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Tobacco Control in Contemporary India

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					06/12/04




      Tobacco Control in Contemporary India




                                      Investigator
                                 Dhirendra Narain Sinha
                         School of Preventive Oncology (POS),
                 A/27 Anandpuri, Boring canal Road, Patna, Bihar 800001

                                  Research Assistants:
                                 Cecily S. Ray, Mumbai
                                  Mrinal Singh, Patna




                                      June 29, 2004


                       This document has not been published.
        Acknowledgement: The development of this document was supported by the
              World Health Organization, South East Asia Regional Office
                     Work on this project began in August, 2002.


Disclaimers: Opinions expressed in this document are of the authors andmay differ from
those of the WHO, SEARO. The authors of this document take full responsibility for any
errors or omissions it may contain.




                                                                                   1
ABBREVIATIONS
ACASH           Association for Consumer Action on Safety and Health
ACS             American Cancer Society
ACT-India       Action Council Against Tobacco-India
ADIC            Alcohol and Drug Information Centre
AFTC            Advocacy Forum for Tobacco Control
AIIMS           All India Institute of Medical Sciences
AP              Andhra Pradesh
ARI             Area Replacement Index
BBC             British Broadcasting Company
CBSE            Central Board of Secondary Education
CCFS            Central Committee on Food Standards
CDC             Centers for Disease Control, Atlanta, Georgia, USA
CERC            Consumer Education & Research Centre
CERS            Consumer Education & Research Society
CLEAR           Council for Labour Education & Social Research
CM              Chief Minister
CMDR            Centre for Multi-disciplinary Development Research
CPAA            Cancer Patients Aid Association
CRY             Child Relief and You
DATE            Drugs, Alcohol, and Tobacco Education
DHFW            Department of Health and Family Welfare
DPH&PM          Department of Public Health and Preventive Medicine
FBIS            Francois Xavier Bagnoud India Societies
FBRS            Francois Xavier Bagnoud Rajasthan Societies
FCTC            Framework Convention on Tobacco Control
FCV             Flue Cured Virginia
FDA             Food and Drug Administration
GCRI            Gujarat Cancer and Research Institute
GSPS            Global School Personnel Surveys
GYTS            Global Youth Tobacco Surveys
HAP             Health Action by People
HC              High Court
HELP            Health Education Library for People
HOT             Health or Tobacco
HRIDAY-SHAN     Health Related Information Dissemination Amongst Youth – Student
                Health Action Network
ICMR            Indian Council of Medical Research
ICS             Indian Cancer Society
ICTC            Indian Coalition for Tobacco Control
ILO             International Labour Organization
IMPACT          International Movement Promoting Action Against Cancer and Tobacco
INB             Intergovernmental Negotiating Body
INGCAT          International Non Governmental Coalition against Tobacco
IPC             Indian Penal Code
                                                                           2
ABBREVIATIONS,   Continued
ISAS             Indian Society Against Smoking
ISEH             Indian Society for Environmental Health
ITC              Indian Tobacco Company
IUALTD           International Union Against Tuberculosis and Lung Disease
MACT             Manipur Branch of ACT-India
MGMT             Mahatma Gandhi Memorial Medical Trust
MOH              Ministry of Health
MOHFW            Ministry of Health and Family Welfare
MP               Madhya Pradesh
MRTPC            Monopolies and Restrictive Trade Practices Commission
NGO              Non-Government Organization
NIH              National Institutes of Health
NOTE              National Organization for Tobacco Eradication
NSS Scheme       National Social Service Scheme
NTA              No Tobacco Association
NTCC             National Tobacco Control Commission
OSH              Office on Smoking and Health
PATH             Program for Appropriate Technology in Health
PGI              Post Graduate Institute
PIL              Public Interest Litigation
PMCH             Patna Medical College and Hospital
POS              School of Preventive Oncology
RCF              Rajasthan Cancer Foundation
SB               Salaam Bombay
SCOPE            Society for Cancer in Oral Cavity Prevention through Education
SEARO            South-East Asian Regional Office of the WHO
SJMP             Sarva Jeeva Mangal Pratisthan
POS              School of Preventive Oncology
TIFR             Tata Institute of Fundamental Research
TV               Television
UIB              Union Information and Broadcasting
UICC             Union International Contre Cancre - International Union
                 Against Cancer
UK               United Kingdom
UP               Uttar Pradesh
VHAI             Voluntary Health Association of India
VMT              Vasantha Memorial Trust
VOICE            Voluntary Organization in the Interest of Consumer Education
WARLAW           Women’s Action Research and Legal Action for Women
WHA              World Health Assembly
WHO              World Health Organization
YAT              Youth As Teachers Programme, Nigeria
ZZPA             Zafrani Zarda and Pan Masala Association of India


                                                                             3
                    Tobacco Control in Contemporary India

CONTENTS                                                                       Page
    Abbreviations                                                                2
    Table of Contents                                                            3
    Executive Summary                                                            5
    Introduction and Background                                                 12
    Objective                                                                   19
    Methodology                                                                 19
1   Chapter 1 - Tobacco control Policy in India                                 20
1.1 Tobacco Control Policy                                                      20
1.2 Policy Development – The process                                            32

2   Chapter 2 - Government and non-government institutions in tobacco              57
    control in India
2.1 Government Institutions                                                        57
2.2 Non-Government Institutions                                                    74

3   Chapter 3 – Policy implementation and gaps in tobacco control              100
3.1 Implementation of Tobacco Control Policies                                 100
3.2 Gaps in the Implementation of Tobacco Control Policies and Mechanisms      101
    to Address Them

4.   Next steps                                                                148

5.   References                                                                149


TABLES AND FIGURES                                                             Page

Figure 1.1.   Tobacco Production and Population Growth in India, 1949-1997         13
Figure 1.2    Logo Developed by National Tobacco Control Cell, India               60

Table I.      Annual Consumption Manufactured Cigarettes and Bidis in India,       16
              1970-1999
Table 1.1     State Tobacco Control Laws in India, as of March, 2004            31
Table 2.1     Cancer Institutes                                                 77
Table 2.2     Scientific Institutes - Government, Semi Government and Non       61
A&b           Government                                                        78
Table 2.3     Strengths and Weaknesses of Non-Government Institutions           92
Table 3.1     Gaps in Tobacco Control in India in the Community, the           101
a, b, & c     Government and in the Non government organisations               to
                                                                               104


                                                                               4
                                   Executive Summary

Executive Summary

       The objective of the present study was to identify gaps in tobacco control and suggest
ways of filling them.

        This report is introduced by a brief description of tobacco production and product
manufacture in India. Tobacco use in terms of prevalence and product preferences are
summarised. The costs and benefits of tobacco in the economy are symbolically weighed,
using results of published studies.

        India is home for 1/6th of global population and is second largest grower of tobacco
leaf. About 80% of tobacco produce is consumed in the country. Tobacco is used in India in
various forms. Bidis and Cigarettes, Hukka, Cheroots and other indigenous products are
smoked where as tobacco leaf(with variable ingredients) and Gutka are chewed and some
tobacco products are applied on teeth and gums as dentifrice.

       The methodology used herein was a search of literature and reference to legal
provisions, as well as personal communication with various tobacco control advocates and
Ministry of Health officials.

         The report is an overview of tobacco control efforts in India. Chapter one describes
policies in force the process of their development. Chapter two describes the institutions
involved in tobacco control, both Government and non-Government, with their strengths and
weaknesses. Chapter three describes efforts in tobacco control policy implementation and
gaps therein. Mechanisms to address these gaps are suggested by experts in the field of
tobacco control.

       In India, policy-making and legislation are done at the levels of the States and the
Union. Current tobacco control policy at Union level is in the form of Acts, Taxation, and
Amendments to Acts, Executive Orders, Codes of Conduct, Judicial Orders and
Recommendations.

        The Union Government took the first step in tobacco control legislation in 1975, after
realising to an extent the magnitude of tobacco related health problems in the country, with
the promulgation of the Cigarette Act, (Regulation of Production, Supply and Distribution),
1975. After that, the Government of India and some State Governments, on the
recommendations of the Parliamentary Committee or after some judgements of the Supreme
Court/High Courts, passed some executive orders on tobacco control. Certain NGOs played a
key role in following up the process of development of these regulations.

       Under the Cigarettes (Regulation of Production, Supply & Distribution) Act, 1975, all
the manufacturers or traders in cigarettes have to display legible, prominent, colored and


                                                                                       5
conspicuous "Cigarettes smoking is injurious to health," on all packets and cartons of
cigarettes and cigarette advertisements.

        Under the Prevention of Food Adulteration Act (Amendment), 1990, chewing
tobacco and pan masala need to bear the statutory warning, "Chewing of tobacco is injurious
to health", and "Chewing of pan masala may be injurious to health", respectively.

        The Drugs and Cosmetics Act 1940 (Amendment), 1992, bans tobacco in dental care
products. The Cable Television Networks (Amendment) Act, 2000 prohibits tobacco
advertising in state-controlled electronic media and publications and on cable television.

        In 1990, through an Executive Order, the Union Government prohibited smoking in
all health care establishments, government offices, educational institutions, air-conditioned
railway cars, chair cars, buses, suburban trains etc. Smoking is banned on all domestic flights
in the country. In 1995 use of tobacco and tobacco products within school premises by the
students, teachers, parents and visitors was banned from 1995 for all CBSE schools.

        In 1995 the Ministry of Health of India submitted the first draft of comprehensive
tobacco control legislation to the Parliament. The key issues were to: (1) Prohibit advertising
and promotion of all tobacco products; (2) Place restrictions on smoking in certain specified
public places and (3) Make printing of nicotine and tar content on the packs a mandatory
requirement. After this bill was withdrawn for various inadequacies, a new tobacco control
bill was introduced in Parliament on 7th March, 2001 and was referred to the Standing
Committee on the 12th March 2001. The Standing Committee gave its recommendations
and the bill completed the process of going through Parliament in April, 2003. Rules and
regulations are being formulated and notifications are on the way.

       In 1999, the Railways Ministry banned the sale of tobacco products, smoking and
gutka and pan masala advertisements on railway premises and trains.

       The apex courts like Supreme Court of India, Kerala High court a banned smoking in
public places in 1999 and this was declared a punishable offence in November, 2001.

        From the early 1990s, bidis began to be taxed, albeit at very low level. Gutka is also
taxed and this tax has increased in subsequent years. Eighty-two percent of total tobacco
excise revenue in India comes from cigarettes. The Union Government has continued to
raise taxes on cigarettes in subsequent years.

       The Union Government has taken some initiatives in public education. Among them,
the National Cancer Control Programme and Radio Dates, 1999, are important ones.

       In India, a number of States have laws to control tobacco use and protect the rights of
non-smokers. Current tobacco control policies at State level are in the form of Acts,
Executive Orders and Judicial Orders.



                                                                                         6
       The Goa (1999) and Delhi Prohibition of Smoking & Spitting Act, 1997, prohibits
smoking or spitting in places; prohibits tobacco advertising; the sale of tobacco products to
minors; and prohibits the sale or distribution of tobacco products within 100 meters of
educational institutions. In Goa, additionally, this Act makes it mandatory for a "No
Smoking/Spitting" board to be prominently displayed at all places of public work.

       Smoking in public places is also banned by law in the States of Maharashtra, Andhra
Pradesh, Himachal Pradesh, Tamil Nadu, Meghalaya, Jammu and Kashmir, Assam,
Rajasthan and Sikkim.

       In 2001, Tamil Nadu banned the sale, manufacture and storage of gutka, other forms
of chewing tobacco and pan masala. Shortly thereafter, this had to be modified to permit the
manufacture and storage of these products temporarily until certain issues were resolved.
Maharashtra, Kerala, Andhra Pradesh, Goa, UP, MP and Gujarat have also banned gutka.

        Non-government organisations (NGO) and individuals have initiated some judicial
interventions through litigation. In addition NGOs have taken interest in advocacy, initiatives
for a smoke- free society, and support for the Framework Convention on Tobacco Control
(FCTC), research and promotion of alternative crops, alternative uses of tobacco, community
interventions, and motivation for cessation. A cessation initiative by one of the private sector
companies (Alkalis and Allied Chemicals Ltd.) is one of the most encouraging role models
for cessation in India. NGOs were successful in community intervention through their
innovative models such as Youth Parliament Model, school models personnel for community
intervention, and communication strategies for rural populations and a tobacco behaviour
modification model.

        There have been several national and international consultations on tobacco control
issues taken by government and non-governmental institutions, mostly supported by the
WHO.

        Existing laws and policies are not properly implemented. The main reasons behind
this are corruption, lack of political will and bureaucratic cooperation as well as high rates of
tobacco use prevalence among policy implementers and media personnel. Goa is
implementing its policy better than other States in India.

        The results of the Global Youth Tobacco Survey in 15 States, till date, clearly
indicate that 87.5 % (median) (67.3% in the northeastern states) students of 13-15 years have
purchased tobacco products without restrictions. About 80 % of students were exposed to
tobacco advertisements in various media.

        Until the recent passing of the Act, 2003, there was no legal restriction on tobacco
advertisements near educational institutions and sale of tobacco products to minors, except in
Assam, Delhi, Goa, Sikkim and West Bengal. No data on enforcement of this legislation was
available.



                                                                                          7
        Some of the reasons identified by tobacco control activists for poor implementation of
laws are as follows: (1) People are poorly informed on tobacco issues, (2) There is a lack of
motivation to take up the issues, (3) There is no clearly designated agency for policy
implementation, (4) Policies are weak, (5) Selfish and shameless actions of the tobacco
industries (6) There is a lack of opposition to the actions of the tobacco industry and (7) a
lack of follow-up action to policy implementation.

        A multi-pronged approach and use of multiple sectors for true implementation is
required. Such an approach would include (1) Community mobilization, (2) Sustained
motivation, (3) Powerful central and state-level mechanisms for implementation, (4)
Comprehensive tobacco policies, (5) Follow-up action and (6) Strong opposition to the
actions of the tobacco industry.

        The tobacco industry must be strongly opposed. Strong public opinion against evils of
the tobacco industry needs to be created by informing the public of the true story of the
multi-national and national tobacco industries killing millions of people globally and in
India. The critical components of opposition to tobacco industry include strong media
advocacy on the Framework Convention on Tobacco Control, public interest litigations,
moving into consumer courts for compensation of victims and unyielding resistance to the
targeting of youth by the tobacco industry.

        Non-government institutions involved in tobacco control in India have been identified
by their previous work in the field of tobacco control. For this report, names of NGOs have
been suggested by members of NGOs of excellence in this field and by their peers. Apart
from these organizations there are many more groups and individuals involved in tobacco
control in India

        There are many academic and health care organizations involved in health research
related to tobacco and other tobacco control activities but some potential institutions like
Association of Health Professionals, the Association of School Personnel, the Association of
Students, various labour unions and the Association of Media Personnel need to be sensitized
to be involved in tobacco control in India.

        The WHO is sponsoring tobacco cessation programs in 12 centres in India, where
pharmaceutical aids to tobacco cessation are being made available along with counselling
and other therapies. A special feature of this program is the inclusion of smokeless tobacco
cessation (apart from smoking), which is a very new topic in tobacco control.

       In the Union government, The Ministry of Health, the Ministry of Information and
Broadcasting, the Food and Drug Administration, the Ministry of the Environment, the Home
Ministry, the Ministry of Labour, the Ministry of Industry and the Ministry of Excise are the
concerned units of the Government of India involved in tobacco control. Under the Ministry
of Health there is an active Anti-tobacco Cell. This cell has been putting lot of efforts for
tobacco control. There is no such cell in any other ministry.



                                                                                       8
       In state governments, there is no specific anti-tobacco cell. District Magistrates are
expected to look into matters of implementation of tobacco control policies.

        The strengths and weaknesses of non-government organizations (NGOs) involved in
tobacco control were identified by self-reports, information from peers, documents of the
World Health Organization, South-East Asian Regional Office (WHO, SEARO) on NGOs,
and materials of meeting highlights. Analysis of the expertise of NGOs involved in tobacco
control has been performed on the basis of their previous published and presented work.

        The NGOs have expertise in advocacy, in judicial intervention, youth intervention, in
community intervention, in tobacco related consumer movement, in material development for
advocacy, in media advocacy, but only a few are involved at full priority to tobacco only.
The general weakness of almost all the organizations is with regard to action, whether it is
legal action or mass-based action on the streets. There is poor networking amongst anti-
tobacco groups and a lack of funds for anti-tobacco activities including counter-advertising.
Non-government institutions need to develop expertise in research, planning, designing and
implementing of need-based interventions, fund raising and in working with all those sectors
needing activation for effective tobacco control.

       Mechanisms to strengthen the weaknesses of non-government institutions involved in
tobacco control include increased use of collective and individual approaches by the NGOs
themselves, capacity building by mutual training in their respective weak areas, outside
support to NGOs by the WHO or other institutions and sensitizing of other institutions
having the potential to work in tobacco control.

        The strengths of government institutions in India involved in tobacco control include
their power to enact laws, power of implementation, tremendous support from NGOs, the
Judiciary, from the WHO and other international agencies, recommendations of expert
committees and of the Parliamentary Standing Committee, and their own research findings.
Internationally there are many examples of government institutions strongly supporting or
active in tobacco control, from which to draw inspiration.

        The weaknesses of government institutions involved in tobacco control have included
a lack of political and bureaucratic will, large investments of public funds in the tobacco
industry, corruption, opposition within the government, absence of a responsible nodal
agency within the government, lack of coordination in actions, opposition from the tobacco
industry in several agencies.

