Graphic pictorial health warnings are a proven and effective strategy to create awareness, especially among the illiterate and children, about the harms of tobacco.
The recent order from the Karnataka high court quashing the rule mandating 85% pictorial warning on the packaging of tobacco products has brought to light several lesser-known issues. The judgment is a big setback for the public health movement globally and in India; Prime Minister Narendra Modi’s ambitious goal of leading the world’s fight against tobacco also suffered a massive blow. At 85%, India ranked at No. 3 in the world (in terms of pictorial anti-tobacco warnings), while Pakistan ranks at 106 with a 40% warning. This judgment has pushed India 103 places down in the rankings – tying with Pakistan for the same spot of 106 in the world.
The court is reported to have said two contradictory things in the same order – that the 85% pictorial warning is unconstitutional, and that the central government is free to make a proper law to set right the infirmity. If a law is judged to be unconstitutional, it will remain unconstitutional even if remade; if the court found fault with procedural infirmity, it does not need to get into the constitutional merit of that law. Courts do not unnecessarily look into the constitutional merit of any law unless the law is first found or presumed to be procedurally proper and lawful.
Prior to the 85% rule coming into being, tobacco products in India needed to display pictorial warnings of harms such as cancer on the one side of the product, covering 40% of the area. This meant that the rest of the area was available to the tobacco industry for their advertisements and to make their products look attractive for customers. So 40% of one side of the packaging was a warning, while 60% of the same side and 100% of the next side was for promotion.
The recent rule by the Indian government to increase this warning to 85% on both sides was part of its commitment towards public health. This meant only 15% of a tobacco product package was available for marketing and promotions of these products. The intention behind this is simple: make the warnings more clear and reduce the promotions. We do not need research and scientists to tell us that customers needs to know if they are buying a product which has the potential to kill them. The bigger the warning, the clearer the message and the less attractive the product looks.
Then health minister Harshvardhan, in keeping with the vision of the Modi government, wanted India to have the largest package warning – 85% of the area – in the world. Pakistan followed India’s example, and soon Nepal announced 90% pictorial warnings. No sooner was the change to be implemented on April 1, 2015, a controversial remark from a BJP MP spurred on the ‘does tobacco really cause cancer in India’ argument.
Graphic pictorial health warnings are a proven and effective strategy to create awareness, especially among the illiterate and children, about the harms of tobacco. There is an added advantage in India – with the existence of 122 major languages, pictures could speak a thousand words.
That tobacco kills is known. But did you know that annually, India loses around ten lakh patients to tobacco-related diseases? In Karnataka alone, around 6,000 people succumbed to cancer caused by tobacco in the year 2011. As per the Global Adult Tobacco Survey by the World Health Organization, 28% of people in the state use tobacco, which accounts to around 1.5 crore people. It is estimated that 30% of these tobacco users will die ten to 12 years prematurely due to various diseases such as cancer or heart or lung ailments.
Consider these statistics about Karnataka’s tobacco consumption:
- Every day 20 people die from tobacco-related cancers in Karnataka.
- The number of new cases of cancer annually in India (incidence) is 10,44,242; the number in Karnataka is 51,070.
- Total number of cancer cases at a given time (prevalence) in India is 28,19,457; in Karnataka it is 1,37,889.
- 2,688 persons die annually only because of chewing tobacco in urban and rural areas, according to the Directorate of Economics.
The healthcare system in India is largely governed by the private sector (80%), which means a person who embraces these habits eventually ends up spending from his/her own pocket to treat the illnesses it causes. This leads to an increase in the financial burden on him/her and his/her family. This is a serious concern, since 80% of India’s population resides in villages, and 75% of the population has purchasing power of less than Rs 100 ($2) per day. How do we expect them to bear the increasing costs of healthcare and, more importantly, why should they pay this price?
According to the government, it’s because the economy needs tobacco. Revenue from taxation, exports and employment (agriculture, advertisement, vendors) are important for fiscal gains. The government on average earns about Rs 17,000 crore from taxes and exports on tobacco, but the expenditure on health diseases caused by tobacco is of the order of Rs 1,00,000 crore.
Another common reason quoted for inaction on this issue is the concern for the well being of our farmers. There is no doubt that this is vital and while it is our duty to protect the interests of farmers who may suffer, it is also our responsibility to not ignore the lakhs of patients and their families who already suffer from dreadful illnesses contributed to by the promotion of these products. It is also paramount to protect the health of the 28% (nearly 1.8 crore) of the citizens in Karnataka who use these tobacco products and will be future patients for the healthcare system. Would it not be more appropriate to prevent this calamity, rather than to get more sanctions for new hospitals?
As a doctor, I often observe that it is not only the patient who undergoes the treatment, but also his or her entire family which bears the brunt both emotionally and financially. Furthermore, lots of these patients do not have access to healthcare in their villages and hence need to move to towns or cities with better facilities.
Despite advances in technology, science has not been able to significantly improve the cure rates in these cancers caused by tobacco. Some may wonder why that is. But why keep looking for an antidote instead of trying to fight the prevalence of the poison?
Modi initiated a exemplary campaign on drugs to raise awareness about the negative impacts of addition. Drugs are illegal and not easily available. However, addiction to tobacco is not just legal, it is also promoted.
Dr Vishal Rao is a head neck surgical oncologist and robotic surgeon at HealthCare Global, Bangalore.