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Current warning labels on Indian tobacco products ineffective¬¬ – concludes an international expert on tobacco control

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India’s new warning labels on tobacco products fall short of the international standards for strong warning labels, according to Professor Geoffrey Fong, of the University of Waterloo in Canada, who is in India with his research team to meet with researchers at the Healis-Sekhsaria Institute for Public Health.

A world expert in tobacco control, Professor Geoffrey Fong made this conclusion based on research that he and his international team of experts have conducted on the impact of warning labels in a massive project across 20 countries.

“Warning labels that include graphic and clear images of the devastating diseases due to tobacco use are known to increase thoughts about quitting and to be used by smokers,” Professor Fong, whose research on warning labels has examined the impact of graphic warnings in Canada, Thailand, Malaysia, Brazil, Uruguay, and Australia, compared to text-only warnings in the other countries, including United States, China, France, Germany, Netherlands.

In July 2006, India introduced new warnings on cigarette and bidi packs and on packages of Gutkha and on tins of loose tobacco used for paanmasala. The original law for picture warnings was passed in 2003 and called for graphic photos of mouth cancer due to tobacco use. The new warnings would also include skull and crossbones, which is an international sign of poison.

“The skull and crossbones is a universal warning sign that the substance or product is very dangerous,” said Professor Fong. “And this is true of tobacco products. For example, we know that between one-third and one-half of all regular smokers will die of a smoking-related disease. It is the only product that kills people when used as intended.”

However, due to extreme pressure from the tobacco industry in India, especially the bidi industry, the implementation of the law was delayed 6 times over 5 years.

Then in March 2008, in an unprecedented move, the strong graphic warnings that had already been notified by the Government in 2006 and 2007 were changedto be weaker. The widely understood symbol of Skull and Crossbones was replaced by a scorpion. The vivid colour photos of real examples of mouth cancer due to tobacco use were changed to a fuzzy image of a chest x-ray.

“Healis has been one of the dedicated organizations in India that has been actively involved in research to facilitate implementation of much more effective warning labels on tobacco products.” said Professor Fong.

But even these new weakened warnings were delayed in their introduction. And they were made smaller (from 50% to 40%), limited (from both sides of the pack to just the back of the pack).

Professor Fong commented on the power of graphic warnings in other countries: “Countries such as Canada, Brazil, Singapore, and Mauritius have introduced very powerful warnings that have helped motivate smokers to quit and prevent young people from starting to smoke.”

“The tobacco industry knows how effective the warnings are, and that’s why they try their best to prevent warnings, weaken them, and delay their introduction.” The fact that the warnings have been so attacked by the tobacco industry in India is a sure sign that they are afraid of the impact of graphic warnings, Professor Fong says.

Close to one million people in India will die this year because of tobacco use. And since the graphic warnings were originally proposed and approved by the Government 6 years ago, about 5 million people have died.

Professor Fong commented on these delays. ”We know that strong graphic warnings are effective in increasing knowledge, motivating quitting, and preventing young people from tobacco use. How many of those that died could have been saved by the knowledge and vivid displays on the warnings that show what tobacco really does to people?”



India to implement pictorial health warnings on packets of tobacco products

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Cancer survivors speak out against tobacco and make case for stronger warnings

India has one of the highest incidences of tobacco use in the world. The World Health Organization has estimated that India has the second largest number of smokers in the world after China. According to the report “Tobacco control in India”, 800,000 – 900,000 Indians die annually due to diseases attributable to tobacco – 50% of cancer deaths, 40% of all health-related problems, and a majority of cardio-vascular and lung disorders in the country. WHO predicts that nearly one million Indians will die from smoking alone in 2010 and 70% of these deaths will be premature.

Every year, May 31st is internationally observed as World No Tobacco Day. This year, the World Health Organization has chosen on the theme of “Pictorial Health Warnings” on tobacco products. There is significant research to show that large graphic warning labels increase knowledge about risks associated with tobacco, motivate smokers and other tobacco users to quit and to discourage non-tobacco users from starting. From 31st May 2009, all tobacco products in India (sold in the market) should have pictorial warnings on their packets.