         There are various gaps in current tobacco control efforts on the part of government
institutions. Areas of inadequate legislation include faulty taxation policy that taxes cigarettes
much more highly than other products, and a lack of uniformity in rules and restrictions
among the different States and Territories. Other gaps include poor implementation of
existing policies, encouragement to the tobacco industry, conflict of objectives, insufficient
counter advertisements and a lack of mechanisms for speedy and efficacious judicial
remedies. Also, the schools governed by state governments do not have a tobacco policy in
most of the States in India.

                                                                                          9
         The judicial system in India is grappling with population pressure, as in other
developing countries, and hence there are delays in justice. Such a situation goes to the
advantage of the tobacco industry, which takes cover under the purported reason that cases
are still being under judicial consideration. This allows the industry time to carry on its
activities and consolidate its position in the market. An example is that of the 'VOICE vs.
ITC, Ltd.' case in 1984, where an advertising strategy of ITC was challenged in court by
VOICE. The case was not decided in time. Meanwhile, WILLS had expanded its market and
was successful in sponsoring the Indian Cricket Team. In India there is a lack of consumer
petitions on tobacco related harms and losses.

        There is data that clearly indicates the astronomical amounts the tobacco industry
spends annually on advertising their various brands against the proven health and social
problems that they raise. These actions include sports pages of newspapers in the wake of the
proposed ban on tobacco sponsorship of sports events and gutka advertisements spotting the
cover pages of school notebooks. Point of sale advertising flourishes adjacent to schools and
colleges as also in restaurants. Tennis tournaments in the country have been sponsored by
Gold Flake and boat racing by Four Square cigarettes. The gutka industry has patronized the
Film fare Awards; the National Bravery Awards recognizing heroes for courage, adventure,
and spontaneous physical action were sponsored by Red and White cigarette brand; local
festivals have been celebrated with great fanfare by gutka companies. The Wills "Made for
Each Other" contest, the "Gold in Gold" contest offering Gold gift options to tobacco users of
Four Square Gold cigarette packs, product placement in movies, free sampling of cigarettes
and gutka sachets, surrogate advertising on television and brand stretching and product
diversification are other examples of advertising tactics the tobacco industry invests in.

       Gaps at the level of non-government institutions and the community include the
absence of a strong NGO lobby, poor networking among NGOs, unplanned tobacco control
approaches by NGOs, a lack of research, a low level of community mobilization, a lack of
awareness in the public, a lack of interest among the medical fraternity, a lack of matching of
requirements and needs to expertise and resources, lack of a clear chain of command for
addressing the problem of non-compliance, and limited pleas on the taxation issue.

        Mechanisms to address gaps in tobacco control include the following: enforcement of
the recently passed anti-tobacco Act, 2003, creation of a strong political will, discussions
within Parliament, creation of a central office/nodal agency on tobacco control, i.e.,
something stronger and more central than the Tobacco Control Cell, which has been created
in the Ministry of Health and Family Welfare. Suggestions for NGOs include effective and
sustained NGO networking, combined approaches, mutual capacity building, total action,
community mobilization, public education, school intervention, tobacco cessation, alternative
crop intervention, ratification of the FCTC, a multi-sectoral approach, workshops on tobacco
for various sectors, integration of tobacco control with other programmes, 'tobacco mapping',
research laboratories, mechanisms to safeguard against brand stretching and surrogate
advertising, strong and effective warnings, multilateral taxes, withdrawal of tax-free
tobacco exports, curtailment of legal channels for tobacco imports and the reduction of tar,
nicotine and nitrosamines in tobacco products.

                                                                                       10
11
       Tobacco Control in Contemporary India


Introduction and Background


This report is an attempt to give a working knowledge of tobacco control in India from 1975
onwards and to analyse the gaps that make it less effective than it could be. “Tobacco
control” refers to policy measures as well as preventive measures and strategies for cessation
of tobacco use. This introduction gives an overview of tobacco production, use, profitability
and health in India from the mid 1900s.


Tobacco production


India is the third largest tobacco producing country in the world, producing about 575,000
                                                                             1
MT (metric tonnes), after China (2,400,000 MT) and Brazil (654,250 MT). However, India
                                                                                              2a
produces only about 3.3% of the world’s Flue Cured Virginia (FCV) or cigarette tobacco.
According to the Tobacco Board of India, the country is also the sixth largest exporter in the
world. The area under cultivation has increased only about 31% from 0.35 million hectares in
1949, to 0.46 million hectares in 1997, while the area cultivated under irrigation has
increased nearly five times from nearly 10% in 1952 to 48% in 1995. Yield nearly doubled
                                                                 3
from 770 kg/hectare in 1949 to about 1400 kg/hectares in 1997.
       The production of tobacco leaf and tobacco products has been increasing over several
decades in India, approximately following population growth, but tending to falter in
comparison to population growth since the mid-1980s (Figure 1.1).




                                                                                         12
Figure 1.1


                      Tobacco Production 3
                  & Population Growth 4 in India,
                            1949-1997


  1.2
     1
  0.8
  0.6
  0.4
  0.2
     0
     1940           1950          1960            1970        1980          1990          2000
                                                  Year

                             PRODUCTION (Million tonnes)
                             POPULATION (billions)

   National Census figures used for population.    (This figure appears in another document in press.)




Some tobacco control advocates in India feel that the ready supply of tobacco products
                                        5
sustains or increases consumption.
         Tobacco products include home-made and vendor-made products as well as cottage
industry (bidis) and industrial products (cigarettes and some bidis). Evidence suggests that
the formal manufacture of bidis in India began in the late 1880s and by 1930 the bidi industry
                                   6
had spread across the country.         The first Indian cigarette factory in India was established in



                                                                                                     13
                                             7
1906, by the Imperial Tobacco Company.           Later, Phillip Morris also entered India and
several smaller Indian cigarette companies emerged.


The Profitability of Tobacco


As a cash crop, tobacco can be the most remunerative, even compared to groundnut, black
                   8d
gram and cotton.        However, the families of tobacco farmers often pay a high price for
cultivating tobacco, as it is labour intensive more than any other crop – children drop out
from school and mothers neglect their homes, the care given to tobacco during the curing
process being like the care given to a patient in an intensive care unit, as described by farmer,
whose family refused to continue taking on the responsibility of tobacco. Additionally, every
tobacco season, workers fall ill during the processing period with an occupational illness
                                                                         9
known as green tobacco sickness, and spend money on health care.
       Beedi industrialists earn fabulous profits (nearly 25% of cost), have a net worth of
between Rs. 50-100 crore and have strong political clout and have occupied posts of MP and
MLA. Some have contributed to philanthropic causes. The money-fed beedi lobby in
Madhya Pradesh was once strong enough to prevent entry of any large industry into the area
in order to perpetuate the dependence of the region’s poor on beedi making. Now with
                                                                      6, 10
competition from mini-cigarettes, the beedi industry is declining.
       The gutka industry in India has grown from small beginnings twenty years ago to a
multi-billion rupee industry with nearly 375 brands, of which, nearly 100 of them are located
in Mumbai. One of the largest, the Manikchand Group of industries, began producing gutka
and pan masala in 1991. In an interview for rediff.com, its Chairman, R.M. Dhariwal, of
Pune, estimated that the total industry-wide sale of gutka, including exports was around
                                                                         11
Rs.50 billion a year before the ban, but there was no official record.        Another major
player in the gutka industry is Kothari Products, Ltd., whose net worth doubled between
September, 1997 and March, 2001. In the 18-month period ending March, 2000, the pan
masala division contributed 96.3% of the total revenue while the packaging division
contributed 3.3% of the total revenue of Rs3.2 billion and its other products, like zarda,

                                                                                           14
spices, oils etc, contributed 0.4% of total revenues during the year. The company exports Pan
Parag to USA, Australia, Middle East, Europe and other parts of the world. State bans on the
                                                                                 12
sale of gutka have affected sales drastically, according to India Infoline.
          As a single commodity, tobacco is the fourth leading revenue earner for the Union
Government, contributing about 10% of total excise revenues and nearly 5% of agricultural
exports from India, corresponding to over Rs. 5000 crores and Rs.1060 crores respectively in
            2a, 13
1997-98.             Exports amount to about one fifth of tobacco produced in India (especially
FCV) and a small portion of tobacco used in India is imported. Forex earnings from tobacco
increased seven fold during 1990-1999 and excise collections from tobacco tripled during the
          14
period.        Clearly tobacco has been a major revenue earner for the Government of India.


Profitability versus Economic Dependence
          Tobacco is a single season crop with a short growing season, allowing farmers to
                                                    15
grow other crops during the rest of the year,            however, tobacco is mostly sown during the
                                                                    8d
monsoon (July-August), and in some areas in March-April,                 competing with food crops.
Tobacco can be grown along with other crops by intercropping, and is often grown on a
portion of a cultivator’s land. As mentioned in the writ petition of Ramakrishnan versus the
                           16
State of Kerala, 1999,          and in a report of the Tobacco Research Institute, Rajahmundry, the
price of FCV tobacco has become erratic and non-remunerative due to increasing awareness
of the health hazards of cigarettes and the use of tobacco in other forms, necessitating stiff
restrictions on tobacco cultivation. Thus many tobacco farmers are looking for a switch over
                                               17
to other suitable and remunerative crops.


Tobacco use in India
The approximately 200 million tobacco users in India consume eighty percent of Indian
                                                                                        8c
tobacco, spending Rs. 24,000 crore (Rs. 270,000 million) on tobacco annually.                During
1950-1955, the annual per capita adult consumption of tobacco in India was around 900g,
which declined to 700g by the late 1980s, small values compared to developed country

                                                                                                15
standards. Per capita tobacco consumption has been increasing by about 3% per year
                                 15
according to industry sources.         At least 30% in men and 12% of women use tobacco,
according to the National Sample Survey of 1998-99 and the National Family Health Survey-
                14
2 of 1998-99.        Information on prevalence of tobacco use available from house-to-house
studies in six different parts of India ranged from 44% to 74% in the general population;
                                                                             18
specifically among men 60% to 80% and among women 15% to 67% .
       In India, tobacco is smoked, chewed and applied to gums and teeth. Less than one-
fifth (19%) of tobacco consumed in India is used in cigarettes, about half is smoked as bidis
                                                                                       8d
about a third is used in smokeless forms and the rest as other smoking products.            In recent
years India has been witnessing a resurgence of smokeless tobacco consumption in
industrially manufactured forms, especially amongst the young.
       Tobacco is applied by millions for dental care. Although incorporation of tobacco in
dental care products is prohibited, this continues. In the recent Global Youth Tobacco
Surveys conducted on high school students aged 13-15 years in 12 north-eastern States, a
range of 11.3% (in Sikkim) to 68% (in Bihar) regularly applied some form of tobacco, the
most popular products being tobacco toothpaste and toothpowder, while several other
                                  19
products were also mentioned.
       Data on yearly per capita consumption of bidis and cigarettes as reported in the WHO
Country Profiles on Tobacco or Health, 2002 are shown in Table below:
Table I. Annual Consumption Manufactured Cigarettes and Bidis in India, 1970-1999 14
                       Cigarettes                                  Bidis
Year        Annual Average                  Total          Annual Average               Total
            Adult (15+ yrs)           Consumption in       Adult (15+ yrs)        Consumption in
              Per Capita              Millions of Sticks     Per Capita           Millions of Sticks
             Consumption                                    Consumption
1970             190                       62,908               840                   284,971
1980                  180                  75,197              1,130                  446,113
1990                  101                  54,867              1,220                  601,911
1999                  147                  95,975              1,297                  850,000




                                                                                              16
Tobacco and Health in India


Health researchers in India have been studying the association of tobacco with various
diseases, like cancers, heart disease and chronic obstructive respiratory diseases and they
found that tobacco was responsible for nearly a third of cancers, over half of coronary artery
disease cases and nearly a third or more of chronic obstructive lung disease cases. The cost of
these diseases in 1999 was estimated to be at least Rs. 27760 crores (Figure 2), including
                             8e
direct and indirect costs.        The findings on health risks due to tobacco have been consistent
with those found elsewhere in the world.




                                                                                           17
Figure 2. The costs and benefits of tobacco in India.




                         Tobacco on the scales:
       + BENEFITS                                                    -   COSTS




                                                                 Pain,
                                                                 suffering,
              “Enjoy-
              ment”
                                                                 & death.

            Yr 1998-99
                                                                     Yr 1999
       Sales: Rs. 24400
                                                                  Costs of
       crores; Excise
                                                                  disease: at
       revenue: Rs.
                                                                  least Rs.
       5540 crores;
                                                                  27760 crores
       Agro-exports:
       Rs.1060 crores.




              Which side weighs more?
                                                                                           8e
                                (Expert Committee Report ICMR Department of Health 2001)


       From the foregoing information it is clear that tobacco control in India is weak.
Hence the idea for this report, to identify areas where efforts in tobacco control need to be
directed.




                                                                                           18
Objective


The objective of this report is to identify gaps in tobacco control in the areas of policy,
implementation, actions of the civil society (the ‘Community), the non-government
organizations and the government institutions in the various sectors and to suggest ways of
filling up the gaps.




Methodology


       Chapter 1 of this report begins with a listing of tobacco control policies emerging
since 1975, and proceeds with a description of their development. Copies of the legal
documents were consulted as well as published articles about them and their development.
       Chapter 2 describes the work of institutions (both government and non-government)
in tobacco control. A questionnaire was sent to 36 non-government organizations (NGOs)
known to the WHO, SEARO that often work together in coalitions for advocacy on policy
issues and of these, eight replied (by e-mail). The general observations of the NGO
representatives (tobacco control advocates) about the anti-tobacco work of other NGOs were
also compiled. Personal communication and literature review were other means to obtain
information about NGOs.
       Chapter 3 elaborates on problems in policy implementation and ends with a
discussion of gaps in tobacco control in the country, as identified through the replies from
NGOs and individual tobacco control advocates, as well as other sources.
       Other information for this report was gathered from the following types of sources:
   •   Communication with the Ministry of Health (MOH)
   •   Communication with the World Health Organization, SEARO.
   •   Globalink searches and other internet searches
   •   Published books and articles




                                                                                          19
Chapter 1


Tobacco Control Policy in India



This chapter is in two sections:


1.1. Tobacco Control Policy
1.2. Policy Development – the Process




1.1 TOBACCO CONTROL POLICY


This section lists and briefly describes existing policies made at the levels of the Union and
the States.




1.1.1 Policy at Union Level




The existing types of regulations at Union level are the following:


      Acts and their Amendments
      Executive Orders
      Supreme Court Orders
      Reports and Recommendations
      Codes of Conduct
      Taxation



                                                                                        20
Under each of these categories are listed the policies and then the contents are briefly
described under each policy:


     Acts and their Amendments


1. Cigarettes (Regulation of production, Supply & Distribution) Act, 1975
2. Prevention of Food Adulteration Act 1954 (Amendment), 1990
3. Drugs and Cosmetics Act 1940 (Amendment), 1992
4. Cable Television Networks 1995 (Amendment) Act, 2000
5. The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and
   Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003


1. The Cigarettes (Regulation of Production, Supply & Distribution) Act, 1975


Warnings on cigarette packets advertisements became mandatory in India under the
Cigarettes (Regulation of Production, Supply & Distribution) Act, 1975 (in force since April
         20
1976).        Under this Act, all the manufacturers or persons trading in cigarettes had to
display a statutory warning, “Cigarettes smoking is injurious to health” on all cartons or
packets of cigarettes and cigarette advertisements. The Act stated that the statutory warnings
should be legible, prominent, and conspicuous as to size (a minimum of 3mm on cigarette
packets) and colour, visible to consumer before opening the packet. The warning had to be
presented in distinct contrast to the background colour or the written or graphic material of
the package. The language(s) used in the warning had to be the same as those used elsewhere
on the package or advertisement. In the case of cigarettes, this usually was English. The Act
did not apply to cigarettes that were to be exported unless the country to where they were
                                                               21
being exported required a health warning on the packages.




                                                                                           21
2. Prevention of Food Adulteration Act, 1954 (Amendment) Rules, 1990


Since 1990, the scope of the Prevention of Food Adulteration Act, 1954 was

expanded to cover chewing tobacco and pan masala, whereby these products need

to bear the statutory warning, “Chewing of tobacco is injurious to health”, and

“Chewing of pan masala may be injurious to health”, respectively. Every package of


areca nut is to carry the warning “Chewing of supari is injurious to health”. 22, 23



3. Drugs and Cosmetics Act 1940 (Amendment), 1992


In 1992, an amendment in the Drugs and Cosmetics Act, 1940 barred manufacturers from
                                                                         22
using tobacco as one of the ingredients in toothpaste and toothpowder.




4. Cable Television Networks (Regulation) Amendment Act, 2000


The Cable Television Networks (Regulation) Act, 1995 was replaced in 2000 by an
amended Act. The Advertising Code framed under its Rules prohibits advertisements
directly or indirectly promoting the production, sale or consumption of cigarettes, tobacco
products (or alcoholic beverages, infant milk substitutes infant food or feeding bottles). The
Head Postmasters are the Registering Authorities for the cable operators whose offices are
                                                   24
situated within their territorial jurisdictions.


5. The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and
Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003




                                                                                        22
This Act, an amended version of the draft Bill of 2001, completed its passage through
Parliament on 30th April, 2003 and was assented to by the President of India on May 18th,
2003. The rules and regulations are presently being formulated with input from experts. The
Act of 2003 applies directly to the whole of India, to all types of tobacco products and
primarily involves demand-reduction strategies geared to prevent new entrants to tobacco
use. It does not contain any provisions directly regulating tobacco production nor does it ban
                                                     25
the sale of any tobacco product, except to minors.


