By Pratishtha Singh
Tobacco use is a major preventable cause of mortality and morbidity, with close to 7 million people succumbing to tobacco-associated deaths globally every year. This entirely preventable, man-made epidemic kills more people than tuberculosis, HIV/AIDS, and malaria combined. Aside from morbidity, research shows that for every smoker that dies, at least 30 people live with a serious smoking-related illness. Another study by ICMR revealed that 50% of all male cancers and 25% of all female cancers in India can be attributed directly to tobacco consumption.
In order to protect and safeguard the health of its citizens, the Government of India developed the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act (COTPA) in 2003. In 2004, the WHO Framework Convention on Tobacco Control (FCTC) was ratified, which lists strategies to reduce the demand for and supply of tobacco. To further strengthen tobacco control provisions under COTPA, the National Tobacco Control Program (NTCP) was launched in 2008. However, despite multiple efforts taken by the government and NGOs, generation after generation continues to use these products and suffer devastating economic, physical, and psychological consequences.
Gaps in Legislation
A recent WHO Report on the Tobacco Epidemic (GTCR) from 2019 observes that India, despite having adopted best practices in health warnings on packs and cessation, falls under the ‘Moderate’ category in all other areas, having made no progress since 2008. A key reason for this stagnation is the “glaring gaps” in tobacco control legislation. At present, even though the law prohibits direct and indirect advertisements of tobacco products, the definition is ambiguous and vague, and it does not exhaustively cover all forms of sponsorship, advertising, and promotion. Due to this limitation, the tobacco industry brazenly continues promoting its product via social media, point of sale displays and advertising, and event sponsorships. This continuous exposure to tobacco products normalizes smoking and is linked to early initiation into smoking and difficulty for regular smokers to quit. Furthermore, COTPA and the Ministry of Health and Family Welfare (MoHFW) provides specifications for Designated Smoking Areas (DSAs) to prevent exposure to secondhand smoke, an endeavor that has proven to be ineffective.
Another worrying trend is the premature initiation of tobacco products during adolescence. With research showing that most users become addicted before the age of 21, the current legislation having 18 as the minimum age for purchasing tobacco products is problematic. The law also permits the buying of single sticks or loose tobacco, causing sales to rocket and resulting in consumers not being regularly exposed to health warnings on the pack. Moreover, COTPA does not regulate the contents of cigarettes, which leaves tobacco industries free to use flavor-enhancing substances, such as mint, vanilla, and cinnamon. This marketing gimmick reduces the harshness of cigarette smoke, making experimentation and addiction more likely while creating an impression that the product is less toxic than it really is. Research also shows that even though awareness regarding the dangers of smoking is high among the masses, an understanding of the potential personal harm and consequences it poses is less, since most individuals hold either incomplete or incorrect knowledge. This trend is prevalent especially among vulnerable populations like youth. Furthermore, the anti-tobacco text warnings may not register with all consumers because of poor literacy levels.
A study found that LMICs spend a mere 1% of the global tobacco control spending. A minimal budget and lack of human resources pose another major barrier. Adding on to these inadequacies, the sin tax on tobacco in India is only 38%, compared to the WHO recommended level of at least 75%.
The Way Forward
It is the need of the hour to ensure the current legislation is in accordance with WHO guidelines to comprehensively tackle this public health problem. COTPA needs to be amended to remove any provision for DSAs and prohibit all forms of advertisement and sponsorship by the tobacco industry, including internet-based promotion. To delay the age of initiation and reduce access to minors, the age of sale needs to be increased from 18 to 21. Furthermore, the recent GATS survey revealed that nearly 55% of smokers in India want to quit but are unable to, pointing to the importance of inculcating changes in public policy that promote tobacco cessation. This can be achieved by prohibiting the sale of single cigarette sticks and loose tobacco, regulating product contents, and including a ban on flavored tobacco products. Adopting plain or standardized packaging is an additional advantageous policy that lowers the overall demand for tobacco.
Another widely-effective strategy, especially among youth and low-income people, is increasing taxation on tobacco products and using the revenue generated to strengthen existing control efforts. Furthermore, worksite prevention is an additional way to curb the epidemic. Inculcating smoke-free policies across different workplaces, including industrial, agricultural, and construction jobs, will have a high impact on tobacco consumption. There also needs to be continuous evaluation and surveillance of tobacco consumption patterns across various demographic groups, based on age, gender, socioeconomic status, and other factors. In addition, rapidly growing evidence shows that generic tobacco control messages may not be as effective as gender and population-specific ones. While all genders fall prey to outcomes of tobacco consumption, studies show that there may be sex-specific consequences. Moreover, with research revealing that the number of women smokers is rapidly increasing and caste-segregated data showing Scheduled Tribes as the highest consumers of tobacco, it becomes extremely vital to integrate population-sensitive interventions to achieve better health outcomes.
In order to prevent the detrimental consequences of tobacco, which include substantial healthcare expenditure, poverty, poor health outcomes, and the loss of human capital, it is imperative that tobacco control strategies are scaled up and strictly implemented. By focusing on data-driven evidence to inform policymaking, India can adopt a more coercive and comprehensive approach to fight this epidemic.
Pratishtha is a Global Health Fellow working in reproductive and maternal health at Swasti.