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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 meet on tobacco pack warnings: Will pack warnings miss the deadline again?

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The GoM on tobacco warnings is meeting on April 8, 2009 and further dilution or delay to pictorial warnings is expected. This is a great concern before the nation when the implementation on pictorial warnings is long due now and the deadline is very close i.e. May 31, 2009. This meeting is scheduled at the time when in the previous month General Election 2009 for Lok Sabha were announced and the Election Commission of India has passed the model code of conduct to ensure that  no impression is given or created by any political party  to influence the electorate in their favour. Hence, any kind of politically motivated decision resulting out of this meeting at this crucial hour is the violation of the this model code of conduct.

Also, considering the Honourable Health Minister, Dr. Anbumani Ramadoss has resigned; convening such a meeting by the GoM will certainly have no one representing the concerns of public health and can result into giving likeminded outputs. The non-representation of the health sector in this decisive meeting will lead to biased decisions and favours to the tobacco industry. According to Monika Arora, Director HRIDAY“The GoM in its earlier 8 meetings has either delayed or diluted the effective pictorial health warnings notified by Ministry of Health and Family Welfare (MoHFW) on July 2006. The implementation of current mild warnings is continuously being delayed due to GoM’s intervention. This is a breach of right to information about the health hazards of the consumption of a deadly product.”

Further, the issue of implementation of Packaging and Labeling rules 2008 is subjudice before our Supreme Court. This case was filed before the apex court seeing the lack of executive will to implement the said rules. Therefore, further interference in the implementation of the rules by GoM would lead to legislative interference when the said matter is pending. According to Bhavna Mukhopadhyay, Senior Director, VHAI,Any decision emerging out of the GoM meeting tomorrow that is likely to delay or dilute the existing rules will be a serious violation of the election code of conduct as it will gift windfall benefits to the tobacco industry and political gains to certain members of the GoM, who have lakhs of tobacco workers in their constituencies”.

Whereas, the Indian Tobacco Control Law (COTPA 2003) and Global tobacco control treaty signed by India, the Framework Convention on Tobacco Control (FCTC) mandates that all tobacco products, including bidis, must display effective pictorial health warnings. Also, a survey conducted in four Indian States by Healis Sekhsaria Institute for Public Health and Voluntary Health Association of India reports 98% of public supporting the pack warnings and 99% supporting government action to strengthen health warnings requiring them to be large and including pictures of all tobacco products. At this juncture, any of the Government’s decision in further deferring the pack warnings will not only dishonor its international commitment and people’s will but also undermines the health of its 1 billion citizens. According to Dr. Prakash C Gupta, Director, Healis Sekhsaria Institute for Public Health“Pictorial warnings on tobacco products are intended to increase consumer knowledge of the deadly health effects of tobacco consumption, to encourage cessation and to discourage uptake.  In India they also break the linguistic and cultural barrier, in addition to informing the illiterate population (a large proportion of this segment smokes bidis) about the harmful effects of tobacco use.”

The issue of pictorial warnings has time and again affected the people working in public health as the persistent delay in enforcing the law to display pictorial warnings on tobacco products has resulted in no forward movement. It is ironical that the very same Government that has vehemently supported the guidelines on Article 11 of the FCTC (pack warnings) for the global community at the Conference of Parties meeting in November 2008 at Durban, South Africa is delaying its implementation on different pretexts in its own country.


Tobacco addiction is a major cause of Tuberculosis!

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Half of all male deaths by tuberculosis in India a result of smoking

“I Am Stopping TB”this is the slogan that has been adopted worldwide for the World TB Day, 2009. “I Am Stopping TB” is the start of a two-year campaign internationally in support for control of TB. In keeping with the theme, a significant effort should be made to highlight the fact that a significant amount of TB deaths in India are caused by smoking – most starkly, including half the amount of males who succumb to TB in the country. Almost 200,000 people a year in India die from tuberculosis because they smoked, and half the smokers killed by TB are still only in their thirties, forties or early fifties when they die. 