The Cigarettes and Other Tobacco Products Act, 2003 covers the following:


   1. Prohibition of advertisement of cigarettes and other tobacco products except at point
       of sale or on a warehouse, and a ban on sponsorship.
   2. Prohibition of sale of cigarettes or other tobacco products to a person below the age
       of eighteen years and within a radius of 100 yards of any educational institution.
   3. Restrictions on trade and commerce in, production, supply and distribution of,
       cigarettes and other tobacco products without specified warnings on the packaging.
   4. Manner in which the specified warning shall be made. The language(s) in which the
       warning is to be expressed must correspond to the language(s) used elsewhere on the
       packaging.
   5. Language in which the specified warning shall be expressed: it has to match
       that/those elsewhere on the package.
   6. Testing laboratory for nicotine and tar contents.
   7. Power of entry and search (for products without proper warnings)
   8. Power to seize (packages, advertisements)
   9. Punishments for offences
   10. Power to add any tobacco products to the Schedule
   11. Power of the Central Government to make rules
   12. Act not to apply to cigarettes or other tobacco products that are exported.




   Executive Orders
                                                                                           23
1. 1990-Order banning smoking in some public places
2. 1995- School policy for all CBSE schools
3. Sale and use of tobacco products in Railways ban
4. Smoking ban by Railways
5. Ban on advertisements by Railways




1. 1990 Ban on smoking in some public places


   To protect non-smokers, in 1990, through an executive order, the Government
   prohibited smoking in all health care establishments, government offices, educational
   institutions, air-conditioned railway cars, chair cars, buses, suburban trains etc.
                                                                  26
   Smoking is banned on all domestic flights in the country.


2. 1995 - School policy for all Central Board of Secondary Education (CBSE) and
  Navodaya Schools


 In 1995, the use of tobacco within the school premises by the students, teachers, parents and
                                                         27, 28
 visitors was banned from 1995 for all CBSE Schools.              In addition, the Central school
                                                                                 29
 subset has a special code of conduct on no tobacco use within the premises.          The Jawahar
 Navodaya Vidyalay Samiti, which runs the Navodaya Schools, had not provided any specific
 written code on tobacco use for these schools but a tobacco policy was enforced in these
 schools through the Central Government circulars. However, both these subsets of schools
 have (Central Schools and Navoday schools) been told by the Central Government to ban
                                                                            27
 sales of tobacco and tobacco products within a distance of 100 metres.


3. Sale and use of tobacco products Railways ban




                                                                                           24
 On June 5, 1999, World Environment Day the Railways Ministry banned the sale of
 cigarettes and bidis on the railway platforms as well as inside the train to promote public
                                                      30
 health and cleanliness of the stations and trains.        In 2001 the Government contemplated
 banning the sale of gutka in railway stations and trains in view of the fact that gutka
                                                                   31
 makes trains and stations dirty, and is also harmful to health.


4. Smoking ban by the Railways: Indian Railways Act, 1989


 In early 2002, the Railways Board banned smoking on railways premises. The blanket ban
 took effect immediately and is applicable countrywide. Persons caught smoking on
 railways premises, including railway property, office buildings another establishments
 such as railways production units, can be prosecuted under the Indian Railways Act, 1989,
                     32
 and fined Rs 100.


5. Ban on advertisements by the Railways


 In late 2002, the Western Railways banned gutka and pan masala advertisements on
 railway premises and trains. Advertisements for cigarettes and other tobacco products are
                                                       33
 to be phased out as their contacts come to an end.




   Supreme Court Orders, Notices, Stays


1. In 1999, the Supreme Court issued notices to four leading tobacco companies on public-
   interest petition seeking permanent display of the statutory warnings against smoking in
   advertisements in the news and publications media, and on billboards. The notices were
   limited to the alleged violation of the statutory obligation in the Cigarette Act of 1975 to
   display warnings permanently. The Court was told that the law on statutory warnings
   was being flouted by tobacco companies, which resorted to every possible measure to
   make the warning inconspicuous, including surrogate advertising and brand stretching.
                                                                                           25
   In addition, absence of regulation, it heard, had encouraged foreign periodicals to
                                                               34
   publish tobacco ads in India without any warnings at all.        VHAI (Voluntary Health
   Association of India), a Delhi based health NGO, sought to counter surrogate
   advertisements or brand stretching ploys initiated by tobacco companies by resorting to
   litigation against WILLS (a subsidiary of BAT) for indulging in sponsorship, by the
   Indian Cricket team by filing a case on the 13th of May 1999 under Article 226 of the
                        35
   constitution of India.


2. In September, 2001, the Supreme Court, in response to a writ petition of 1999, passed
   an order to the Central Government for implementing the 1975 Act banning smoking in
   public places. It issued directions to the Union of India, the State Governments and to
   the Union Territories to take effective steps to ensure prohibition of smoking in public
   places, namely: auditoriums, hospital buildings, health institutions, educational
   institutions, libraries, court buildings and public offices. Nevertheless, the Central
   Government did not respond to the Court during the hearings. In November, 2001, the
                                                                               36, 37
   Supreme Court declared smoking in public places a punishable offence.


   Reports and Recommendations


   1. The twenty-second Report of the Indian Parliament Committee on sub-ordinate
       legislation (Tenth Lok Sabha, 1995): The Committee had considered the issue of
       rules and regulation framed under the Cigarette Act after consulting evidence
       provided by various government officials, persons concerned with tobacco
       promotion and anti-tobacco promotion activists. The Committee observed that the
       guidelines on warnings were often not followed. Considering the tobacco issue in
       totality, the Committee expressed the need for stricter measures and provided
       various suggestions for control of tobacco. Its recommendations led to the
                                                                                        20, 38
       modification of the proposed comprehensive legislation on tobacco control.




                                                                                            26
   2. The CCFS recommended a ban on smokeless tobacco products in 1998, as a result
                                                                                          39
         of an earlier litigation on tobacco tooth powder in the Rajasthan High Court.


   Codes of Conduct at Union Level


At present, the Programme and Advertising Code applies to the government controlled
electronic media that prohibits them from carrying advertisements related to alcohol and
tobacco products. However, tobacco advertising continues unrestricted in newspapers,
                                                                      40
magazines, posters, billboards, and in videocassettes of Indian films.


The Advertising Standards Council of India Voluntary Code, 1998 envisages prohibiting
advertising targeting underage consumers, as well as suggestions that using tobacco
products is sage, healthy or popular; enhancing courage. Being a voluntary code, it has little
                    41
enforcement value.




   Taxation at Union Level


According to Article 246 and the Seventh Schedule of the Constitution of India, Parliament
has exclusive power to make laws with respect to excise duties on tobacco produced in the
country. All manufactured tobacco products are to be taxed under the Finance Acts. Various
duties are levied, such as SED, National Calamity Contingent Duty, etc. Eighty-seven
(Pricewaterhousecoopers) percent of total tobacco excise revenue in India comes from
                                                                         42
cigarettes and they were taxed at a rate of 55% of retail price in 1999.      Part of this revenue
goes into research for higher yields of tobacco. The specific excise duty rate for cigarettes
based on their length was introduced in 1987, with a lower rate on mini-cigarettes (59mm
         43
long).




                                                                                            27
                                                                                 44
The north-eastern states are exempted from excise duties on tobacco products.         This is
probably to prevent some smuggling by keeping prices down, since most cigarette smuggling
takes place across international borders in this area.




1.1.2 Current Tobacco Control Policy at State level


In India, several States have legislation and/or other policies to control tobacco use and
protect the rights of non-smokers. This section briefly describes State level tobacco control
policies under the following headings:


   Acts (State Level)
   Executive Orders (State Level)
   Judicial Orders (State Level)
   Taxation (State Level)
   Other Initiatives (State Level)


   Acts (State Level)


 1. The Maharashtra Police Act, 1951, Section 116:
      “No person shall in any court, police station, police office building occupied by the
     Government or building occupied by any public body, smoke or spit in contravention
                                                                         45
     of a notice by a competent authority in charge of such places …”
 2. The Goa Prohibition of Smoking & Spitting Act, 1999 prohibits smoking or spitting in
     places of public work or public use, as well as in public service vehicles in the State of
     Goa. It also prohibits tobacco advertising, sale of tobacco products to minors (below
     21 years), and sale or distribution of tobacco products within 100 metres of a place of
     worship and educational institutions. In addition, this act makes it mandatory for a



                                                                                          28
   “No Smoking/Spitting” board to be prominently displayed at all places of public work.
   46, 47, 48

3. The Delhi Prohibition of Smoking and Non-smokers Health Protection Act 1996
   prohibits smoking in places of public work or in public service vehicles. It also
                                                   46, 49
   prohibits sale of tobacco products to minors.
4. Public smoking is also banned by legislation in the States of Himachal Pradesh, Tamil
   Nadu, Meghalaya, Jammu and Kashmir, Assam, Rajasthan, West Bengal and Sikkim
                     50
   by legislation.


  Executive orders (State level)


1. The State of Maharashtra issued a resolution containing orders prohibiting smoking in
    August, 1987, applicable inside the buildings, premises and compounds of all courts,
                                                                      51
    police stations and offices, and any government or public body.
2. On September 11, 2000, the Delhi Cabinet ordered a ban on the sale of cigarettes,
    rolled tobacco leaf bidis, and other substances of abuse to children younger than 18
                                                                                           24
    years of age. It also barred the sale of such products within 100 metres of schools.
3. In 2001, a notification of a ban was issued in Tamil Nadu by the Public Health
    Department against the sale, manufacture and storage of gutka and other forms of
    chewing tobacco and pan masala. This later had to be modified to permit the
                                                                               52
    manufacture and storage temporarily until certain issues were resolved.
    Maharashtra, Tamil Nadu, Kerala, Andhra Pradesh, Goa, UP, MP and Gujarat have
                     53, 54
    banned gutka.


    Judicial Orders (State Level)


1. In July, 1999, the Kerala High Court imposed a ban on smoking in public places as a
   result of litigation, based on Art. 21 of the Constitution regarding the fundamental right to
                                                                               55, 16
   the protection of life and Art. 268 of the IPC regarding public nuisance.
                                                                                        29
2. In 2000 the Kerala High Court directed kiosks in the State not to provide smokers with
   a light, such as the customary smouldering rope, small kerosene, lamp, petrol lighter
                  56
   or matchbox.
3. In 2000, the Delhi High Court, on a public-interest writ petition, specifically charging
   Delhi Government for not implementing sections 8 and 9 of the Delhi Prohibition of
   Smoking and Non-Smoker Health Protection Act, 1996, issued notice to the
   government to take necessary action. Sections 8 an 9 pertained to the sale of tobacco
   products to anyone younger than 18 years of age and sale of such substances in the
                                           24
   vicinity of educational institutions.
4. The State of Maharashtra banned the manufacture and sale of gutka in the state from
                       55, 57
   August 1, 2002.

5. In 2002, the High Courts in Uttar Pradesh and Madhya Pradesh had also banned Gutka
   but the same has been stayed. Tamil Nadu, Andhra Pradesh, Goa and Bihar have
   recently banned sale of Gutka in their states. Other States like Rajasthan have also
   shown an intention of banning sale of gutka. 23, 50




                                                                                      30
  Table 1.1 State Tobacco Control Laws in India, as of March, 2004
State or           Smoking in        Advertisement       Sale to minors    Sale/storage     Pan masala and gutkha
Territory          place of public   in place of         (date)            w/in 100 m of    bans (orders)
                   work or use or    public work or      below 18 years    educational
                   public service    use                                   institutions
                   vehicles
Andaman and
Nicobar
Andhra Pradesh                                                                              27 Feb., 2002: Pan
                                                                                            masala with tobacco and
                                                                                            chewing tobacco
Arunachal
Pradesh
Assam             1999 bill only       1999 bill only     1999 bill only   1999 bill only
Bihar                                                                                       1 April,2003
Chandigarh
Dadra & Nagar
Haveli
Daman & Diu
Delhi             26 January, 1997     26 January, 1997   5 Sept. 2000     1 Jan., 2001
Goa #             18 Aug., 1999        18 Aug., 1999      18 Aug., 1999    18 Aug., 1999;   26 Jan., 2003
Gujarat
Haryana
Himachal          1997 bill only       1997 bill only
Pradesh
Jammu &           29 April, 1997       29 April, 1997
Kashmir
Karnataka
Kerala            12 July, 1999        12 July, 1999
                  H. Court Order *     H. Court Order *
Lakshwadeep
Madhya P.
Maharashtra       Resolution of                                                             1 Aug., 2002
                  the Public
                  Health
                  Department,
                  1987
Manipur
Meghalaya         13 July, 1998        13 July, 1998
Mizoram
Nagaland
Orissa
Pondicherry
Punjab
Rajasthan         Yes – Document not
                  obtained
Sikkim            27 Aug., 1997        27 Aug., 1997      27 Aug., 1997    27 Aug., 1997
Tamil Nadu #      14 May, 2003         14 May, 2003                        14 May, 2003     19 Nov., 2001: includes
                                                                                            chewing tobacco
Tripura
Uttaranchal
Uttar Pradesh
West Bengal#      7 Dec., 2001         7 Dec., 2001       7 Dec., 2001     7 Dec., 2001

                                                                                               31
Notes: Dates shown are the latest mentioned in the referenced document. Table shows information available to the authors
in the form of notifications or pending bills as specified. # includes prohibition of spitting. * Order based on PIL based on
Constitution, IPC and Kerala Motor Vehicles Rules


      Taxation (State Level)
According to Article 246 and the Seventh Schedule of the Constitution of India, the States
have power to impose on taxes on luxuries and agricultural income. Ten State Governments
have imposed a luxury tax on cigarettes (ranging from 3 to 10 per cent), the most noteworthy
                 58
being Kerala.
Taxation on bidis: the early 1990’s bidis and other products began to be taxed, albeit at very
low level .


      Other Initiatives (State Level)


A crop holiday was observed in Maharashtra, Andhra Pradesh and Orissa for the year 2000-
   59
01.     This type of initiative, promoted by the Tobacco Board, actually has the purpose of
restoring the price of tobacco to a remunerative level after a slump.




1.2 POLICY DEVELOPMENT – THE PROCESS


The process of development of the above listed policies is briefly described in this section.
First a description of the international backdrop is given, and then the development of
policies at Union and State levels is described.




1.2.1 The Influence of the International Agencies


International organizations and India’s participation in their tobacco control activities form a
backdrop to policy development in India.
                                                                                                         32
       With an anti-tobacco climate strengthening throughout the globe since the mid-
eighties, the World Health Organization (WHO), of which India is a member, has been in
the background to anti-tobacco activity in India. Early research on oral and pharyngeal
cancers partly funded by the WHO in India had helped to bring out the role of tobacco in
cancer causation. In 1986, the 39th World Health Assembly, the governing body of the
organisation, resolved that “smoking control strategies” would include “measures to ensure
that non-smokers receive effective protection, to which they are entitled, from involuntary
exposure to tobacco smoke”. In addition, the 43rd Assembly in 1990 resolved that there
should be “progressive restrictions and concerted action to eliminate eventually all direct
                                                                              60
and indirect advertising, promotion and sponsorship concerning tobacco.
       The South-East Asian Regional Office (SEARO) of the WHO has been participating
in advocacy for tobacco control and inter-sectoral action for demand reduction. In addition,
SEARO assisted the Ministry of Health of the Government of India in drafting
                                             61                              55
comprehensive tobacco control legislation,        submitted to the Cabinet        in 1995.
       On May 25, 1996, the 49th World Health Assembly adopted a resolution that
requested the WHO Director “to initiate the development of a Framework Convention for
Tobacco Control in accordance with Article 19 of the WHO Constitution.” Three years later,
on May 24, 1999, the 52nd Assembly “recalled and reaffirmed” the 1996 resolution and
decided “to establish an Intergovernmental Negotiating Body (INB) open to all Member
States to draft and negotiate the proposed WHO Framework Convention on Tobacco Control
          60
(FCTC).        On 21st May, 2003 the World Health Assembly officially adopted the
Framework Convention on Tobacco Control in its Plenary session. Countries were called
upon to ratify the pact by the next meeting of WHO members in 2004 - it will become
enforceable when 40 countries ratify it. As of the end of July, 2004, 168 countries had signed
it and 25 had ratified it. India signed it on 10th September, 2003 and ratified it on 5th
February, 2004 (http://fctc.org/sign_rat/signed.shtml - Accessed August 4, 2004). In South
Asia, Bangladesh and Myanmar have also ratified it. Bhutan, Nepal and Pakistan have signed
it and are yet to ratify it. Ratification requires cabinet and Parliamentary approval. When 40
countries would submit their instruments of ratification by national authorities, the treaty


                                                                                             33
would "come into force". Only then the treaty could be called an internationally binding
legal instrument for implementation and operationalisation purposes.
        The purpose of the FCTC is to block the advance of the tobacco problem,
empowering governments to resist the tobacco industry by requiring countries within five
years of ratification (unless constitutional barriers exist.) to enact comprehensive legislation
to restrict advertising, require a higher standard of health warnings on product packaging,
reduce secondhand smoke by prohibiting smoking in public places, raise tobacco taxes to
increase prices, reduce cigarette smuggling and diversify agriculture away from tobacco. The
framing, enactment and enforcement of comprehensive laws in each country will engage a
cross-section of areas of governance: health, finance, trade, labour agriculture, and social
affairs. This time consuming multi-sectoral process has already started in several countries,
                   62
including India.
        In May 2000, the 53rd Assembly resolved “to convene the first session of the
Negotiating Body in October 2000”and “to draw up, for consideration by the Negotiating
                                                                 60
Body at its first session, a draft timetable for the process.”
        India, represented at the World Health Organization by both government as well as
non-government institutions, has taken a firm stand on various clauses of the Framework
Convention on Tobacco Control (FCTC) that protect the public health interest of member
countries. The progressive stand of the Indian Government delegation at the Second Round
of Negotiations on the FCTC fetched them an Orchid Award on its final day at Geneva in
April 2001, signifying positive contributions to tobacco control. The Award was instituted by
the Framework Convention Alliance, an international coalition of non-government
                                                63
organizations advocating for a strong treaty.
        During the third round of negotiations of the INB held in Geneva in late November
2001, delegates from across India, representing non-government organizations including
women's groups, youth groups, consumer activists and cancer care and prevention centers,
issued a joint declaration calling for deeper commitment from the opinion leaders of the
nations favoring public health and well-being over transient commercial gains. They
expressed hope that the Indian Government would continue to play a proactive role in
                                                                      63
leading the South-East Asian countries towards a strong FCTC.
                                                                                          34
        India expressed the desire for the creation of a Global Fund with a financial
mechanism to help tobacco-growing countries grow alternative crops. A suggested
mechanism was a tax on exported tobacco products. India emphasized its support for public
                     55
health over trade.        In this, India also emphasized the need for multi-sectoral actions and
comprehensive bans and wanted the prohibition of tobacco vending machines. Many other
                             63
countries supported this.
        January 2000, the WHO, SEARO began a year-long campaign to curb tobacco
consumption in South East Asia, in which educational programmes on television about
                           64
tobacco were initiated.         The WHO, India Office has been instrumental in providing seed
funding to NGO pilot projects on awareness generation and tobacco cessation in 2004.
        Since 1991, the World Bank has had a definite policy on tobacco, according to which,
it would not invest, lend for, or promote any tobacco related project, be it production,
processing, marketing or trade, with a qualified exception made for economies heavily
dependent on tobacco. Also, the policy of the World Bank on the health sector discourages
                                  60
the use of tobacco products.
          India is a founder member of the International Labour Organization, which came
into existence in 1919. India’s labour laws have been influenced by its relationship with the
ILO. Children working in the beedi industry generally work at home, but some work in the
employer’s home – working conditions have been found to be hazardous in both settings
and particularly abusive in the employer’s home. Under the Child Labour Act, 1986,
children below the age of 14 years are not permitted to engage in any hazardous work,
including beedi making, except in the process of family-based work. This essentially
                                                               65, 66
permits children to continue in this hazardous occupation.




