The controversy on Union Health Ministry’s decision, to defer the mandatory display of large pictorial health warnings (PHWs) on tobacco packs, has mostly focused on the conflict of interest created by a beedi industry owner influencing the recommendation of the Parliamentary Committee on Subordinate Legislation. While this brings tobacco industry influence to the forefront for public scrutiny, it is also necessary to highlight the need for effective pictorial warnings.
The World Health Organisation’s Framework Convention on Tobacco Control (FCTC) came into force in 2005 and now has 180 countries as Parties to the treaty. FCTC prescribes several measures for reduction of both demand and supply of tobacco. An important demand reduction measure is the placement of prominent health warnings on all tobacco product packages, to caution current and potential users, on the harmful effects of tobacco consumption. Elaborate guidelines have been developed and adopted by the Parties to FCTC, including India, on how these warnings should be displayed as a combination of pictures and text.
India passed its own legislation in 2003, to regulate all tobacco products. This too has a provision for health warnings which must be displayed in a rotational series of different warnings. Under this provision, the Health Ministry has to periodically issue notifications on the nature of warnings that must be displayed — covering the size, content and nature of display.
The intent of mandating PHWs on tobacco product packs is to communicate the very real and horrific health risks of tobacco consumption, to dissuade a user from continued or first use of these dangerous products. While public education campaigns also do that, the effect of seeing the graphic picture of tobacco related disease on a pack which is personally handled is stronger and immediate.
Warnings adopted by many countries now depict scary images of cancer, heart attack, stroke, leg gangrene, respiratory failure, cataract, impotence and low birth weight or stillbirth on tobacco packs. These are indeed among the dangerous effects on health, of which most people are unaware. Now we know that tobacco consumption also increases the risk of acquiring and dying from TB and even of developing diabetes. Warnings also convey the fact that second hand smoke harms loved family members.
The guidelines provided by FCTC call for both prominent surfaces of the pack to be covered by the warnings. It is recommended that over 50 per cent of the area should be covered, though the minimum mandated is 30 per cent. Several countries have opted for PHWs which cover 80 per cent or more. Australia introduced plain packaging, which eliminates brand colours and logos but only lists the brand name in plain lettering. This not only reduces the visual appeal of the pack but also highlights the pictorial warning. Ireland and United Kingdom have recently enacted similar laws and New Zealand is likely to follow soon.
The need for prominent pictorial warnings is even greater in India than in high income countries, because the largest segment of tobacco users in our country are poor and have low levels of literacy. Yet, the introduction of effective warnings on tobacco packs of smoked and chewed products has been slow and stubbornly resisted by the tobacco industry. Initially, two very feeble warnings were introduced, with a scarcely discernible spot in a Chest X-Ray and cartoon of a scorpion, supposedly indicative of cancer. Field studies showed that people did not understand what they meant. The international symbol is the crab and not the scorpion!
More recently, stronger pictures have replaced those comical attempts at subterfuge. However, the 40 per cent display on only one surface means the total display area is only 20 per cent, falling short of FCTC’s minimum requirement. A larger warning, with 60 per cent picture and 25 per cent text, has been proposed. The Health Ministry now has pre-tested larger warnings and dummy packs have been prepared even for conically shaped beedi packets. The new set was to be notified on April 1, 2015. However, the recommendation of the Parliamentary Committee halted the notification.
The health risks, of active and passive consumption of tobacco, are well proven by several scientific studies from India and abroad. Even beedi smoking has been shown to increase the risk of cancer and heart attacks.
Every tobacco user has the right to be informed of the health risks, so that an informed choice can be made. If our policy makers are earnest in their commitment to reduce tobacco consumption and its harm to the Indian people, as stated in the legislation passed unanimously by the Parliament in 2003, they should introduce effective PHWs without delay or dilution. If cancer does not make a pretty picture, neither does political procrastination in protecting people's health.
President, Public Health Foundation of India, Delhi
