Paper size: 210mm x 270mm The war against tobacco A progress report from the Indian front A report from the Economist Intelligence Unit Sponsored by Pfizer LONDON NEW YORK HONG KONG 26 Red Lion Square 111 West 57th Street 6001, Central Plaza London New York 18 Harbour Road WC1R 4HQ NY 10019 Wanchai United Kingdom United States Hong Kong Tel: (44.20) 7576 8000 Tel: (1.212) 554 0600 Tel: (852) 2585 3888 Fax: (44.20) 7576 8500 Fax: (1.212) 586 1181/2 Fax: (852) 2802 7638 E-mail: [email protected] E-mail: [email protected] E-mail: [email protected] The war against tobacco A progress report from the Indian front Contents Preface 3 A global battle 5 On the Indian front... 7 Outlook: Continued scattered gunfire 13 © The Economist Intelligence Unit 2009 1 The war against tobacco A progress report from the Indian front © 2009 The Economist Intelligence Unit. All rights reserved. All information in this report is verified to the best of the author’s and the publisher’s ability. However, the Economist Intelligence Unit does not accept responsibility for any loss arising from reliance on it. Neither this publication nor any part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Economist Intelligence Unit. 2 © The Economist Intelligence Unit 2009 The war against tobacco A progress report from the Indian front Preface The war against tobacco: A progress report from the Indian front is an Economist Intelligence Unit report, sponsored by Pfizer. The Economist Intelligence Unit bears sole responsibility for this report. The Economist Intelligence Unit’s editorial team conducted the research, carried out in-depth interviews with relevant experts and wrote the report. The findings and views expressed here do not necessarily reflect the views of the sponsor. The editor of the report was Manoj Vohra, and Gaddi Tam was responsible for design and layout. Our sincere thanks go to the executives who participated in interviews for sharing their time and insights. March 2009 © The Economist Intelligence Unit 2009 3 The war against tobacco A progress report from the Indian front 4 © The Economist Intelligence Unit 2009 The war against tobacco A progress report from the Indian front A global battle ccording to the World Health Organisation (WHO), an estimated 100m people died prematurely Aduring the 20th century as a result of tobacco use, making it the leading preventable cause of death and one of the top killers overall. Another 1bn more may die from tobacco use this century if current trends continue unchecked. Many countries have clamped down on smoking in public places, increased tax rates on tobacco and implemented other measures designed to curb smoking. Over 150 countries have already ratified the Framework Convention on Tobacco Control (FCTC), which requires countries to take a range of anti-smoking measures. India, the world’s second-largest consumer and third-largest producer of tobacco, is among those taking action. There are currently about 240m tobacco users aged 15 years and above (195m male and 45m female) in the country. In all, 57% of men and nearly 11% of women use tobacco in some form, according to a recent government survey. About 120m Indians smoke cigarettes and a leaf-rolled local mini cigarette—the bidi (the remaining tobacco users are chewers). More than 800bn bidis and 100bn cigarettes are sold in India each year. The WHO predicts that India will witness the fastest rate of rise in deaths attributable to tobacco in the first two decades of the 21st century. A recent study by the New England Journal of Medicine makes equally horrifying predictions. It estimates that 1m people will die prematurely in India each year during the next decade because of tobacco use. India’s tobacco problem has serious implications for the country’s fragile healthcare system. The total cost of just three tobacco-related diseases—coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and tobacco-related cancers—is estimated to be over Rs308bn (US$7.2bn)1 1 Based on 1999-2000 costs; Report on Tobacco Control in per year. This is ironic and shocking for a country which is struggling to provide basic healthcare India, Ministry of Health and infrastructure and services to its billion-strong population. Family Welfare, Government of India, 2004 While India’s central government has implemented several measures to control tobacco use over the past decade, these have been mostly piecemeal and ineffective. “Despite the plethora of laws and regulations, it is only since 2007 that more effective anti-tobacco measures such as smoke-free rules have been instituted and implemented,” according to a senior official from India’s Ministry of Health. Even now, according to experts, India’s roadmap for tobacco control seems convincing only on paper. “While several tobacco control laws exist in the country, implementation and enforcement remain a challenge,” says Hemant Goswami of the Burning Brain Society, a voluntary civil-society organisation in India with a focus on tobacco policy. Prevalence of tobacco use in India Males (%) Females (%) (age group: 15-54) (age group: 15-49) Tobacco users: 57.0 10.8 Smokers 32.7 1.4 Chewers 36.5 8.4 © The Economist Intelligence Unit 2009 5 The war against tobacco A progress report from the Indian front History of tobacco control in India 2001: Ministry of Railways imposed ban on sale of gutkha (a packaged chewing tobacco) in railway stations, inside trains and on railway premises. 