1.2.2   Union Level Policy Development


In India, advocacy by non-governmental organisations (NGOs) has been helpful in
preparing the climate for tobacco control, through both community mobilization and

                                                                                           35
advocacy with policy makers and media. This climate also helped in eliciting judicial
                                                             67
intervention (e.g. ban on smoking in public places in 1990).      Tobacco control policies
have been built by government opinion makers and input from NGOs, based on results
from surveys conducted by various medical institutes, epidemiologists, anti tobacco groups.
                                                                              68
Public interest litigations (PILs), have also have also been a major input.
       The Cigarette Act of 1975 was based on public health concerns deriving from
earlier epidemiological studies conducted in the 1950s, ‘60s and ‘70s in India, the U.S.A.
and elsewhere on the association of health problems with tobacco use. Under this Act, the
Union Government regulated cigarettes, while the States had responsibility for regulating
all other tobacco products.
       The process of further policy development started in the early 1980s with public
awareness generation through lectures, programs on TV and Radio, articles in the
newspapers and magazines, education of students of schools and colleges regarding effects
of tobacco use, mobilization of youth for mass movement against tobacco, advocacy of
women’s organizations and other social and medical organizations towards legislators to
                                                   47
persuade them to adopt laws for tobacco control.
       Also in the eighties, the Consumer Education and Research Centre (CERC) took
Indian manufacturers of tobacco-based toothpaste to the Monopolies and Restrictive Trade
Practice Commission and compelled them to provide labelling information in English and
the local languages regarding the composition of the toothpaste, the content of tobacco and
a statutory health warning, stating tobacco is injurious to health. Manufacturers were also
                                                                                    23
directed to publish similar information in these languages in all advertisements.
     On the recommendations of the Luthra-Bisht Committee in 1984, the National Cancer
Control Programme was formulated, giving impetus to the anti-tobacco cause. Primary
prevention of tobacco related cancers became a major objective of this programme since,
according to research findings, tobacco-related cancers accounted for about one-third of all
cancers in the country. Within a few years, most of the States and Union Territories set up
                                              26
cancer control boards, under the programme.



                                                                                         36
       The international symposium held in January 1990 at TIFR, Bombay, (WHO
Collaborating Centre for Oral Cancer Prevention), with support from the U.S. Public Health
Service and National Institutes of Health, recommended two strategies for tobacco control:
public education and legislation/regulation. The recommendations for implementing public
education included four aspects: 1) education of children and youth to prevent tobacco use,
2) education of the public through the mass media on the ill-effects of tobacco, 3) education
of existing medical/paramedical personnel and 4) medical/paramedical students, on the
adverse effects of tobacco and on the prevention and cessation of its use. Recommendations
on legislation and regulation included the aspects of advertising, sports and event
sponsorship, health warnings, and product promotions, as well as bans on smoking in public
places. It was predicted that close interaction among scientists in health, agriculture and
                                                                                         26
industry, as well as politicians and administrators would strengthen political will.
       In 1990, the Government of India issued an Executive Order prohibiting smoking in
selected public places like hospitals, educational institutions, domestic flights, air
                                                     46, 23
conditioned trains and buses and suburban trains.             It appeared that tobacco control
was gaining momentum. Also in 1990, the scope of the Prevention of Food Adulteration
Act was expanded to cover chewing tobacco and pan masala, whereby these products need
                                     23
to bear statutory health warnings.
       Current policies for tobacco control have mostly evolved since 1991, as result of
further regional and national consultations on Tobacco or Health, conjointly organized by
the Ministry of Health and Family Welfare, Government of India and the WHO.
       The National Conference on Tobacco or Health, held on July 27 and 28, 1991 in New
Delhi, was organized by the Ministry of Health and Family Welfare, in collaboration with the
World Health Organisation at the All India Institute of Medical Sciences. Recommendations
were formulated on six aspects: a) Health education, b) Legislation, c) Tobacco economics
and agro-industrial restructuring, d) Role of youth and non-governmental organizations
(NGOs), e) Countering tobacco advertising and promotion and f) Research Priorities. The
recommendations of this meeting formed the basis for drafting an anti-tobacco bill, which
was later submitted by the Ministry of Health in 1995. After the draft bill was considered by
the Cabinet, it was diverted to a new Committee on the economics of tobacco or health.

                                                                                              37
Meanwhile, the recommendations for health education, which could have prepared the
public to respond favorably to legislation, were not taken up.
       Advocacy by non-governmental organisations with policy makers and the media has
been helpful in preparing the climate for legislation on tobacco control and in eliciting
                                                                     67
judicial intervention (e.g. ban on smoking in public places in 1990).     Tobacco control
policies were built by government opinion makers with input from NGOs, based on results
from surveys conducted by various medical institutes, epidemiologists, anti tobacco groups.
Public interest litigations (PILs) have also been a major input, including one filed by a
                                                      68
Member of Parliament on smoking in public places.          Further recommendations on
tobacco control legislation for the Union came out of two large meetings of concerned health
professionals that took place in January, 1990 in Bombay and July 1991 in New Delhi,
                                                                            69, 70
encompassing the aspects of public education, legislation and regulation.
       In 1992, the Union Government banned the manufacture and sale of tobacco based
toothpaste (‘creamy snuff’ or ‘manjan’) and toothpowder by the Amendment to the Drugs
and Cosmetics Act, 1940. A tobacco toothpaste manufacturer, Kastoori Udyog, filed a
petition in the Rajasthan High Court demanding that the respondent (the Government of
India) not interfere with their manufacture of tobacco toothpaste. This 'manjan,' which had
been manufactured for 20 years, was being sold as an ayurvedic medicine for several tooth
ailments. The Director, Ayurved Department, had granted a license in favour of the
petitioner. The Rajasthan High Court, however, ruled that there was sufficient risk posed to
human lives to let the Central Government prohibit manufacture of a drug containing
tobacco. Some years later, the Supreme Court dismissed an appeal by an Ayurvedic
manufacturer from Madhya Pradesh that had challenged a judgement of the State High Court
upholding the ban on tobacco based oral hygiene products. The Supreme Court ruled that the
government was justified in imposing the total ban in the public interest because oral hygiene
products containing tobacco can cause oral cancer, as stated by the World Health
                                        22, 35
Organisation and other expert bodies.
       In connection with the tobacco-based toothpaste and toothpowder controversy, the
Rajasthan High Court directed the Central Government to appoint a committee of experts to
determine the health effects of chewing tobacco in various products, including gutka, being
                                                                                        38
openly sold in the market as mouth fresheners and easily accessible to users of all ages. The
expert committee concluded that ample scientific evidence was available to prove that
consumption of gutka was harmful to health. A strong recommendation was made to ban the
use of chewing tobacco pan masala /gutka or in any other food items. The report was sent to
the Central Committee for Food Standards (CCFS), which included representatives of
consumer associations. The CCFS agreed with the expert committee on the proposal to ban
chewing tobacco. The report was then forwarded to the Ministry of Health and Family
                                             35
Welfare, which also supported the move.
          Intense lobbying ensued for and against the ban on chewing tobacco. The Ministries
of Commerce, Agriculture and Labour vehemently opposed the ban when the ban threatened
to hurt economic interests. The clash of opinions between the Ministries has been the cause
of delay of implementing a ban on chewing tobacco. On the instance of consumer groups like
VOICE (Voluntary Organization in Interest of Consumer Education), the CCFS reiterated its
recommendation for a ban. A convention of consumer organizations and NGOs held at New
Delhi on 2nd November, 1999 called upon the Indian Group of Ministries constituted for this
purpose to impose a ban on this product. Above and beyond the need for localized
networking, a need to improve communication amongst various stakeholders was being
increasingly felt. Identification of common interests was considered the first step in building
a network, which could acquire the force of a responsible pro-consumer lobby at the global
         35
level.
          In 1995 a Parliamentary Committee on Subordinate Legislation considered the issue of
reframing the Cigarette Act, 1975 after consulting evidence provided by various government
officials, tobacco promoters and anti-tobacco promotion activists. The Committee felt the need
for stricter measures and provided various suggestions for control of tobacco. The Committee
considered the information and views of various ministers, departments, experts and unions/
associations, connected with tobacco control as well as tobacco promotion. That same year, the
major impetus for a multi-sectoral approach for tobacco control occurred with the submission
                                   20
of the report of that Committee.        Considering the issue of tobacco in totality, the Committee
made wide-ranging recommendations, including strong, and rotatory warnings in regional
languages on tobacco products; prohibition of smoking in public places; initiation of measures

                                                                                          39
for awareness on tobacco through health infrastructure, educational institutions and mass
                                                                                                20
media, and initiation of efforts for persuasion of farmers to switch over to alternate crops.
Thus, the Government began considering a proposal to bring forward a comprehensive
legislation against the use of tobacco in the country.
       In 1995 the Ministry of Health submitted the draft of a comprehensive tobacco
control bill to Parliament. The key issues were to prohibit advertising and promotion of all
tobacco products, place restriction on smoking in certain specified public places and make
                                                                                71
printing of nicotine and tar content on the packs a mandatory requirement.
         Under the existing Cigarette Act of 1975, Parliament was competent to enact laws
relating to cigarettes, and not other forms of tobacco products, which instead fell within the
authority of the State Assemblies. Thus the amendments and additional proposals in the Bill
were deemed inadequate, and the bill was withdrawn. The Ministers began exploring other
steps that could be taken to discourage use of chewing of tobacco. Subsequent bills were
introduced into Parliament, only to be withdrawn later for other inadequacies. The valuable
views and suggestions expressed by the ministers during the successive debates were
incorporated in progressively later versions of the bill. The delay emphasized the complex
nature of the tobacco problem in the country. Ministers mentioned the need for striking a
balance between health considerations and the interests of the chewing tobacco
industrialists and workers, and to account for the revenue that the Government earns from
                  72
chewing tobacco.
       The long gap between the Cigarette Act of 1975 and a new tobacco bill was
attributed by anti-tobacco activists to the absence of a coordinated and consolidated anti-
tobacco lobby in the country. Most of the people who have raised their voice against the use
of tobacco have been researchers, epidemiologists or health professionals, like surgeons and
oncologists, who day in and out were seeing people suffering of tobacco related cancers or
cardiologists who had a hard time saving the victims of tobacco, who often died
prematurely. But a scarcity of informed activists who could dedicate time to lobbying kept
tobacco control at a slow pace. In the past several years some of these health professionals
became activists and the pace has increased. With their influence, now there are also civil
                                                                           73
servants in the Ministry of Health who are dedicated to tobacco control.
                                                                                         40
       In June 1999, Indian Railways, operating under the Government of India, banned
                                            46, 55
the sale of tobacco on railway platforms.
       Also in 1999, the Consumer Education and Research Society (CERS) filed a Writ
Petition (Public Interest Litigation) (No.7930/1999) against the Government of India, the
Government of Gujarat and the Manufacturers of Tobacco (of both smoking and non-
smoking products) appealing the court to (1) Direct the Union and the State Government to
immediately ban the sale and consumption of tobacco and tobacco products in all public
places and to minors (2) To direct the authorities to undertake compulsory education of
children and youth on tobacco hazards (3) Take up public campaign against the use of
tobacco products. Gujarat Cancer and Research Institute (GCRI) joined as a party to the
proceedings and filed a reply mentioning the increased use of tobacco particularly the
                                                                 23
smokeless tobacco products by an increasing number of minors.
       In 1998, the Central Committee on Food Standards (CCFS) recommended a ban on
smokeless tobacco products. The CCFS had collected scientific evidence that links chewing
tobacco with oral cancer and took into account other complications and various studies on
the health effects of tobacco from Indian research institutions, reporting that nearly 60-85%
of oral cancer cases could be caused due to the consumption of chewing tobacco. On this
basis the CCFS recommended a ban on such products. All the members of CCFS
unanimously wanted a ban on gutka because young boys and girls who fall into using gutka
regularly develop cancer over a shorter duration and die earlier respect to those who smoke
cigarettes or bidis. A renowned surgeon of Ahmedabad analysed information on 130 of his
cancer patients and found that among them, smokers contracted cancer after exposures
ranging from 15-68 years, while the gutka chewers contracted it within about 10 years of
exposure. Among patients who had died, the average age of death for patients who smoked
was 54 years, but for gutka chewers it was 41 years. Members of CCFS also wanted other
smokeless products banned, because women often used them, while shunning smoking
                                       74
products, due to social disapproval.
       The CCFS received a communication from the Committee of Secretaries appointed
by the Government of India, suggesting certain new wordings for the warnings on Gutka.
The members of CCFS replied to the Committee of Secretaries with the question of why,

                                                                                         41
after the unanimous recommendation by the CCFS of a ban on the manufacture and sale of
gutka, the matter was again being placed before them for examination of the warnings.
Again, in February 2002, the CCFS was again asked for recommendations on warnings for
gutka. Additionally, they were requested to do the same for pan masala. The Committee of
Secretaries had suggested ‘Pan masala may be harmful’, but the CCFS recommended that
                                                                     23
‘Pan masala is harmful if taken regularly’. This was not accepted.
       Newspapers reported in 1998 that as the Health Ministry pondered over a
recommendation to ban the production and sale of all chewable tobacco products, the Rs.
1400 crores (140 million) panmasala-zarda-gutka industry went into a ‘tizzy’. The industry
objected to the resultant loss of jobs and the loss of government revenue in excise duty (said
to be Rs.700 crores). A representative of the smokeless tobacco industry complained that
instead of banning cigarettes, the Government had singled out the chewing tobacco industry
                       39
on baseless grounds.        The Union Government said it would not press for a gutka ban until
                                                                                        75
all sides had been heard, even though some state governments had already banned it.
       When in 2000, the Union Information and Broadcasting (UIB) Ministry moved to
ban advertisements of tobacco and alcohol on cable networks, a spokesperson of the Cable
Association of India objected saying, "We are mere carriers of the channels.” Such a
statement was strongly objected to by the National Chairman, National Organisation for
Tobacco Eradication, representing 20 organisations in 14 States, in his letter to the Minister
for UIB, stating that this was like "The mosquitoes claiming that we are mere carriers of
malaria, or the rats saying they were the mere carriers of the flea that carries plague. “So
                 76
don't bother us!"     Nevertheless, in September 2000, an amendment to the Cable Network
                                                                                        24
Rules was made prohibiting the cable operators from airing tobacco advertisements.
       In 2000, CERC, along with a cancer patient and a cancer surgeon filed a writ
petition in the High Court of Gujarat against the Department of Health and Family Welfare
(DHFW), the Commissioner - Food and Drug Administration (FDA) and the Department
of Finance and Revenue (Spl C.A. No.10437/2000) to seek a ban on smokeless tobacco.
Unfortunately, the cancer patient died during the pendency of the case. An application was
filed in the case against the gutka manufacturers for compensation for the benefit of his

                                                                                         42
family. The Court directed the State Government to inform it of the expenditures for
treating cancer patients in the State and the total number of cancer patients in the public and
private hospitals. The prayer to formulate a compensation scheme related to the cost of
treating cancer patients is an effort to evolve a new principle in Indian Jurisprudence,
namely to affix financial liability on manufacturers of defective and harmful products, such
as gutka. The liability is a strict tort liability wherein the Government and the
manufacturers are liable for prima facie making available for sale, a harmful product even
though it may carry a warning. The principle of framing a common scheme is to ensure that
all past, present and future victims of cancer due to smokeless tobacco products are
compensated on the principle of strict liability by both the Government and the
                                              23
manufacturers of such defective products.
       In the first half of 2001, the Railways Ministry banned the sale of gutka on railway
platforms and inside trains in view of the fact that gutka makes trains and stations dirty and is
                        31
harmful to health.           In late 2002, the Western Railway recently banned gutka and pan
masala advertisements on railway premises and trains. It was ordered that advertisements for
cigarettes and other tobacco products had to be phased out as their contacts come to an end.
A company spokesman said the railway had certain social obligations and it was its
                                                                               33
endeavour, along with other agencies, to help in creating a good society.
       The revised comprehensive tobacco control bill was introduced in Parliament in
               46, 67                                                                 77
March, 2001.            The salient features of the new draft Bill were as follows:


       1. Prohibit the advertisement of all tobacco products. This has been identified by
           many studies as the most important prerequisite for tobacco control. It also
           responds to the principle that commercial enterprises must not be allowed to
           mislead the public.
                                                                        78
       2. Prohibit smoking in public places, as defined in the bill.         This is based on the
           premise of protecting nonsmokers from tobacco smoke and its attendant
           dangers. Children are the most vulnerable, as shown by scientific studies.