As a party to the Framework Convention on Tobacco Control (FCTC), the Government of India is obligated to implement pictorial warnings as highlighted under Article 11 of the FCTC, which states that parties to the convention must enforce the use of health warnings which “should be 50% or more of the principle display areas but shall be no less than 30% of the display areas” and may be in the form of or include picture warnings. For most cigarette packages, the “principal display areas” are the front and back of the package. The warnings to come into effect on May 31 do not meet the FCTC standards to which India is obligated, and under which, India was due to implement pictorial health warnings from 27th February, 2008, more than a year ago.

Despite the delay in implementing the pictorial warnings, the diluted pictorial warnings are welcomed with mixed reaction.

According to Dr. P.C. Gupta, Director, Healis Sekhsaria Institute for Public Health, “The beginning of Pack Warning labels on all tobacco products from May 31, 2009 is welcome, but it should be recognized that the original set of pack warnings have been considerably weakened and diluted. We can only hope that when the warnings are reviewed every six months as per the provisions in the Act, they would be stronger and more effective as it has been adopted in other countries.”

Recently, in an event themed Voice of the victim held at Tata Memorial Hospital, Mumbai, cancer patients from across the country came together on a common platform to complain against the sale of tobacco in the country without any mention of the health hazards on any of the tobacco products being sold. They highlighted the circumstances under which they became addicted to tobacco, and the singular pattern that emerged was that the patients did not fully realise the impact that tobacco could have on their bodies and lives. This was mostly due to the fact that tobacco usage was glorified by the tobacco industry, and tobacco manufacturers did not provide any specific warnings to highlight the dangers that threaten tobacco users.

Dr. Pankaj Chaturvedi, Associate Professor, Head and Neck surgery service, Tata Memorial Hospital said, “The cancer patients who are speaking out against tobacco clearly highlight the vital need that pictorial warnings be implemented on tobacco products effectively, so that those who do not know the ill effects of this deadly substance can be made aware of it. There is nothing out of ordinary in the demand as the manufacturers of every product have to inform the consumers about the risk of the products.

Voicing his opinion on the effectiveness of the pictorial warnings, cancer survivor Mr. Deepak Kumar said, “It is a good start, but not sufficient. The pictorial warnings need to be improved. The warnings should cover 50% and that too on both sides of the pack with the picture of skull and bone on one side and pictorial warning on the other.”

According to another cancer survivor Mr. Pradeep Lahiri,There should be big pictorial warnings which show the reality of cancer and convey the message of anti-tobacco. These warnings should make the people feel guilty subconsciously and stop smoking. That is when the pictorial warnings would be effective.

The warnings in place definitely do not serve the purpose required of them. For one it is still unclear and worrying as to what the public would make of these images as there is no direct link for these images to the threat of cancer and other diseases caused by tobacco. Besides, the entire intention of issuing the stronger pictorial warnings covering 50% of the packet is to highlight the uneducated or unaware public of the dangers of tobacco. These images, on the other hand, simply do not match the standards required to highlight the grave threats posed by tobacco. Strong action needs to be taken to ensure that the effort towards implementing stronger pictorial warnings on tobacco products continues.

GOM COUNTING TOBACCO VOTES OVER TOBACCO DEATHS

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Tobacco use is the biggest cause of death, disease and disability. The death clock of tobacco strikes every six seconds globally and the product kills nine lakh Indians every year. Since the first notification of the pictorial health warnings in July 2006, nearly 26, 52,500 Indians have died from tobacco-related diseases.

Studies point that forewarning tobacco users of the ill-effects of tobacco use through pictorial health warnings is one of the most effective measures to contain tobacco use and the consequent death, disease and disability. Evidence from countries having pictorial health warnings have revealed that larger, comprehensive warnings on tobacco packages are more likely to be noticed and rated as effective by tobacco users and contribute to reduction in tobacco use, since more people are willing to quit tobacco after repeatedly seeing the warnings.