On the occasion of World TB Day (24th March 2009), Dr.P.C.Gupta, Director, Healis Sekhsaria Institute for Public Health, said “Smokers expose themselves to a plethora of diseases and illnesses, and as research and studies show, Tuberculosis is one of the most life threatening diseases caused by tobacco.
We therefore urgently need to take extensive measures to increase social awareness about tobacco as a cardinal cause of tuberculosis and make an effort to educate society about the dangers of the disease.”

Studies have shown that half the male tuberculosis deaths in India are caused by smoking, and three quarters of the smokers become ill with tuberculosis (TB) through smoking. A major study led by the Epidemiological Research Center in Chennai, India and funded by the UK Medical Research Council and Cancer Research UK have come up with detailed results on tobacco being a major cause of tuberculosis. The study found that in India male smokers are about four times as likely to become ill with TB as non-smokers, and consequently four times as likely to die from the disease. The study also showed the smokers had higher death rates from heart disease and from various types of cancer. In total, about a quarter of the smokers studied were killed at ages 25-69 by their habit, those killed at these ages losing, on average, 20 years of life.

Tuberculosis still causes about 1.6 million deaths a year worldwide, including more than a million in Asia, 400,000 in Africa and 100,000 in the Americas and Europe, and in some countries it is now becoming more common.

 

Indians Support a Smoke Free Nation

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According to the results of a survey released in January 2009, conducted by the Healis-Sekhsaria Institute for Public Health
through Synovate’s Global Omnibus
on attitudes and behaviour among consumers in four major Indian cities, a near-unanimous majority of Indians strongly believe that the government should implement all new regulations that prohibit smoking inside all public places and workplaces in India.

An overwhelming 99% of the respondents of the survey have voiced their opinions strongly in favour of enforcement of rules prohibiting smoking in all public places and workplaces. 98% of the respondents have come out in favour of regulations prohibiting smoking in workplaces.

Speaking on the results of the survey, Dr. P.C. Gupta,
Director, Healis – Sekhsaria Institute for Public Health, said,
“The results of this survey have now shown that Indians clearly support the implementation of the law to ensure a right of citizens to breathe clean. Every aspect of controlling the brazen incursion of tobacco in public life must be exercised fully. By next year smoking will cause about 930,000 adult deaths each year in India, up from about 700,000 deaths per year in 2004. It is therefore vitally essential for the government and public bodies to take substantial steps to make sure that the compliance and implementation of the law on tobacco control is in fact realized, so that every common man can be protected from the dangers posed by tobacco.”

“India has always been faced with the rampant use of tobacco across all sections of society. However, the results of this survey show that most Indians are still resistant to tobacco usage, and the general consensus achieved by the survey is a very positive indicator of the sentiments of the public. It is very heartening to know that Indians recognize the fact that secondhand smoke is a major health hazard, and feel that the ban on smoking in public places should be more strictly enforced”, said Dr. S.S. Shastri, Professor and Head, Department of Preventive Oncology, Tata Memorial Hospital, Mumbai.

The respondents have also shown a high regard for the adverse effects of secondhand smoke, with 92% clearly stating that exposure to secondhand smoke constitutes a serious health hazard for non-smokers. With regard to office environment, 94% percent of Indians surveyed strongly agreed that all workers in India should be protected from exposure to secondhand smoke in the workplace. These concerns translate to the very strong belief among Indians that the right of customers and employees to breathe smoke-free air in workplaces and public places (including restaurants and bars) is more important than the right of smokers to smoke inside these places.

The majority of respondents from all locations have said that restaurants and bars are healthier and more enjoyable now that they are smoke-free. 85% of the respondents have agreed to this fact, out of whom 72% have agreed very strongly that these places are healthier. 88% of the respondents have strongly agreed that it is nice to go out and enjoy local restaurants and bars without smelling like smoke when they get home.

The results of the survey have highlighted the fact that Indians have decisively spoken out against smoking in public, and the recognition of the fact that secondhand smoke is a health hazard. This clearly shows that there is ample scope for the ban on smoking in public places has ample scope to succeed in the country, and it is the responsibility of civic bodies to ensure that the rules necessary for the campaign to succeed are uniformly enforced.

For more details, visit http://www.healis.org