                                                                                            43
       3. Prohibit the selling of tobacco products to persons below 18 years of age. This
           is an emotive and politically correct policy, which even the tobacco companies
           support. However it is very hard to enforce, and has been found ineffective in
           curbing tobacco use among children, as children usually get what they want.
       4. Indicate nicotine and tar contents on the packets. This is to be seen in the context
           of the next point, although it does little for tobacco control and sometimes may
           actually be harmful by providing false assurances.
       5. Have warnings of adverse health effects on tobacco product packages in English
           as well as Indian languages. The public, as consumers, should be informed of
           the risks of using tobacco products.
       6. Place a total ban on sponsoring any sports/cultural event by cigarette and other
           tobacco product companies. Sponsorship is a form of advertising and as such
           should be banned. A study carried out in India showed that this form of
           advertisement led to children experimenting with tobacco
       7. Empowering Sub-Inspectors of Police or equivalent officers of State Food or
           Drug Administration of the Central/State Governments to carryout the
           provisions of this legislation and confiscation of the goods in case of any
                                                                46
           violation and to impose a fine for minor offences.


       The Bill was referred to a Standing Committee in March 2001 for further
                78                                                                       46
negotiations.        The report of the Standing Committee recommended the following:

   •   Use the overriding power provided for in the constitution to make the bill effective
       for other tobacco products all over the country.
   •   Require visual symbols as warnings through the Act itself.
   •   Rationalize penalties meant for sellers and manufacturers under the Act.
   •   Require the printing of maximum permissible levels of nicotine and tar on other
       tobacco products also.
   •   Ban the sale of tobacco products within radius of 500 yards of educational
       institutions.
   •   Remove the provision of arrest without warrant.

                                                                                          44
       In November, 2001, the Supreme Court issued a directive banning smoking in
enclosed public places as a consequence of a litigation in Kerala in which the Kerala High
Court banned smoking in public places. This demonstrated the interaction between actions
at State level and those at the Centre.
       Although tobacco control legislation at the Union level advanced slowly for some
years, there was in recently times a considerable and creative use of existing laws and
litigation by individuals and non-governmental organizations towards advancing tobacco
control, according to the Supreme Court Advocate, Ms.Rani Jethmalani. Under Part III, The
Fundamental Rights in the Constitution of India, Art. 21 provides for the Protection of life, of
which health can be construed to be a part. Art. 32 refers to 'Remedies for enforcement of the
fundamental rights', which include the right to move the Supreme Court. An individual or
group can ask the Supreme Court to make an order giving directions to the State, e.g. on
prohibition of smoking in public. Part IV of the Constitution contains the Directive Principles
of State Policy, under which, Art.47 refers to the Duty of the State to improve public health.
Although the Constitution states that the provisions contained there are not enforceable in
any court (due to financial limitations), they are nonetheless fundamental to the governance
of the country. Writ petitions to the Supreme Court have also often contained references to
                                                              74
these principles and the Articles of the Indian Penal Code.
       Also in November 2001, a petition by teen-aged school children, calling for speedy
action on a comprehensive tobacco control bill, collected a total of 877,404 signatures in the
southern state of Kerala, the campaign was organized by Health Action for People (HAP).
                                                                                           79
The Prime Minister of India personally congratulated the students and promised action.
       The antitobacco lobby felt it was high time for the comprehensive bill, pending for 8
years, to be passed, especially as momentum for the adoption of the FCTC was picking up,
needing full support around the world. The draft FTCT was to be tabled for adoption in mid-
             5
May, 2003.
       In November, 2001, the Supreme Court directed all States and Union Territories to
ban smoking in public places and transport and directed State agencies to enforce it. The
ruling came from a public interest lawsuit filed by a Congress leader in Maharashtra State. In
                                                           37
Chennai, hundreds of smokers spent the night in custody.
                                                                                          45
       In late February, 2003, an all-India coalition based in Delhi and Mumbai, called the
Advocacy Forum for Tobacco Control (AFTC), met in separate meetings in Mumbai and
Delhi. The coalition had the participation of experts on various aspects of public health
including research scientists, health professionals and officers from NGOs. AFTC member
organisations included the following: the Action Council Against Tobacco-India (ACT-
India), Mumbai, the Cancer Patients Aid Association, Mumbai, the Consumer Education and
Research Centre, Ahmedabad, Govt. Dental College & Hospital, Ahmedabad, Health Related
Information Dissemination Amongst Youth – Student Health Action Network (HRIDAY-
SHAN), New Delhi, Path – Canada, Mumbai, the Rajasthan Cancer Foundation, Udaipur,
Salaam Bombay Foundation, Mumbai, Sanrakshan, New Delhi, the School of Preventive
Oncology, Patna, the Voluntary Health Association Of India, New Delhi, and some
individual experts. A number of the representatives of these organisations had worked for
many years among vulnerable sections of society to campaign against the evils of tobacco.
       The timing was such that on the morning before the first meeting in Mumbai (20th
February, 2003) the newspapers had reported that the Indian Cabinet had tabled the new
Tobacco Bill in Parliament (Rajya Sabha). The group of experts availed of advice and
support from the American Cancer Society and planned to insure that the proposed law was
actually scheduled for a vote and passed by the parliament and to assure that it was free of
“loopholes”. They planned to target key decision makers with informative messages that
could persuade them to pass the bill. The participants planned to involve the media, through a
media relations consultant, supportive politicians, youth, associations of health professionals,
economists, consumer organisations and health NGOs in communicating these messages,
through letters, meetings, news articles, as well as interviews on television and radio. The
NGO HRIDAY-SHAN mobilised high school students to campaign in the capital for the bill.
Special informational cards were prepared by AFCT and distributed to the Ministers of
Parliament who were to meet for the pre-budget session.
       The Health Minister pledged support for the bill and helped to persuade the rest of the
Ministers. The National Tobacco Control Cell also supported the efforts of the AFTC and
suggested the timing of the actions. The hard work of the coalition bore fruit and within two
months the bill passed through both houses of Parliament: the bill passed through the Rajya
Sabha apparently on April 8th, though this was not noted to have been reported in the media.

                                                                                        46
An informal press meeting followed by lunch was arranged on April 18, 2003 in Delhi with
selected members of the press before the Lok Sabha debate, with the purpose of countering
some of the negative comments about the bill, which had appeared in some sections of the
press, especially non-English media. On Wednesday, April 23rd, the AFTC urged lawmakers
                                                                                                  80
in the Lok Sabha to expeditiously clear the bill as they were due to meet the following week.
       A few changes were made in the bill before its passage. For example, according to the
Health Minister, “When this matter came before the Cabinet, we felt that this 500 yards
recommendation of the Standing Committee was not feasible. That is why, we have reduced
                    81a
it to 100 yards.”
        The Bill passed successfully through the Lok Sabha on the evening of April 30th,
2003. According verbal feedback received by the Delhi organisers, the AFTC's efforts were
acknowledged and lauded by some of the MPs. This was believed to have been largely due to
the informational cards that AFTC sent them in relation with the bill. The Ministers also
referred to the appeals sent by HRIDAY-SHAN students to them for supporting the bill. This
                                                                           82
was cited by AFTC as a clear example of the fact that advocacy works!.
       The cards advocating the passage of the Bill distributed by the coalition to the MPs
stated that demand reduction due to the prohibition of advertisement would not be sudden but
will be spread over several years, giving sufficient time to set in motion alternate
employment opportunities to anyone dependent on or engaged in tobacco production. This
was to placate the fears of the MPs concerned about unemployment among tobacco workers,
farmers and retailers. The cards suggested the government could aid the process of
diversification wherein people engaged in tobacco production could be shifted to alternate
occupations (See Appendix - Cards).
       As emphasised by the Health Minister in the debate in the Lok Sabha, “…if we
impose restrictions on advertisements of these products, it will definitely affect the business
of these products, which may create problems of unemployment in the long run. In view of
this, we are exploring other alternative crops, which can give them more income. One such
type pf crop is medicinal plants. We are also continuously in touch with the other Ministries
as far as the question of beedi workers and tobacco growers are concerned”.


                                                                                         47
        After the passage of the bill, the Health Minister categorised the participants to the
debate in four categories: one category supported the bill but raised certain questions like the
issue of employment and rehabilitation of those engaged in this field; some objected to the
skull and bone warning; another group requested to make the bill more stringent; the third
category vehemently opposed the bill, whereas the last one extended full support to it. In
response to those who wanted a more stringent bill, the Health Minister replied that “the first
step should be taken very cautiously so that nobody should feel that we have brought an
oppressive Bill … There is a provision in Cable Act, in so far as the question of surrogate
                                   81a
advertisement is concerned.”
        The bill received the assent of the President on 18th May, 2003 and became an Act.
Now the rules and regulations are being formulated and notifications will follow. This Act
will be nationally enforceable throughout the whole of India – a very important aspect which
                               78, 46
differs from the draft bill.


Evolution of Tobacco Taxation


From the late 1980s through the early 1990s, taxation of various tobacco products received
attention and budgetary provisions were made for taxation. The Union Government has raised
tax on cigarettes in subsequent years and from the early 1990’s bidis and other products began
to be taxed, albeit at very low level. Gutka is also taxed and tax has increased years in
                                                                                        22, 83
subsequent to 1992. For example, cigarette taxes were raised by 5% in 2000-01.
Total excise duty collections from tobacco reached Rs. 72 620 million in 1999, up from Rs.
                          14
23 390 million in 1990.        It has been opined that rates of tobacco taxes on other products
seem to have been guided more by the consideration that the people in the lower income
groups should be burdened lightly than by the need to impose punitive rates with a view to
discourage consumption in order to reduce health and environmental hazards even at the cost
                                         8d
of some possible revenue sacrifice.           Another point of view is that “Such a pattern of duty
imposition by the government is due to the desire for a high level of employment-generation



                                                                                                 48
in the unorganised tobacco sector and its political implications. In addition, the unorganised
                                                                              58
nature of the non-cigarette tobacco industry makes tax recovery difficult.”
       According to the tobacco industry, continued punitive taxation at the Central and
State levels over the years has led to a progressive migration from cigarettes to other forms
of tobacco consumption, the share of cigarettes falling from around 23 per cent in 1971 to
                                58
below 16 per cent in 2000-01.
       The 15 per cent excise duty surcharge on cigarettes (in 2000-01) was the highest
imposition in eight years. According to the industry, the net effect of the skewed taxation
policy of the Central government was an increase in contraband cigarette sales apart from a
gradual shift in tobacco consumption patterns in the country towards the lower end of the
market, especially bidis, on which Rs 6,876 crore was spent, a good 29 per cent higher than
the 1994-95 level. (Consumer spending on cigarettes during 1999-2000 was about Rs 8,850
crore.) Industry estimates total tobacco consumption is growing at around 2.1 per cent per
annum in India. Total tobacco consumption is currently pegged at 406 million kg, cigarettes
                                                                                    58
constituting 77m kg, beedis 219m kg, and other forms of tobacco about 110m kg.
       In the budget for the year 2000, the Union Government raised taxes on cigarettes by
5%. The Tobacco Institute objected by saying that the progressive increase in tax retarded the
growth in revenue collection by the Government, but health economists said this was highly
            83
unlikely.




1.2.3 State Policy Level


Tobacco control policies in the States began by addressing smoking in public places before
moving on to address production and sale of smokeless tobacco products.


Smoking and spitting in public places


Several states have developed legislation to control tobacco use and protect rights of non-
smokers. Legislative action taken by some States has preceded similar action at the Union
                                                                                         49
level. The Bombay Police Act of 1951, Section 116, prohibited smoking and spitting in
                                        45
government premises in Maharashtra.


       The Public Health Department of the State of Maharashtra began its tobacco control
activities in 1986 with a campaign against smoking. The reason for starting with public
education instead of advocating legislation given by a former Director of Health Services,
Government of Maharashtra was the belief that “It has been our experience that legislation
                                                                               45
without proper public awareness and commitment will not be successful.”




                   “It has been our experience that
                   legislation without proper public
                   awareness and commitment will not
                   be successful.”


                   Former Director of Health Services, State of Maharashtra,
                   1986.




       The campaign was based on reported observations of the Indian Council of Medical
Research (ICMR) regarding tobacco being the major cause of cancer in the country and the
fact that other diseases like respiratory and digestive diseases can be caused by tobacco. The
first reaction of smokers, mostly of the urban upper-middle class, was “We smoke because
we like it. It’s none of your concern. After all, it is we who would suffer, not you.” The
Public Health Department responded by adopting the slogan on posters, “Your smoking is
injurious to our health”. Non-smokers began to use this slogan to counter the indifference of



                                                                                        50
smokers. Outdoor advertisements by cigarette companies were countered with posters with
                                                                               51
anti-advertisement slogans and visuals to neutralise the wording of the ads.




                “Your smoking is injurious to our health.”


                Poster slogan of the Maharashtra Public Health Department, 1986.
                Was later used by non-smokers to counter the indifference of
                smokers.



       In January 1987, the Tata Memorial Hospital, Bombay and the Public Health
Department of Maharasthra organized a two-day workshop on cancer, in collaboration with
the UICC (Union Internationale Contre Cancre – The International Union Against Cancer).
At this workshop a plan for a state-wide cancer control programme was adopted. One of the
strategies that came out of the workshop was to launch an aggressive anti-smoking campaign.
The Public Health Department issued an administrative order and put up notices in the
corridors of the State Secretariat that smoking was prohibited. This measure proving
ineffective, a more powerful measure was found in the provisions of the Bombay Police Act,
1951, which read as follows: Section 116: “No person shall in any court, police station,
police office building occupied by the Government or building occupied by any public body,
smoke or spit in contravention of a notice by a competent authority in charge of such places
…” On conviction, an offender could be fined up to Rs.100 as punishment for this a criminal
           51
offence.


       After application was made to the Home Department of the State of Maharashtra and
the General Administration Department, approval by the Minister of State for Health and the
Health Minister were obtained and a resolution containing orders prohibiting smoking was
issued in August, 1987. It was applicable inside the buildings, premises and compounds of all
courts, police stations and offices, and any government or public body in Maharashtra.
                                                                                       51
Notice boards were put up outside the gates and within the premises. All ashtrays were
removed from all government offices. Cigarette and bidi kiosks within these premises were
closed down. While the bidi industry threatened to protest, no counter action materialized
and the public responded positively in letters to the media. A member of the public asked in a
letter why the State Government was not banning smoking in all other public places as well.
The belief in the Public Health Department was that much public education would be needed
to achieve a smoking ban in all public places. It began putting up billboards countering the
ads of the cigarette companies in Bombay. The Department believed that the enforcement of
the Bombay Police Act, 1951, Section 116 had created a fear of being convicted and a feeling
of guilt about breaking the law. The environment for giving up tobacco had become more
                                                                               51
congenial. Other States in the country were also taking up similar measures.




                    The enforcement of the Bombay
                    Police Act, 1951, Section 116 in
                    Maharashtra had created a fear
                    of being convicted and a feeling
                    of guilt about breaking the law.
                    The environment had become
                    more congenial for giving up
                    tobacco. 51



         The Goa Prohibition of Smoking and Spitting Bill, 1997, was introduced in the
Legislative Assembly of Goa on 14th, July, 1997 and was referred to and discussed by the
Select Committee in July, 1997. The then leader of the opposition tabled several
amendments, mainly regarding Prohibition of Advertisements of any products and their
storage and sale near educational institutions. Also certain suggestions including those of the
Chairman of the National Organisation for Tobacco Eradication, which appeared in the press,
                                                                                        52
were also placed before the Committee. The Committee, after holding the discussion in
detail, decided to incorporate almost all the amendments in the Bill. The suggestion to
prohibit the sale of cigarettes and other tobacco products to persons below the age of 21 years
was accepted. The Goa Prohibition of Smoking and Spitting Act, 1999 (Goa Act 5 of 1999)
was passed by the Legislative Assembly of Goa on 31st July, 1997, assented to by the
President of India on 18th August, 1999, and was published for general information of the
Public. It includes prohibition on sale to minors (below 21 years) and advertising in or near
no smoking and no spitting zones; prohibits the sale and distribution of tobacco products
within an area of 100 metres around any place of worship or any college, school or other
educational institution; no advertising in any place and on any public service vehicle any
material which may directly or indirectly promote smoking or chewing of tobacco or any
tobacco product or products containing tobacco even if classified as by any other name. The
owner or manager or in charge of affairs of every place of public work or use shall display
and exhibit a board at a conspicuous place or places in and outside the premises visited or
used by the general public prominently stating that place is a “No Smoking and No Spitting
Zone” and that “Smoking/Spitting is an Offence. This law came after 25 years of anti-
                        47, 84
tobacco work in Goa.
       A woman in Kerala filed a writ petition, stating that she found commuting difficult in
a bus in which her co-passengers smoked. As a result, in July, 1999, the Kerala High Court
the Kerala High Court declared that smoking in public places was illegal and prohibited it on
the basis of Article 21 of the Constitution on the Protection of Life, as well as IPC 268
(Public nuisance) and 278 (Making atmosphere noxious to health) and the Air (Prevention
and Control of Pollution) Act, 1981. In 2000 ordered kiosks in the State not to provide
                        56
smokers with a light.        Encouraged by this ban on smoking in public places in Kerala,
similar public interest petitions were filed by anti-smoking activists in the states of
                                                              85
Karnataka, Tamil Nadu, Andhra Pradesh and Maharashtra.
       A bill was passed in the National Capital Territory, Delhi, in 1996, prohibiting
smoking in public places or public transport. The Delhi Prohibition of Smoking and Non-
Smoker’s Health Protection Act, 1996 also prohibits sale of tobacco products to minors and
within 100 meters of educational institutions. In September, 2000, the Delhi Government was

                                                                                          53
forced to act after a public interest writ petition in the Delhi High Court charged it with non-
implementation of the Smoking and Non-Smoker Health Protection Act, which was passed in
January, 1997. The petition charged that the Government was not implementing the sections
of the Act relevant to keeping tobacco products away from children and adolescents. In fact,
these sections of the Act had been omitted from the original notification in January 1997.
Delhi's Health Minister responded that the ban on tobacco sales to children would come into
effect immediately, and the ban on sales near educational institutions would come into effect
later, in January 2001. Police were given the power to implement these provisions. Violators
could be fined between 500 and 1000 rupees and sentenced to up to 3 months'
              24, 86
imprisonment.
       Smoking in public places is also banned in the states of Himachal Pradesh, Jammu
and Kashmir, Sikkim, Meghalaya, Assam, Rajasthan, West Bengal and Tamil Nadu by
legislation. The wording of most of these laws is very similar to that of parts of the
                                                              50
comprehensive tobacco control bill submitted to Parliament.