However, it seems politics has overtaken scientific evidence and abandoned public health commitments, to sound a retreat from the implementation of a tested measure against a known pandemic. The GoM, mostly comprising of the prominent candidates contesting in the general elections for the 15th Lok Sabha, in the absence of the former Health Minister and under pressure from the tobacco industry – there is no reason to believe otherwise – has disregarded all scientific evidence, undermined an international treaty (Framework Convention on Tobacco Control-FCTC) obligation and transgressed the Model Code of Conduct to derail an important public health measure.

The civil society alliance for tobacco control in India had already voiced this concern when the GoM sought to meet on April 8, though it seems the Election Commission did not grant the permission for the GoM to convene. But no one would have ever imagined that the GoM could go back and alter the minutes of its February 3 meeting to oblige the tobacco industry and to influence the voters in their tobacco dependent constituencies.

It is shocking to believe that the apprehensions expressed by the former Health Minister on Saturday (he has said, “The minutes of that (GoM February 3, 2009) meeting seems to be changed after I quit the government“) have come true. Such a hasty decision by the GoM and the consequent notification by the Ministry of Health is a serious concern for the Government of India and the Election Commission of India should take notice of this politically motivated move and initiate immediate corrective action to uphold the democratic ethos and practices of the country and save an important public health measure from being needlessly diluted.

For very short term political considerations, the GoM must not be allowed to drag the country back from its commitment by diluting rules, breaking promises and endangering India’s image before the international community. The global public health movement which previously applauded and honoured India for its pro-people actions to curtail tobacco consumption will now react with dismay as the Government dishonours its commitments. Besides, this is contrary to the standards set by a pro-public health Government which is responsible for the launch of the National Rural Health Mission and the National Tobacco Control Programme during its regime.

It is unfortunate that the GoM since its constitution, in early 2007, has already delayed the implementation of the pictorial warnings for two years and during this time diluted stronger warnings for milder ones, reduced size of the warnings from 50% of the principal display area to 40% besides exempting large packs from the purview of the packaging labeling rules. As if all this was not sufficient in itself to negate the efficacy of the pictorial warnings, the GoM on Sunday (May 3) cast a death blow to the warnings by making them appear only on one side of the pack – thereby scaling them down to 20% of the principal display area which is below the minimum standard set (30% of the principal display areas) by the FCTC – and only on the packages meant for retail sales.

Speaking on the dilution of the pictorial warnings, Dr. P.C.Gupta, Director – Healis Sekhsaria Institute for Public Health has said, “It is most unfortunate that the GoM since its constitution in early 2007 has already delayed the implementation of the pictorial warnings for two whole years, not to mention having diluted stronger warnings for milder ones. This is a serious issue of concern, considering that the warnings have not only been delayed, but have also been cut down. Serious measures need to be taken at this juncture to highlight the grave irresponsibility of the GoM towards public health through this action”. “I would state that the tobacco control community strongly condemns this irresponsible decision by the GoM to dilute and amend the pictorial warnings notification”.

Evidence from countries like Panama and Brazil with warnings restricted to a single side indicates that industry sabotages the initiative by advising retailers to stack the packs on the retail shelves in a manner that hides the warnings from public view. Further, even as Parties to the FCTC, including India are negotiating a protocol to curb illicit tobacco trade, health warnings on wholesale and export packages are a key marker to track and trace illegal tobacco products across the borders.

The apparent urgency of the GoM to revisit and alter the rules pertaining to the pictorial warnings at a time when the general elections are in progress, with the Model Code of Conduct in force, and above all when the implementation of the rules was to be considered by the Supreme Court of India only two days later (Tuesday, May 5), is uncalled for and amounts to a colourable exercise of power.

The tobacco control community strongly condemns this devious decision by the GoM to dilute and amend the pictorial warnings notification that was to come into force from, May 31, 2009, the World No Tobacco Day the theme of which, ironically, is tobacco pack warnings. We appeal to the Prime Minister of India to urgently intervene and prevent this repudiation of public interest. While politicians may count their success in terms of votes gained, statesmen should count their success in terms of lives saved.