Indian Journal of Cancer, Vol. 44, No. 4, October-December, 2007, pp. 129-130
Indian needs stricter implementation.....
Head and Neck service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai
Code Number: cn07023
India needs stricter implementation of antitobacco law
Chaudhry et al. in this issue have highlighted yet another instance of violation of the antitobacco law in India. The Government of India passed the Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution Bill in 2003.  The key provisions of the law include prohibition of direct and indirect advertisements of tobacco products, prohibition of the sale of tobacco products to minors, and prohibition of smoking in public places. The rules clearly mention that in point-of-sale advertising of tobacco products only the type of tobacco product should be mentioned; no brand name, promotional message, or picture is permitted.  However, advertisement of other consumer products with the same name as the tobacco product (surrogate advertisement) is rampant, smoking in public places remains unabated, and sale of tobacco to minors continues. Unfortunately, violators are rarely penalized. As usual, India has reasonably strong laws but the implementation and monitoring remain half-hearted. In a country where up to 50% of cancers in some registries are directly attributable to tobacco, our society appears to be very tolerant of such violations and do not seem to consider it as an important public health issue. Chandigarh is the only city in India that can boast of good compliance with this law; this has been possible thanks to a relentless campaign by antitobacco activists, which made it the first 'smoke-free city' of India.
Tobacco use is not just a habit disorder: the International Classification of Diseases (ICD-10) has now notified 'tobacco dependence' as a disease. We are making great strides in conquering many diseases by vaccination, early diagnosis, and effective treatment; at such a time, the continuing availability of tobacco, the use of which is strongly associated with several lethal diseases and numerous chronic disabilities, defies all logic. During the 2010s there will be about 1 million tobacco deaths a year in India and about 70% of these deaths will be before old age.  Currently, tobacco is responsible for 1 in 5 of all male deaths in middle age. Men who are cigarette smokers lose ten years of their lives, mainly as a result of tuberculosis, respiratory and heart diseases, and cancer. Unlike alcohol, there is no safe level of smoking, and consumption of a few cigarettes / bidis per day increases the risks of dying prematurely by up to 50%.  This menace is not even sparing our children and youth, with nearly 50% of school children using tobacco products in northeast India.  Another study reported that every day 55,000 new children take up tobacco habits in India, whereas a mere 2% of Indian adults quit the habit-often only after falling ill.  There is a plethora of evidence-based information on the hazards of tobacco. If you type in the keywords 'smoking' and 'cancer' on Google, you get whopping 5,120,000 search results in 0.3 seconds. If you type smoking, cancer, research on Google, you get 5,68,000 results in 0.36 seconds. Tobacco is the only legally available consumer product in the world that kills even when used as per the manufacturer's specifications. The International Agency for Research on Cancer of the World Health Organization has categorized tobacco as a category I carcinogen (confirmed human carcinogen). Tobacco smoke has 10 additional category I carcinogens (4-aminobehenyl, benzene, chromium, nickel, cadmium, etc.) and several dozen category II and III carcinogens.  Is that not sufficient to ban tobacco? In August 2007, an agitated public and media had cornered few soft drink makers after an NGO released data showing that their products contained unacceptable levels of pesticides; in response, several state governments swiftly banned sales of Coke and Pepsi. Opium (source of Morphine), with it's important role in the modern medicine was branded illegal product whereas tobacco has got no whatsoever medical usage continues to be legally available. Rofecoxib was withdrawn from the market after it caused heart attacks in some rare instances. In comparison, tobacco, as per an ICMR study conducted in 1996, was responsible for 42 lakh cases of coronary artery disease and 37 lakh cases of chronic obstructive lung disease as well as about 1.5 lakh new cancers! The Indian tobacco industry, for the last 15 years, has consistently highlighted the same ridiculous facts: India is the world's second largest producer of tobacco, tobacco cultivation provides livelihoods to over 6 million farmers, and the industry employs 20 million workers and contributes over 70 billion rupees to government's earnings.  Are 250 million tobacco users in India victims of a politician-tobacco industry nexus? Can these reasons be a valid excuse for not banning a lethal product? If the Industry and the government had noble intentions and had embarked on tobacco systematic de-growth strategies, by now the tobacco industry would have happily diversified into other areas.
The newest example of the government's apathy is the failure to implement the law mandating an effective pictorial warning on tobacco products. Widespread illiteracy and the lack of effectiveness of the current statutory warning on tobacco products make it necessary to display more effective warnings. Bowing to the pressure from the tobacco lobby and despite the intervention of the Shimla High Court and the demands of civil society, government dragged its feet and has finally decided that a picture of a scorpion and a lung will suffice as a graphic warning!
Gutka and pan masala (with or without tobacco) pose a bigger challenge in the current society than smoking. Their non-tobacco counterparts, with similar names, are being constantly advertised and the industry is making huge profits while continuing to expand its customer base. Several states have tried to ban these products but the ban has been reversed by the courts on legal technicalities. There is a need to disseminate the information that areca nut, an essential ingredient of gutka / pan masala / mawa, is addictive and potentially carcinogenic.  The myth that '0% tobacco' products are safe needs to be shattered.
Health professionals can play a pivotal role in the fight against this epidemic. By making use of every opportunity to discourage the tobacco habit they can make significant contributions to tobacco control. All health professionals in India should possess the skill to help people quit tobacco and they need to lead by example and quit the habit themselves.
Copyright 2007 - Indian Journal of Cancer