this, leading to differences of opinions between various stakeholders and ministries. The health ministry endorsed this ban to extend to all smokeless tobacco products a few days ago. At present the enforcement of the ban is weak, with the result that gutkha manufacturing industry has proliferated in the unregulated informal sector, and gutkha can often be bought illicitly at prices several times higher than that in pre-ban days. It remains to be seen how India can move towards a tobacco endgame, given the inconsistent implementation of its basic national provisions.
Another recent development in India is the new Companies Act, 2013, under which the Ministry of Corporate Affairs stipulates that any company having a turnover of greater than INR 500 crore (about 60.2 million Euros) would be required to constitute a Corporate Social Responsibility Committee, and allocate every year at least 2 percent of average net profits of three preceding financial years to corporate social responsibility activities. This is seen as a way of normalizing and legitimizing the tobacco industry and their investments in the social sector. Some such efforts include the National Recycling Day celebration of the Indian Tobacco Company (ITC), and various women’s self help and farmers groups they support.
Recent international developments highlight the necessity of the endgame, as so clearly elaborated in the New Delhi conference. The European Union recently passed a Tobacco Products Directive to ban packs of ten (which are easier for younger persons to afford) and flavored cigarettes (also favored by the youth), within three years. Tobacco companies however successfully lobbied to ensure a longer phase out time (eight years) for another youth favorite, menthol-flavored cigarettes. The draft law also brought forth another debate: many lawmakers were of the opinion that electronic cigarettes should be governed by the same regulations that apply to other tobacco products; while others thought of them similar to medicinal products such as nicotine patches or gums (an opinion vociferously shared by both tobacco companies and some doctors’ associations). Further away, Indonesia (which has not ratified the FCTC) recently filed a complaint with the World Trade Organization, challenging Australia’s plain packaging legislation, citing infringements of international trade rules and intellectual property rights of brands. Ukraine, Honduras, the Dominican Republic and Cuba, which are major cigar producers, have earlier challenged Australia’s legislation with the WTO.
These developments highlight the multiplicity and complexity of the tobacco problem, and how no single control measure has been sufficient on its own. The ambitious goal of ending tobacco is especially needed in a country like India, where government ministries are mandated to promote tobacco for fiscal gains over the cost to public health. While the “Endgame” may seem radical and totalitarian, with questions being raised on the effectiveness and feasibility of prohibition policies as well as on limits to individual choice, it connects and amplifies many different tobacco control approaches into one unified voice.