Bans on gutka and pan masala


     A key event that led to the ban on gutka and pan masala in Tamil Nadu was a
newspaper article reporting that 4-12% of students of 12-17 years of age were consuming
tobacco, more girls than boys, and that tobacco products were being sold around schools.
This article was discussed in the Legislative Assembly in December 1997. Pressure from
the medical profession on the Chief Minister led to a draft proposal by the Department of
Public Health and Preventive Medicine (DPH&PM) of a ban being submitted to the
Government in 2001. Citing the Prevention of Food Adulteration Act, 1954, the High Court
ruled that anything put in the mouth for eating, including tobacco, was a food and that gutka
and pan masala were harmful. The objections of the Revenue Minister were set aside.
Approval was obtained from the Governor, who issued an order referring to the
carcinogenicity of pan masala and gutka and their other adverse health consequences. A
notification of a ban was issued with effect from 19th November, 2001, for a period of five
years, published in all the newspapers for one full week. Meanwhile, police and local food

                                                                                        54
and health authorities were alerted and the banned products were confiscated from shops
and warehouses. Parents expressed much appreciation for these measures. Soon, however,
legal hurdles began to appear – about 30 court cases were filed by the manufacturers to stay
the ban. After tremendous pressure, the ban was modified to allow manufacture and
storage of the smokeless products with the proviso that the sale of these would be in other
States. Out-of-state distributors and dealers were stopped from bringing in banned goods.
Some smuggling and black marketeering occurred, especially in border areas. Eleven
prosecutions were launched against evaders of the ban, which the DPH&PM felt to be a
painfully inadequate number. The State of Tamil Nadu prepared itself to consider a bill
banning the sale and use of all tobacco products in public places and near schools and
places of worship. Emotive issues come up, like the poor bidi workers would lose their
jobs, and conversely that more poor people would die prematurely if there were no ban on
           74,52
tobacco.
       In Maharashtra, the State Food and Drug Administration had found that gutka and
pan masala sold in the State contained magnesium carbonate, a substance that is regulated
in food. The manufacturers of gutka and pan masala used it without ever requesting
permission. For two years it periodically seized stocks to check for magnesium carbonate
content and found it in all the samples. The agency then proposed that the State ban gutka
and pan masala. A public interest litigation was filed in the Maharashtra High Court for
banning gutka. The High Court, in its judgment, directed the Central Government to find
out whether gutka was a dangerous product. The Central Committee on Food Standards
conducted hearings and investigations and concluded that gutka was a dangerous food
product, recommending its outright ban. The Maharashtra State FDA then banned the sale
of gutka and pan masala within 100 metres of schools, but the ban was not effective. A
state-wide ban was announced in July, 2002 and began to be implemented from August 1,
                                                     55
2002, with district level committees to be set up.        In Maharashtra there has been some
concern that ‘Click’, an oral tobacco product manufactured by Swedish Match and
                                                                      75
consumed between the lips and gums, has escaped the State ban.
       The U.P. High Court took note of the recent bans on the sale and advertisement of
pan masala and gutka by the States of Maharashtra and Tamil Nadu on the basis of reports of

                                                                                          55
medical experts. The Allahabad High Court directed the U.P. Government to issue a similar
notification to ban production, sale and advertisement of pan masala and gutka. It further
directed that from that day all manufacturing and sale of pan masala and gutka (by whatever
names they might be called or under whatever names they were sold) should be stopped
immediately, that the administration including the police would see to it, and that
manufacture of pan masala and gutka were no longer permitted. The Government of Uttar
Pradesh had implemented the order of the Allahabad High Court of July 18, 2002, banning
sale and manufacture of pan masala and gutkha. However, on August 5th, 2002, the Supreme
Court stayed this order after hearing a batch of petitions challenging it. The Zafrani Zarda
and Pan Masala Association of India (ZZPA) spokesman said the stay had given some hope
that a decision would not be taken without considering the plight of millions dependent on
the industry for a livelihood. The then Health Minister, while welcoming the stay and the
public debate on the issue, however admitted that tobacco is harmful to health and said there
could be no simplistic solutions and he recommended a multi-pronged approach using every
                                          87
institution to curb the tobacco menace.
       The Chief Minister of Bihar, while contemplating banning the sale and consumption
of all kinds of gutka, directed the Chief Secretary to procure the relevant documents and
notification from those states that had already prohibited gutka. Speaking to newsmen, the
CM justified her initiative saying that gutka was adversely affecting the younger generation.
She noted that the states of Maharashtra and Rajasthan had already imposed a ban on gutka.
                                                                                 75
The Bihar State Government soon banned the sale of chewing tobacco (gutka).
       The high courts in Madhya Pradesh and Andhra Pradesh also ordered bans on gutkha,
although in each case, implementation was stayed by the Supreme Court on procedural
           75                                                                                88
grounds.        Also, the Government of Goa recently banned and sale of gutka in the State.
Gujarat, and Kerala have imposed similar bans following orders from their High Courts
                                                        89
under the Prevention of Food Adulteration Act, 1954.




                                                                                        56
Chapter 2




Government and Non-Government Institutions Relevant to Tobacco
Control in India



This chapter has been divided into two main parts:
2.1 Government institutions
    • Identification
    • Initiatives
    • Strengths and weaknesses
    • Suggested mechanisms to strengthen institutions
2.2 Non-Government (non-governmental institutions)
    • Identification
    • Initiatives
    • Strengths and weaknesses
    • Suggested mechanisms to strengthen institutions



2.1 GOVERNMENT INSTITUTIONS


2.1.1 Identification of Government institutions relevant to tobacco


1. The Union (Central) Government:


Institutions of the union government may be classified according to the stand they take on
tobacco – control, promotion or neutrality.




                                                                                      57
Central government institutions involved in tobacco control:


This section is given for the purpose of helping the reader to visualise how multi-sectoral
cooperation among government institutions. During the Lok Sabha debates on the new
tobacco control bill, one of the honourable ministers stated, “I would like to sum up that there
should be a clear vision in enforcing this enactment. This should not be for the purpose of
enacting for international obligation alone. It should be for the welfare of the people, and
welfare of the people can be done only by united efforts. The Agriculture Department, the
Commerce Department, Information and Broadcasting and all other Departments should
come together and see that smoking habit in cinema, television, songs, etc. should be
curtailed. At the same time, children should be educated and the youngsters should also be
educated. The people who are addicted should be protected by counselling with the funds of
the Government.”
       Additionally several ministers mentioned the need for anti-tobacco education in the
schools: “I would suggest that health education should start from the schools. It should be
included in the syllabus, at least, from the third standard. Children should be spoken to about
the common diseases, and they should know it even before they become adolescent. You
have to teach the children before they know what to face. They should know about
tuberculosis; they should know about cigarettes, and what will be the effects of every disease
so that before they could venture into experiencing them, they should be made aware of the
                                               81b
consequences. It will be a preventive step.”


Government Institutions at Union level involved in tobacco control include the following:


 •   The Ministry of Health and Family Welfare
           o Central Committee on Food Standards
           o National Tobacco Control Cell
 •   The Ministry of Railways
 •   The Ministry of Information and Broadcasting
 •   The Supreme Court


                                                                                         58
The Ministry of Health and Family Welfare –
Under the Ministry of Health and Family Welfare there is an Anti-Tobacco Control Cell with
one nodal person at the Ministry and two National Professional Officers, deputed by the
WHO, India Office. There is no analogous cell in any other ministry. This cell has provided a
good platform for tobacco control both inside and outside the Government. The latest two
Ministers of Health have helped to get the comprehensive Tobacco Bill passed.
       The National Cell for Tobacco Control was set up in New Delhi, as a joint effort by
the Ministry of Health and the World Health Organization (WHO) in February 2001 to
devise strategies and to co-ordinate all tobacco control efforts. The main areas of work
include: 1) Execution of a comprehensive Information, Education and Communications
(IEC) plan, 2) NGO capacity building in the area of tobacco control, 3) Establishment and
strengthening of the network of tobacco cessation clinics and 4) Undertaking research on key
policy issues of tobacco economy and legislation. The Cell has developed an India specific
slogan and logo for tobacco control activities: “Choose Life, Not Tobacco” – the logo is a red
circle surrounding a hand in the gesture of a victory sign holding a flower. On the blue
background there are three brushstrokes, one, saffron colour, one, white and one, green, as in
the Indian national flag. The Cell has also developed IEC materials including TV
‘commercials’, documentaries, bus panels, messages for the print media, brochures, stickers,
flip charts and posters. These IEC materials are being disseminated through Doordarshan (the
National TV Channel), DAVP, DFP and various NGO’s working on tobacco control. The
Ministry of Health has sponsored a Health Programe on Doordarshan – “Kalyani”. This
program covers the Hindi-speaking belt and deals with 6 major health issues including
tobacco. The rural audiences where mass media does not reach are being covered by
grassroot level interventions like: 1. The SEAAT Flame rally covering 14 States, in which an
anti-tobacco flame was carried by road around India; 2. Awareness dissemination through
                                                                        50
268 DFP field units; 3. World No Tobacco Day functions in all States.




                                                                                       59
           Fig 1.2 Logo Developed by the National Tobacco Control Cell, India.


       The Central Committee on Food Standards functions under the Prevention of Food
Adulteration Act administered by the Ministry of Health and Family Welfare, at Nirman
Bhavan, New Delhi.
       The successive Health Ministers have been very supportive of anti-tobacco
legislation, as mentioned in Chapter 1.


Scientific Body of the Government
The ICMR is a scientific body of the Government, under the Ministry of Health and Family
Welfare, shown in the table below: (Table 2.2a):




                                                                                   60
Table 2.2a Scientific Institutes of the Government
Scientific Institutes              Level of Involvement in Tobacco Control
Indian Council for Medical         This institution has provided lot of scientific input on tobacco
Research (ICMR), New Delhi         control for India and has been involved in policy making.
Ansari Nagar, Post Box 4911
New Delhi 110 029




The Ministry of Railways –
As mentioned in Chapter 1, this ministry has banned tobacco from its premises.


The Ministry of Information and Broadcasting –
This Ministry is responsible for the implementation of laws prohibiting advertisements in
media, as mentioned in Chapter 1.


The Supreme Court –
This apex judicial institution has been instrumental in making orders and notices to control
tobacco use, as described in Chapter 1.


Central government institutions involved in or benefiting from tobacco promotion:


 •   The Ministry of Agriculture
 •   The Ministry of Commerce and Industry
 •   The Ministry of Finance
 •   The Tobacco Board
 •   The Tobacco Research Institute


The Ministry of Agriculture –
This Ministry has three subordinate bodies connected directly to tobacco and areca nut
(another addictive and carcinogenic ingredient of gutka and pan masala): The Directorate of
Tobacco Development, Chennai, the Directorate of Cocoa, Arecanut and
Spices Development, Calicut and the National Cooperative Tobacco, Grower's Federation
                              90
Limited Anand (Gujarat).
                                                                                                      61
       In recent years the Ministry of Agriculture requested major tobacco growing States to
consider action for reduction in production of non-FCV tobacco. Efforts were initiated in the
States of Andhra Pradesh, Tamil Nadu, Orissa, and Karnataka. The Department of
Agriculture and Cooperation and Indian Council of Agriculture Research in a joint meeting
decided to explore the potential of alternative crops like medicinal plants, soybean, sugar
cane, waxy type maize, oil palm, vegetable, etc. It was considered that the schemes for
assistance to the tobacco system should be discontinued and that research efforts should
concentrate on development of a low-tar, low-nicotine FCV tobacco crop, and on alternative
uses of tobacco. It was also mentioned that a scheme should be chalked out for weaning
away of farmers from cultivation of non-FCV tobacco. Follow-up discussions on
implementation of these recommendations with various concerned ministers showed the
various relevant sectors are conducive to drastic measures for tobacco control, but also
                                                                                       22
pointed out the potential fallout of these measures on the Indian economy and trade.
       During the Lok Sabha debate in the House on the new tobacco control Bill, one of the
honourable ministers made the following suggestions (verbatim): “In the Empowerment of
Women Year 2001, we had concentrated on empowerment and allocated nearly Rs. 25,000
crore for the empowerment of women. … Self-help groups created as a result of
empowerment of women can help in this regard. All these agriculturist women can be
grouped and we can help them through the banks, through the money we have already
allocated. We can help them grow alternative crops in their own lands and for that, the local
administration, the district administration, Agriculture Department of the State, the Centre
and the agricultural universities have to play a role of concentrating on rehabilitating these
agricultural labourers through the self-help groups. We can utilise the ladies in the same self-
help groups. As a federation, as a movement, they will be able to take the message of ill
effects of smoking and they will be able to find a solution. A woman will be able to sensitise
the smoker, be it her husband, father, brother or son. I think women can sensitise people
more than any law or any other method that we have enumerated. … I think we can have a
high-powered Committee with the consent of the Empowerment of Women, the Agriculture
Department, and also the Department of Tribal Development as to how we are to go about it.
I am saying this because in our area -- it is my practical experience -- in one village where


                                                                                            62
people used to drink and indulge in all other bad habits were stopped by the women
                81b
movement.”


The Ministry of Commerce and Industry –


The Economic Division of the Ministry of Commerce and Industry records and publishes the
                                                    91
export of various commodities, including tobacco.
       The Office of the Economic Adviser (OEA) is an attached office of the Ministry of
                                                                                  92
Commerce and Industry, under the Department of Industrial Policy & Promotion.           The
main functions of the Office of Economic Adviser include, inter alia the formulation of
industrial policies and the effect of trade policies on them, examination of general economic
issues and recommendations regarding rates of excise & customs duties on industrial
products. In these respects the OAE is in a key position for collaboration on tobacco control.
       The Federation of Indian Export Organizations (FIEO), an apex body of Indian export
promotion organizations was set up jointly by the Ministry of Commerce, Government of India
and private trade and industry in the year 1965. The FIEO is thus a partner of the Government
                                                                                         93
of India in promoting India’s exports has among its members, 62 exporters of tobacco.
      The Tariff Commission, set up in September 1997 under the Department of Industrial
Policy and Promotion of the Ministry of Commerce and Industry, looks into tariff related
matters and recommends appropriate levels of tariff for different products (including
tobacco), keeping in view the larger economic interests of the country and commitments to
           94
the WTO.


The Ministry of Finance –


In preparing the yearly budgets, the Finance Minister may make changes in various tax rates
and impose new taxes or remove them. With regard to tobacco products, the Finance
Ministry is involved in determining the rates of excise and customs duties and imposing
special taxes like the National Calamity Contingent Duty (NC duty) after the Gujarat

                                                                                        63
earthquake. CENVAT and SED are other taxes that apply to tobacco products and certain
other items.