1975: Cigarettes (regulation of production, supply and distribution) Act. 2001-2003: Production and sale of chewing tobacco products banned in states of Tamil Nadu, Andhra 1980: Central and state governments imposed Pradesh, Maharashtra, Madhya Pradesh, Bihar and restrictions on tobacco trade and initiated efforts for Goa using the provision of the Prevention of Food comprehensive legislation for tobacco control. Adulteration Act. 1990: Central government issued directive 2003: The Cigarettes and Other Tobacco Products prohibiting smoking in public places, banned tobacco (Prohibition of Advertisement and Regulation of Trade advertisements on national radio and TV channels, and Commerce, Production, Supply and Distribution) advised state governments to discourage sale of Act (COTPA), 2003 was introduced. tobacco around educational institutions and extended the display of statutory health warning to all chewing 2004: India became a signatory to Framework tobacco products. Convention on Tobacco Control (FCTC)—one of the first ten countries in the world to do so. 1999: High Court of Kerala announced ban on smoking in public places. 2007: India defers pictorial health warning issue repeatedly. It is now expected to be implemented from 1999: Ministry of Railways banned sale of cigarettes May 31st 2009. and bidis on railway platforms and in trains. 2008: Revised smoke-free rules implemented that 2000: Central government banned tobacco defined public places and identified people responsible advertisements on cable television. for maintaining smoke-free work places. The government announced that all public places across 2001: Supreme Court of India mandated a ban on the entire country would go smoke-free. smoking in public places. 6 © The Economist Intelligence Unit 2009 The war against tobacco A progress report from the Indian front On the Indian front… he strategies adopted by India are all tried and tested in the developed world. In India, however, Tsome initiatives are easier to implement than others. Measures like a comprehensive, nationwide ban on smoking in public places and a ban on direct tobacco advertising are showing encouraging results. For instance, many public places (restaurants, offices, shopping malls, etc) have gone smoke-free after the government’s comprehensive smoke-free policy announcement in October 2008. Taxation policy, however, has not yielded the desired results because it has not been evenly applied across different tobacco products, leaving users with cheaper alternatives to their usual fix (in some countries like Canada and South Africa, higher taxes on tobacco have led to a significant decline in the number of tobacco users). On other counts such as mandatory use of pictorial healthcare warnings on tobacco products, public awareness and structured cessation programmes, India seems to be lagging behind other countries—and this undermines the holistic approach that appears to have been the key to the effectiveness of other countries’ anti-tobacco crusades. Despite a broader commitment to curbing tobacco use, concrete actions aimed at doing so remain hampered by politics and weak enforcement capabilities. A prime example is the introduction of mandatory pictorial warnings on tobacco packaging. India made a binding commitment to have pictorial health warnings on all tobacco products by ratifying the FCTC in 2004. However, according to Mr Goswami of Burning Brain Society, a strong political lobby protecting the interests of the tobacco industry has prevented the necessary legislation from being introduced. Despite the FCTC ratification, pictorial warnings were included on the government’s agenda only after a writ was filed by an advocate in the Simla High Court. Originally pictorial warnings were to be implemented in February 2007, but the government has since then deferred the move six times. The government now aims to implement the measure by May 2009. The type of warnings to be used has also been toned down—instead of photos of cancer sufferers and gangrened feet, there will be a lung X-ray and a scorpion. Public health activists argue that pictorial warnings are effective in educating young children who may take up the habit and millions of illiterate people in India who consume tobacco without knowing its ill effects. India’s government, rather surprisingly, believes that graphic images will hurt Indian sensibilities, and hence the scorpion and X-ray will mildly remind people of the dangers of tobacco.