Report on Tobacco Control in India Edited by K. Srinath Reddy Prakash C. Gupta This report is jointly supported by Ministry of Health & Family Welfare, Government of India Centers for Disease Control and Prevention, USA World Health Organization Tobacco Control in India Report on Tobacco Control in India (New Delhi, India), 25 November 2004 Ministry of Health & Family Welfare, Nirman Bhawan, Maulana Azad Road, New Delhi 110011, India Disclaimer: The views expressed in this report are not necessarily those of the Ministry of Health & Family Welfare, Government of India, who commissioned the report as well as the World Health Organization and Centers for Disease Control and Prevention (USA), who provided technical guidance. Preparation of this report has been jointly undertaken by HRIDAY, New Delhi, India and Tata Memorial Centre, Mumbai, India HRIDAY Tata Memorial Centre T-7, Green Park Extension Dr Ernest Borges Marg, Parel New Delhi 110016 Mumbai 400012 India up to 31 July 2004; since then Healis Sekhsaria Institute of Public Health 601, Great Eastern Chambers 6th Floor, Plot No. 28, Sector 11 CBD Belapur (E) Navi Mumbai 400614 India on behalf of Ministry of Health & Family Welfare, Government of India The report has been technically edited by BYWORD EDITORIAL CONSULTANTS A-217, Somdatt Chambers I, Bhikaiji Cama Place New Delhi 110066, India Printed at Shree Om Enterprises Pvt. Ltd., A-98/3 Okhla Industrial Area, Pahse II, New Delhi 110020 ii Tobacco Control in India Foreword Hkkjr ljdkj LokLF; ,oa ifjokj dY;k.k ea=ky; ubZ fnYyh & 110011 GOVERNMENT OF INDIA MINISTRY OF HEALTH & FAMILY WELFARE NEW DELHI - 110011 J.V.R. Prasada Rao Health Secretary Tobacco use is a serious public health challenge in several regions of the world. It has assumed the dimension of an epidemic resulting in enormous disability, disease and death. It is estimated that five million preventable deaths occur every year globally, attributable to tobacco use. At this rate, the number of such deaths is expected to double by 2020. In addition to damage to personal health, tobacco use results in severe societal costs like reduced productivity and health care burden, environmental damage and poverty of the families. The degree of destruction brought to bear upon the individual and society surpasses the returns generated by tobacco production and consumption in terms of revenue and employment. India has been very conscious of the harmful effects of tobacco use, disease burden and related social and economic costs of health care. Over the period, various administrative measures were taken to prohibit tobacco smoking in public places and regulate the sale of tobacco products and their advertisements. A serious need was felt for framing a comprehensive national legislation on tobacco control, which would ensure uniform and effective enforcement of measures to achieve desired results. After detailed deliberations, the Government of India enacted The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 in May 2003 with a view to protect public health by prohibiting smoking in public places, banning advertisements of the tobacco products, banning sale of tobacco products to minors and near educational institutions, prescribing strong health warnings including pictorial depiction on tobacco products and regulation of tar and nicotine contents of tobacco products. For any legislation to be successful there is a need for adequate preparedness on the part of civil society, locally and globally, with regard to awareness of the existing problem and acceptance of the necessity for such legal measures. At the global level, India has been a forerunner in the negotiations leading to the Framework Convention on Tobacco Control, which was ratified by India in February 2004. At the domestic level, the State Governments, which are the main implementing agencies, have been advised to enforce the provisions of the tobacco control legislation strictly. As a measure to sensitize members of civil society, policy-makers, parliamentarians, scientific and public health professionals, researchers and the general public, it was necessary to compile basic data and analysis of tobacco use in the country, the extent of disease burden, present status of tobacco control measures, global experience in this field and proposed road map for future course of planning and action. This report Tobacco Control in India has been commissioned with this purpose in view. This report is a product of the untiring efforts of the editors, Dr K. Srinath Reddy, Dr P.C. Gupta, their research teams and also the valuable contributions made by individual experts. The Centers for Disease Control and Prevention, Atlanta, USA extended all technical support during the entire period of report development. This publication, I am confident, will fulfil its purpose of raising the awareness among policy-makers, experts, activists and the public at large about the threat of tobacco use and its consequences, which impinges upon the health of the people of India and its economy. 5 November 2004 (J.V.R. Prasada Rao) iii Tobacco Control in India Preface This report owes its origins to the recent global surge in action against tobacco. As awareness of the dangers posed by tobacco spread, nations across the world resolved to forge a campaign strategy and frame a battle plan to overcome the tobacco threat. Indias anti-tobacco law emerged in April 2003, close to the closure of the intergovernmental negotiations on the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in March 2003. Soon thereafter, the Ministry of Health and Family Welfare, Government of India (MOHFW), decided to commission a detailed review of the status of tobacco control in India. This was intended to collate the Indian experience and craft a plan for future action based on a critical appraisal of global evidence and Indias specific needs. The series of scientific reports published by the Surgeon General of the United States of America have served, over the years, as the best sources of evidence-based information on the adverse health effects of tobacco use and a resource for the best practices for tobacco use, prevention and control. The collaboration of the US Centers for Disease Control and Prevention (CDC) was, therefore, welcomed by MOHFW for the purpose of providing technical support to the development of this report. In order to engage the expertise and the energy of a wide range of experts, public health advocates and civil society representatives, MOHFW invited two Indian agencies which have been actively contributing to knowledge acquisition and public health action on issues relevant to tobacco control. As their representatives, we were given the privilege of compiling and editing this report. We undertook this task by inviting several Indian contributors, with specific expertise in different areas related to tobacco control, to contribute (individually and jointly) to different sections of defined chapters. Their manuscripts were extensively reviewed by other Indian and international experts and were later edited and integrated by us to form the text of this report. In undertaking the major task of bringing this report together, we were guided by an advisory group of public health experts from India and the United States. It is an interesting coincidence that the thread of history which originally brought tobacco to India from the Americas had now knit together public health experts from the two countries into a combined effort to advance the agenda of tobacco control and promote public health in India. The potential impact of such an undertaking ensures that children are protected from the social and cultural influences that lead to tobacco addiction, that all tobacco users are encouraged to quit, and that non-smokers are protected from second-hand smoke. This report provides a major source in our national efforts to prevent and control tobacco use. It is also intended to inform and assist many sections of our society who are committed to protecting Indias national interests by preserving and promoting the health of our people. Since several of such readers will not be health professionals, an attempt has been made to keep the language as free from technical jargon as possible. Most of the readers will know that tobacco is harmful but not how harmful. We hope this report will inform them. Many of our readers will want to control tobacco but not know how best to do it. We hope this report will aid them. Above all, we hope this report will provide policy-makers the necessary impetus to initiate and implement a coordinated comprehensive national strategy for tobacco control. K. SRINATH REDDY 15 November 2004 PRAKASH C. GUPTA iv Tobacco Control in India Acknowledgements Advisory Group SAMIRA ASMA ALTAF LAL Associate Director Science Section Global Tobacco Control Office on Smoking and US Embassy Health New Delhi Centers for Disease Control and Prevention Atlanta India USA VINEET GILL MUNISH DILEEP BAL National Professional Officer Chief, Cancer Control Branch Tobacco Free Initiative California Department of Health Services World Health Organization (Country Office) USA New Delhi India THOMAS J. GLYNN Director, Cancer Science and Trends KHALILUR RAHMAN American Cancer Society Regional Focal PointTobacco Free Initiative Washington World Health Organization (SEARO) USA New Delhi India NISHA GUPTA Public Health Analyst K. VIKRAM