The Tobacco Board and the Tobacco Research Institute –
       In 1938, the British Raj in India established a cigarette tobacco research station at
Guntur, Andhra Pradesh, from where scientific inputs began to be provided for tobacco
production. After independence in 1947, the Indian Government continued this practice
                                                                                           95
through the Central Tobacco Research Institute at Rajahmundry, Andhra Pradesh.
       Of interest to tobacco control is the study published by the Tobacco Research
                                                            17
Institute on viable agricultural alternatives to tobacco.        It contains reports on efforts by the
Central Tobacco Research Institute and its Regional Stations located in different agro-
climatic zones to identify remunerative alternate crops to tobacco – an important issue for
tobacco control. Yields and economics of growing various crops are compared to the returns
and economics of growing tobacco under rain-fed conditions in various zones. None of the
alternate crops on their own (mono-crop) were as remunerative as tobacco in almost all the
zones, but crop sequence studies and intercropping trials clearly indicate that net returns from
two crops can equal net returns from a sole crop of tobacco. Data are (briefly) reported from
trials in seven CTRI research stations, with more details comparing the various crops
presented in the tables.
       The Tobacco Board: In 1976 the Union Government established the Tobacco Board
with its headquarters at Guntur in Andhra Pradesh (in place of Tobacco Export Promotion
Council), under the Tobacco Board Act of 1975, which aims at the planned development of
the tobacco industry in the country. The Board was set up to regulate production, promotion
of overseas marketing and to control recurring instances of imbalances in supply and
demand. Such imbalances lead to market problems, e.g., if the production exceeds the
demand, farmers suffer due to fall in prices on the other hand, if production were short,
                                                                                    2b
country would suffer due to loss of revenue and foreign exchange earnings.
       The Tobacco Board is involved in developmental activities and supply of inputs to
tobacco growers. Through the Board, farmers receive inputs like seeds, coal for curing
tobacco in states deficient in forests (Karnataka), fertilizers, pesticides and suckericides and

                                                                                                64
developmental support through the Board’s wide network of trained technical field staff. The
Board also disseminates the latest technology on crop production developed by Central
Tobacco Research Institute (CTRI), Rajahmundry through training programmes, study tours
and on-farm trials. It provides analysis of soil and water samples free of cost. The Board
provides a number of the inputs on subsidy in some areas, including pesticides, sprinklers,
tarpaulins, barns and curing sheds. The Board also arranges crop loans for procuring inputs
like coal, fertilizer etc., from Nationalized banks; it arranges additional loans from the banks
in case of crop/ barn damage due to natural calamities.
       The Tobacco Board is a nodal agency, as it comprises members from different
                       2c
government agencies.        Members of the Tobacco Board comprise the following:


       Rajya Sabha – 2 MPs
       Lok Sabha – four MPs
       Ruling Party – One functionary
       Ministry of Commerce and Industry, Udyog Bhavan, New Delhi – 3 members
       Directorate of Tobacco Development (Ministry of Agriculture), Chennai- Director
       Central Tobacco Research Institute, Rajahmundry, A.P – Director
       Department of Rural Development, Nirman Bhavan, New Delhi
       Secretariat/Directorate of Agriculture of the State Governments of Andhra
       Pradesh, Gujarat and Karnataka
       Department of Industry of the Government of Bihar – Special Secretary
       State of W. Bengal – one unspecified representative
       Local Tobacco companies of Andhra Pradesh – 2 directors
       Growers from A.P. villages – several
       University of Agricultural Sciences, Gandhi Krishi Vignana Kendra (GKVK),
             Bangalore – 1 academic in agricultural marketing
       Chairman – IAS officer
       Excecutive Director- IAS officer




                                                                                         65
Other Central Government institutions relevant to tobacco include the following:


 •   The Ministry of Education
 •   Ministry of Labour
 •   Ministry of Social Justice and Empowerment
 •   Ministry of Rural Development
 •   The Ministry of Environment


The Ministry of Education –
This ministry is responsible for implementing laws on education. It has the potential to
require schools to include anti-tobacco education in their curricula.
During the Lok Sabha debate on the new tobacco Bill, one of the honourable members said
this: “I would suggest that health education should start from the schools. It should be
included in the syllabus, at least, from the third standard. Children should be spoken to about
the common diseases, and they should know it even before they become adolescent. You
have to teach the children before they know what to face. They should know about
tuberculosis; they should know about cigarettes, and what will be the effects of every disease
so that before they could venture into experiencing them, they should be made aware of the
                                                81b
consequences. It will be a preventive step.”


The Ministry of Labour –


The Ministry of Labour is concerned with the implementation of various laws designed to
promote the health and welfare of beedi and cigar workers and the protection of women and
                                96a,b
children in the labour force.           The Government has been slow to implement these laws,
but in recent years many home-based women beedi workers have received identity cards
entitling them to health care and other benefits. However it is precisely these workers who
have cited a decline in available work and remuneration. As far as women beedi workers and
alternate avenues of employment are concerned, these workers could theoretically avail of
the National and ten Regional Vocational Training Institutes that organize training

                                                                                           66
programmes for women in income generation. However, it is not clear if any women beedi
                                                96 c
workers have yet availed of these facilities.
         India is a founding member of the International Labour Organization (ILO), now
under the United Nations. However, the Government of India has India has yet to ratify two
ILO conventions on child labour: the Worst forms of Child Labour Convention (No.182)
(includes beedi making) and the Minimum Age Convention (No.138) (14 years). Reasons
given by the Ministry of Labour for non ratification of the above conventions include:
“Fixing of minimum age for admission to employment needs to be preceded by creation of
suitable enforcement machinery and measures as would warrant the children not being
compelled by circumstances to seek employment. The setting up of such machinery,
particularly, for the unorganised sector in agriculture, cottage and small-scale industries …
becomes a difficult task in a developing country like India.” Consultations have been held
by the Ministry of Labour and the ILO with the concerned Ministries/Departments (like the
Department of Women and Child Development under the Ministry of Human Resource
Development) and State Governments to examine the existing provisions of national laws
and practices on child labour with regard to the provisions of the Worst forms of Child
                                                                                       96 c
Labour Convention (No.182), but the Ministry expects the process to be long drawn.


Ministry of Human Resource Development –
In the year 2001, declared by the Prime Minister as Women’s Empowerment Year,
Department of Women & Child Development, Ministry of Human Resource Development
and its organisations viz., National Commission for Women, Central Social Welfare Board,
Rashtriya Mahila Kosh and National Institute of Public Cooperation & Child Development
have coordinated and organised the activities for observing the year as Women's
Empowerment Year. A Sub-group (1) formed under the Task Force on Women & Children
                                                                               97
reviewed in a comprehensive manner, the following laws concerning women.
   1. Child Labour (Prohibition and Regulation) Act, 1896
   2. Beedi and Cigar Workers (Conditions of Employment) Act, 1966.
   3. Bonded Labour System (Abolition) Act, 1976


                                                                                         67
The Convention on the Rights of the Child was Adopted and opened for signature,
ratification and accession by the United Nations General Assembly resolution 44/25 of 20
November 1989. It entrered into force on 2 September 1990. India also ratified the
                                                                  98
Convention on the Rights of the Child on December 2, 1992.             Two of the articles of this
Convention are relevant to tobacco control in that they relate to child labour in the beedi
                                    99
industry and tobacco cultivation:



Article 24
1. States Parties recognize the right of the child to the enjoyment of the highest attainable
standard of health and to facilities for the treatment of illness and rehabilitation of health.
States Parties shall strive to ensure that no child is deprived of his or her right of access to
such health care services.


Article 28
1. States Parties recognize the right of the child to education, and with a view to achieving
this right progressively and on the basis of equal opportunity, they shall, in particular:
(a) Make primary education compulsory and available free to all;
(b) Encourage the development of different forms of secondary education, including general
and vocational education, make them available and accessible to every child…


Ministry of Rural Development –


Under the Ministry for Rural Development, the Council for Advancement of People`s Action
and Rural Technology (CAPART) was formed as an autonomous body for catalysing and co-
ordinating the emerging partnership between voluntary organizations and the Government of
                                                    100
India for sustainable development of rural areas.         It is not clear whether this organization
has been active in tobacco producing areas in any capacity, but the potential would be there
for weaning away farmers from tobacco or areca nut to other crops.




                                                                                             68
Ministry of Environment and Forests –
Tobacco does not figure amongst the priorities of the Ministry for the Environment and
Forests – its website contains no mention of tobacco (http://www.envfor.nic.in/ ). Yet air
pollution caused by tobacco smoke is an environmental concern, as are the air pollution and
deforestation caused by felling and burning of trees used in the curing of cigarette tobacco.
One former tobacco farmer who stopped growing tobacco due to losses and mounting debts
said he used to bring 30 cartloads of wood (that he estimated at about 30 tonnes) from the
near-by forests, paying the forest guard Rs100-150 per cartload to cure his tobacco grown on
3-5 acres of land. He said that in pre-Board days the tobacco companies would provide the
                                          9
farmers with coal for the curing process. In addition, deforestation is also an outcome of
obtaining certain ingredients such as sandalwood extract and catechu required for the
preparation of gutka and pan masala. Tobacco activists could write about these concerns to
The Secretary, Government of India, Ministry of Environment & Forests, Paryavaran
Bhavan, CGO Complex, Lodhi Road, New Delhi - 110 003.


2. State Governments:
In the States, the Ministries or Directorates of Health look into the matter of tobacco control.
There is no specific anti-tobacco cell in any State ministry or directorate or in any part of any
State Government. District Magistrates are expected to look into matters of implementation
of tobacco control laws.




2.1.2 Initiatives of Government Institutions at Union Level


Ministry of Health –


1. Public Education
The National Cancer Control Programme was launched in 1984, and gave high priority to
eliminating tobacco-related cancers. It emphasised public education about the dangers of
           26
tobacco.


                                                                                         69
Radio DATES, 1999: Educational efforts through the mass media are an excellent example
of inter-sectoral activity for tobacco control. The acronym DATE stood for Drugs,
Alcohol, and Tobacco Education. The radio programme was in the form of 30 weekly
episodes of 20 minutes each. Ten episodes focused on tobacco, eight each on alcohol and
                                            101
drugs, and two episodes on legal aspects.         The introductory and concluding episodes
touched all the three themes. The episodes were broadcast from 84 stations of All India
Radio (out of 104 existing at that time) at prime time simultaneously in sixteen languages.
The broadcast was during a specified time (between 8.00A.M. on Sundays, with a repeat
broadcast during the week, generally in the evening). The reach and effect of the tobacco
component of the programme was evaluated through two community-based surveys. It was
shown that the potential listeners were constituted by 80.4% of the population in Goa and
59.1% of the population in Karnataka. About 4% tobacco users in Goa and About 6% users
                                                                 22
in Karnataka quit using tobacco after hearing the programme.


2. Research


Identification of tobacco related deaths
In 1999, to help measure tobacco-related deaths, the Registrar General of the Census
department considered including a question on death certificates about the dead person's
tobacco use as it was estimated that 400,000 Indians die every year from tobacco-related
diseases, and unless current smokeless users quit, this will rise to 1.5 million by the year
     102
2020.


3. Consultations


Multi-sectoral consultation granted before banning gutka: MOH wanted multi-sectoral
consultation before passing a bill on gutka and desired a multi-pronged and multi-sectoral
                                103
approach to curb this menace.


                                                                                         70
International Meeting on Verbal Autopsy and on the Epidemiological Aspects of the
Sample Registration System, 25-26 May, 2001, Tata Institute of Fundamental Research
New Delhi, India, co-sponsored by- Office of the Registrar General, India, WHO, CDC.


See also the list of consultations under Non-Government Organisations (most consultations
involve both government and non-government institutions).




2.1.3 Strengths and weaknesses of Government institutions


1. Strengths of Government institutions involved in tobacco control


   Power of enactment
   Power of implementation
   Tremendous support from NGOs
   Access to recommendations of expert committees, parliamentary standing committees
   Possess research findings
   Support from the judiciary
   Support of WHO and other international organisations
   Can draw on many international examples


2. Weaknesses of Government institutions involved in tobacco control


   Lack of awareness of some of the problems
   Lack of political will sometimes
   Opposition within Government
   Lack of nodal points of authority
   Poor enforcement mechanisms
   Lack of information sharing and coordination among institutions




                                                                                    71
3. Opportunities (Untapped potentialities)


   Wide scope to improve coordination with NGOs.


4. Threats


   Opposition from tobacco industry, through several agencies.




2.1.4 Suggested mechanisms to strengthen government institutions and make their
efforts more comprehensive and effective


A greater transparency of the working of the Ministries and the agencies under them would
help. Better mechanisms for communication between the Ministries and the NGOs would be
beneficial, to raise awareness of the problem to a very high level and create a mutual
understanding of respective roles and constraints faced. Vocal opposition to corruption
needs to be made by individuals and NGOs. NGOs and Government institutions need to be
prepared to empathise with each other concerning the problems they each face, in order to
collaborate more effectively in defining and pursuing common goals. An understanding
needs to be created regarding the overlap between overall national goals for development
and tobacco control. In particular, awareness needs to be created in the separate Ministries
on of the dovetailing of their goals with the need for alternatives to tobacco in the economy.
This type of awareness can be created by presenting relevant information to the Ministries
periodically, since the persons involved change periodically. Thus periodic awareness
programmes for the Ministries are suggested.


1. Increasing political will


This is the most essential component and may be achieved by educating politicians at all
levels especially in terms of economic loss of country as compared to economic gain. Indian
politicians in the Government and in the opposition have the misconception that tobacco

                                                                                         72
control in India will lead to unemployment. This can be avoided by various mechanisms. The
recent passing of the new comprehensive tobacco control bill has shown that support for
tobacco control among politicians has increased.


2. Concerted efforts of all concerned ministries in tobacco control


This could be initiated by forming a tobacco control unit at the level of the PMO with
representatives from each concerned ministry and non-Government institutions.


3. Creation of nodal points


Creation of a nodal point for tobacco control in each concerned ministry and further
strengthening of the existing nodal point in the MOHFW would be a very important step
forward.


4. Opposition to the tobacco industry


The tobacco industry must be opposed strongly. This may be simply executed by
implementing existing policies in the best way, and by creating harder policies on tobacco
control.


5. Faster enactment of policies by state governments


Central enactments tend to lie pending with the various state governments. They should be
enacted in due time. Unequal enactment makes the neighbouring States unruly.


6. Creation of a nodal agency for implementation in state governments


Implementation is a state subject. State governments should make a nodal agency for
implementation. They may identify the implementers at the grass route level involving their
respective civil societies.

                                                                                         73
7. Integration of existing programmes with tobacco control


The Ministry of Health and Family Welfare, for example, with the help of tobacco control
experts, could integrate tobacco education into the training programmes for its health
personnel in the areas of maternal and child health, tuberculosis and general health (oral
health, cardiovascular health and respiratory health). Tobacco use cessation programmes
need to be developed for health personnel of the MOHFW as well as for the communities
they serve.




2.2 NON-GOVERNMENT INSTITUTIONS


2.2.1 Identification of non-Government institutions by type:


Non-state, i.e., non-government, institutions have been identified by their previous work in
the field of tobacco control. Categories are as follows:


 •   NGOs and trusts
 •   Autonomous academic institutions
 •   Associations of health professionals
 •   Institutes involved in tobacco cessation programmes
 •   Religious bodies and associations
 •   Pharmaceutical companies


1. Non governmental organizations (NGOs) and trusts:


The names of the following NGOs are from the WHO list as they been suggested by NGOs
of excellence in the field of tobacco control known to the WHO and individuals in the field
{peers}. This list is not by any means exhaustive:


                                                                                         74
State-wise list of some NGOs:


 •   All India - ACT-India, VHAI, Indian Cancer Society and VHAI State Chapters in each
     State; Prajapati Brahma Kumari; Francois Xavier Bagnoud, India (HQ in Delhi)
 •   Andhra Pradesh-.Mahatma Gandhi Memorial Medical Trust, SCOPE
 •   Arunachal Pradesh - State chapter of ACT-India
 •   Assam - POS, State Chapter of ACT-India
 •   Bihar - School of Preventive Oncology, Patna, Bihar
 •   Delhi - HRIDAY SHAN, IUALTD, CRY, FBIC, VHAI, VOICE
 •   Goa - NOTE-India
 •   Gujarat - CERS & CERC, GCRI, IMPACT
 •   Haryana - SWASTHYA
 •   Karnataka – INGCAT TASK FORCE
 •   Kerala - ADIC INDIA, HAP
 •   Madhya Pradesh - CLEAR
 •   Maharashtra - ACT-India, Salaam Bombay, ACASH, PATH Canada, HELP, Vatsalya,
     Consumer Guidance Society of India, NTA, Sarva Jeev Mangal Prathisthan, CPAA
 •   Manipur - POS, State chapter of ACT-India- MACT
 •   Meghalaya - POS, chapter of ACT-India-MACT
 •   Mizoram - POS, State chapter of ACT-India- MACT, Mr. Lalthuoma
 •   Nagaland - POS, State chapter of ACT-India NACT
 •   Orissa - POS, OACT - State chapter of ACT-India
 •   Rajsthan - RCF, Francois Xavier Bagnoud Rajasthan Society, RACT, Narayan Seva
     Sansthan
 •   Sikkim - POS
 •   Tamilnadu - VMT, ADIC, ISEH
 •   Tripura - ACT-India, TVHA
 •   Uttar Pradesh - INGAT, ISAS and others




                                                                                    75
Website wise NGO LIST:


1. ACT         www.act_india.org
2. HRIDAY www.hriday-shan.org
3. CPAA         www.cpaapune.org
4. HAP         www.hapworld.org
5. VOICE       www.consumer-voice.org
6. CRY         www.cry.org
7 FBIS          www.fxb.org/india.htm
8 FBRS         www.fxb.org/india.htm
9. HELP        http://www.healthlibrary.com
10. ISAS       http://tambakookills.globalink.org
11. INGCAT http:// members.rediff.com/kmcmangalore
12. IUALTD www.IUATLD.org
13. George Foundation www.tgfworld.org
14. VMT        www.vasantha.org


2 . Autonomous academic institutions


These institutions include some cancer institutes and some other institutes, semi-government
and private institutions. A list of cancer institutes actively involved in tobacco control, their
addresses and level of involvement is presented below (Table 2.1):




                                                                                           76
Table 2.1 Cancer Institutes
Cancer Institutes                                         Functions in tobacco control
1. Tata Memorial Centre, Parel, Mumbai                    Research/ Cessation / Conference Community
                                                          work / one of the Collaborating Centre of WHO
                                                          in India/ Public Education
2.Rotary Cancer Hospital, AIIMs, Ansari Nagar, New        Public Education and Research
Delhi
3.Dharamshila Cancer Hospital and Research centre,        Public Education
Dharamshila marg,Vasundhara Enclave, Delhi-110096
4. Chitranjan National Cancer Institute, Department of    Research
Epidemiologgy, and Biostatistics, 37, SP Mukkherji        Advocacy
Road, Calcutta – 700026.                                  Education
5. Cancer Institute, Div.of Epidemiology and Cancer       Lot of Research, especially on cause of death
Registry, Cancer Institute (WIA), 38 Sardar Patel Road,   Cancer Registry
Chennai-600036 Tamil Nadu
6. Kidwai Memorial Institute of Oncology, Anti            Research & Education
Tobacco Cell, M. H. Nargawda, Road, Bangalore
7. Regional Cancer Centre, P.O. Box No. 2417,             Cancer Registry /Public /Education / Research
Thiruvananthapuram - 695 011, Kerala
8. Jawaharlal Nehru Cancer Hospital & Research            Cancer Research
Center, Idgah Hills, P.B.2, Bhopal 462 001, M P
9. Bangalore Institute of Oncology, 44-45/2, IInd         One of the Centers for Cancer Registry
Cross, Raja Ram Mohan Extension, Bangalore - 560027
10. Sanchetee Hospital & Cancer Institute (Unit of        Public Education
Rajasthan Cancer Cure Hospital Ttd,429, Pal Link
Road, Jodhpur - 342008




                                                                                                     77
         A list of non-government scientific institutes actively involved in tobacco control,
their addresses and level of involvement is presented below (Table 2.2b):


Table 2.2b Scientific Institutes – Non-government and Semi-government
Scientific Institutes                  Level of Involvement in Tobacco Control
1. All India Institute of Medical      The Department of Cardiology associated with HRIDAY- SHAN
Sciences, Ansari Nagar, New Delhi      and AFTC conducts tobacco related research; tobacco related
110029                                 research is also conducted at the Institute Rotary Cancer Hospital
                                       associated with AIIMS; other departments may also contribute.
2. Epidemiology Research Unit,         This group has produced a tremendous amount of published
Tata Institute of Fundamental          research on tobacco and cancer .It has sponsored lot of tobacco
Research (TIFR),                       research meetings and very active in national tobacco control
Homi Bhabha Road                       program. It is one of the collaborating centers of WHO in India.
Mumbai-400005                          Weakness – no specific succession plans.

6. Institute of Toxicology             This institution has analyzed tobacco products. These analyses
                                       contributed to advocacy.
7. The Centre for Multi-disciplinary   The Centre for Multi-disciplinary Development Research (CMDR)
Development Research                   is one of the national level social science research institutes
 (CMDR)                                recognized by the Indian Council of Social Science Research
                                       (ICSSR), Government of India, New Delhi. The Centre has
                                       undertaken major initiatives for tobacco control with action
                                       research. It has adopted novel methodologies for tobacco control
                                       from the supply side rather than the demand side.
8. School of Preventive Oncology       Range of activity: Eastern and north-eastern India
(POS),                                 Research: Tobacco related issues
A/27 Anandpuri, Boring canal           Surveillance: GYTS and GSPS in 12 states of India
Road, Patna 800001                     Intervention: Youth Intervention.
Bihar                                  Media Advocacy
                                       Advocacy for policy making
                                       Advocacy among health professionals
                                       Collaboration with centres like TIFR, TMC etc



  Types of tobacco related research carried out at Government and Non-government
  academic institutions:
  •   Epidemiology- Research institutions (notably the Tata Institute of Fundamental
      Research), Cancer Institutes (especially Mumbai, Kolkatta and Chennai), the Regional
      Cancer Centres (especially the one at Thiruvananthapuram), Cancer Registries
      (especially the one at Bangalore) numerous medical colleges (e.g. Postgraduate
      Institute of Medical Education & Research, Chandigarh), hospitals (e.g. Monilek
      Hospital, Jaipur) and medical foundations all over the country. Many of them have
      includee tobacco as a risk factor in epidemiological studies of multi-factoral diseases
      and conditions like heart disease, stroke, hypertension, asthma and chronic bronchitis.
                                                                                                      78
  •   Hospital-based clinical - e.g., Cancer Institutes, Indian Cancer Society, etc., medical
      colleges.
  •   Analysis of chemical properties of tobacco: Environmental Assessment Division,
      Bhabha Atomic Research Centre Mumbai-400 085; Carcinogenesis Division, Cancer
      Research Institute, Tata Memorial Centre, Parel, Mumbai; Department of
      Biochemistry, Panjab University, Chandigarh; Carcinogenesis Division, Tata Memorial
      Centre, Parel, Bombay; Carcinogenesis Division, Cancer Research Institute, Mumbai;
      Environmental Mutagenesis Unit, School of Life Sciences, Sambalpur University,
      Orissa; Department of Pharmaceutical Sciences, University of Kashmir, Srinagar,
      Jammu.
  •   Population-based and clinical research - e.g., Cancer Institutes, TIFR, POS, ICS, etc.


3. Other Non-Government Institutions involved in tobacco control in India:


 •    Associations of health professionals – a potential group:


  Health professionals in India, although they have done some work on tobacco control in
  India, it has not been to the necessary extent. They have great untapped potential to work in
  tobacco control, as a large number of people can be influenced by them.
  This category includes Indian Medical Association, Indian Dental Associations, and
  Association of Surgeons of India, Association of Surgical Oncologists of India, Indian
  Association of Pediatricians, Association of Cardiologists.


 •    Institutes involved in tobacco cessation programmes:


The WHO, SEARO recently initiated of a pilot project on community tobacco cessation in 12
centres in India. A special feature is inclusion of smokeless tobacco cessation, a very new
topic, as little is known on this subject till date.




                                                                                         79
          1. Indira Gandhi Institute of Cardiology, PMCH, Patna
          2. Tata Memorial Hospital, Mumbai
          3. Postgraduate Institute of Medical Education and Research, Chandigarh
          4. National Institute of Mental Health & Neurosciences, Bangalore
          5. Pramukhswamy Medical College and Srikrishna Hospital, Kamsad
          6. King George Medical College Research Centre, Lucknow
          7. Jawahar Lal Nehru Cancer Hospital, Bhopal
          8. S M Research Center, Goa
          9. Cancer Institute Chennai
          10. A.H. Regional Cancer Center, Cuttak
          11. Bhagwan Mahaveer Cancer Hospital, Jaipur
          12. Institute of Human Behaviour & Allied Science, Delhi


•       Religious bodies and associations with interest in tobacco control:
          1. Prajapati Brahakumari organization
          2. Arya Samaj (at least formerly)
          3. Buddhist Associations


•       Pharmaceutical companies with interest in tobacco control:
          1. Novartis
          2. SmithKline Beecham Consumer Healthcare Limited
          3. Glaxo India Limited


    •     NGOs working to uplift child beedi workers:


    The Indian Council of Child Welfare (ICCW), is an NGO that has worked with the
    Government on several different projects. Their work with child beedi workers at Vellore
    and at Srivilliputtur with child match workers has made the Right to Prevention of
                                                                           104
    Exploitation and Right to Education a reality to scores of children.


                                                                                         80
2.2.2 Initiatives by Non-Government institutions (NGOs) and Individuals


1. Litigations


In the eighties, the Consumer Education and Research Centre took Indian manufacturers of
tobacco toothpaste to the Monopolies and Restrictive Trade Practice Commission and
compelled them to provide labelling information in English and the local language
regarding the composition of the toothpaste, content of tobacco and a warning of tobacco
being injurious to health. Publication of similar information in both the languages was also
                                              23
a part of directions for the advertisement.


       In the ‘VOICE Vs ITC Ltd.’ Case, an advertising strategy of ITC was challenged by
                              35
VOICE in the court in 1984.
       Encouraged by ban on smoking in public places in Kerala through court orders,
similar public interest petitions had been filed by anti-smoking activists in the states of
Karnataka, Tamil Nadu, Andhra Pradesh and Maharashtra.
       CERS filed Writ Petition No.7930/1999 (Public Interest Litigation) against the
Government of India, Government of Gujarat and Manufacturers of Tobacco (Smoking and
non-smoking products) appealing the court to (1) Direct the Union and the State
Government to ban immediately the sale and consumption of tobacco and tobacco products
in all public places and to minors (2) Direct authorities to undertake compulsory education
of children and youth on tobacco hazards (3) Take up a public campaign against the use of
tobacco products. Gujarat Cancer and Research Institute (GCRI) have joined as a party to
the proceedings and have filed a reply containing the increased use of tobacco particularly,
                                                           23
the oral tobacco products by increasing group of minors.
       In the 2000, CERC along with a cancer patient and a cancer doctor, filed a writ
petition in the High Court of Gujarat against the Department of Health and Family Welfare
(DHFW), the Commissioner, Food and Drug Administration (FDA) and the Department of
Finance and Revenue for banning on non-smoking tobacco. After the patient died, an


                                                                                          81
application was filed against the gutka manufacturers for compensation for the benefit of
                                                                          23
his family. These petitions are pending before the Gujarat High Court.
       In 2000, an NGO, ‘Women’s Action Research and Legal Action for Women,’ filed
a writ petition in the Supreme Court for banning smuggling of cigarettes into the country.
Petitioner’s Counsel, Rani Jethmalani, also said that though the cigarette majors like ITC
and VST earned huge profits, they had so far not expressed their willingness to contribute
to a fund for the victims of smoking.
       In 1995, the Voluntary Health Association of India (VHAI) filed a writ petition in
the Delhi High Court, just before the cricket world cup in England, against the BCCI for
accepting sponsorship from ITC, displaying cigarette logos on cricketers' apparel, and
thereby encouraging children and youth to take to smoking that particular brand. This
Public interest litigation sought prohibition of advertisements by cigarette companies during
TV broadcasts of cricket matches. VHAI questioned the Government on an advertising ban.
The High Court in New Delhi ordered the Ministry of Health to report on what had been
done to meet the requirements of new legislation seeking a ban on advertising of tobacco
products. A Health Ministry spokesman had told the court in February that comprehensive
                                                                                      35
legislation aimed at reducing the consumption of tobacco was being contemplated.
       In 1999, School of Preventive Oncology filed a writ petition, PIL C.W.J.C.
No.11639 of 1999, through its advocate, Ram Kishore Singh (Ram Kishore Singh Vs. The
State of Bihar and others), for banning the use of tobacco and related products in public
                                                             105
places. The Court however, dismissed the writ application.


2. National and International Consultations


UICC Workshop "Tobacco or Health," Bombay India, April 15-16, 1987, organised by the
Tata Memorial Centre, Mumbai. The meetings participants covered the available scientific
information in the country on the issues of ill-effects of tobacco use on health, toxic
constituents of tobacco products, studies on behavioural intervention through education,
tobacco control policy and the role of the health sector. Agricultural experts also


                                                                                           82
participated in this workshop presented their experiences on alternate substitutes of tobacco
by other crops and alternate uses of bidi tobacco.


National Conference on Tobacco or Health, in New Delhi, July 27 and 28, 1991, organised
by the Ministry of Health and Family Welfare in collaboration with World Health
Organisation at the All India Institute of Medical Sciences. Topics covered by different
groups included health education, legislation, tobacco economics, roles of youth and NGOs,
countering tobacco advertising and promotion and research priorities. Recommendations
coming out of each of the groups were summarised and strategies for tobacco control were
enumerated at the end by the Adviser on Health to the Planning Commission of India.
                                            69
Recommendations included the following:
   1. A National Tobacco Control Commission should be established to co-ordinate all
       the tobacco related activities. The NTCC should set up laboratories for testing
       nicotine and tar content of Bidis and Cigarettes; provide incentives to farmers to
       change to alternate crops, rehabilitate those people who will lose employment due to
       control of tobacco and give income tax exemption to money donated for anti-
       tobacco campaigns.
   2. A National plan of action (MOH and FW) should be formulated, for implementation
       in a phased manner.
   3. A comprehensive tobacco act should be passed to encompass all legislation in
       relation to tobacco promotion, sale, consumption, labelling, warnings, etc.
   4. A separate legislation should mandate compulsory compensatory reforestation to
       make up for the loss of forests from flue curing of tobacco.
   5. A committee should be appointed to go into the details of tobacco economics.
   6. Health education strategies should be carefully formulated and a specific
       programme of health education drawn up, not relying only on one-way
       communication, like posters, TV and radio. The messages should be such that they
       can reach the illiterate as well. A committee should be set up to formulate the
       health education strategy, having major emphasis on children and adolescents,
       through the school curriculum and the teachers’ training course (B.Ed). Anti-
       tobacco information should also be an essential component of community medicine.
                                                                                         83
An International Symposium on the Control of Tobacco- Related Cancers and Other
Diseases during January 15-19, 1990 was held at TIFR, Bombay, with funding from the
U.S.-India Fund and the support of the U.S. Public Health Service and the Fogarty
International Center, National Institutes of Health, USA. It was a multi-disciplinary
conference, covering public health and epidemiology, clinical and other sciences,
behavioural science, law and economics. The Proceedings were published by TIFR in
Control of Tobacco- Related Cancers and Other Diseases, 1992.


First International Workshop on Certification of Causes of Death, 22-24 February, 1999,
was organised and held at Tata Institute of Fundamental Research, Mumbai and co-
sponsored by- Brihanmumbai Municipal Corporation, WHO, World Bank and CDC. The
proceedings were published in Counting the Dead in India in the 21st Century, 1999.


The New Delhi Conference on Global Tobacco Control Law – Towards a WHO
Framework Convention on Tobacco Control, was held from 7-9 January, 2000. The
meeting aimed to consider to consider issues from a developing country perspective, that
they may encounter in formulating the proposed WHO Framework Convention on Tobacco
Control and difficulties they might encounter in enacting tobacco control measures. It
received very strong political support from the Government of India with the attendance of
the Prime Minister of India, Law Minister, Health Minister, the Director General of WHO
and other senior officials from Indian government. Participants with an interdisciplinary
background especially public health, law, policymakers and NGOs were drawn from over
50 developing and least developed countries from Asia, Asia, Middle East and the
       106
Pacific.


Second International Workshop on Certification of Causes of Death, 9-12 February, 2000,
was held in Goa. Organized by Tata Institute of Fundamental Research and co-sponsored
by the WHO, World Bank, and CDC. The proceedings were published in Counting the
Dead in India in the 21st Century, 2000.


                                                                                         84
International Scientific Expert Meeting on the Possible Causality between Smoking and
Tuberculosis, November 17-19, 2000, was held in Thiruvanathapuram, Kerala, India,
Hosted by TIFR, Mumbai and co-sponsored by the WHO and CDC. The proceedings were
published in Evidence for a Causal Link between Smoking and Tuberculosis.


Indian Tobacco Control Leadership Fellows Program, February 2002, was held in Mumbai.
It was organised by ACT-India in collaboration with the Centres for Disease Control
(CDC), Atlanta, USA and the Advocacy Institute of USA, with a four-day interactive
program on different aspects of tobacco control in India.


Tobacco Control Research in India Meeting, April 2002, was held in New Delhi. It was
organized by TIFR in collaboration with the CDC and World Bank where present and
future research initiatives related to tobacco control in India were discussed. The
proceedings were published in Tobacco Research in India. Proceedings of an Expert
Meeting on Supporting Efforts to Reduce Harm, 2003.


3. Advocacy


Advocacy against marketing ploy: The Action Council against Tobacco-India (ACT-India),
a non-government organization, had criticized the aggressive promotion of ‘Click’ a
recently introduced smokeless tobacco product, a version of traditional Swedish ‘snus’,
which the is being marketed as a safer alternative to smoking. Dr. Prakash Gupta, a leading
epidemiologist at the Tata Institute of Fundamental Research in Mumbai said that there is
not enough scientific data to substantiate Swedish Match's claim. He emphasised that all
smokeless tobacco products carry the risk of fatal diseases such as oral cancer and many
                  107
other diseases.         Oral smokeless tobacco is estimated to cause over 260,000 new oral
                                     75
cancer cases in India every year.




                                                                                        85
Advocacy for oral health: In September 2001, more than 600 dental and health care experts
attending the Inter-State Dental Congress, 2001 urged the Government to formulate strict
                                                                 107
oral health regulations to prevent increasing dental diseases.


NGOs support FCTC: In December, 2001, twenty-four NGOs from India reaffirmed their
support for both the Jakarta and Thimphu declarations on FCTC and called on the
Intergovernmental Negotiating Body on the Framework Convention on Tobacco Control to
ensure that the final negotiated text of the Convention prioritises public health over
everything else. They urged the Central and State Governments in India to raise tobacco
taxes and allocate a portion for the enactment and implementation of tobacco control
policies that have been proven effective in reducing use, to impose a total ban on all forms
of tobacco advertising, promotion, and sponsorship and encourage measures to protect the
public from exposure to tobacco smoke and initiate international community to control
smuggling of tobacco products. The organisations included the National Organization for
Tobacco Eradication, Goa, Goa Cancer Society, Goa, Action Council against Tobacco –
India (ACT-India), Voluntary Organization in Interest of Consumer Education (VOICE),
New Delhi, No-Tobacco Organization, Nagpur, Cancer Institute, Chennai, National
Association for Environment and Health, Madurai, Health Foundation, Mumbai, Tata
Institute of Social Sciences, Mumbai, Associations for Consumer Safety and Health,
Mumbai, National Organization for Tobacco Eradication, Bhopal, Joint Action Committee
for Anti-Tobacco Bill, Regional Cancer Center, Thiruvanathapuram, National Organization
for Tobacco Eradication, Patna, Sarv Jeev Mangal Pratishthan, Pune, Consumer Education
& Research Society, Ahmedabad, Consumer Guidance Society of India, Mumbai, Action
Council Against Tobacco, Jaipur, National Organization for Tobacco Eradication, Kerala,
Anti-tobacco Cell of Karnataka, Bangalore, School Health Action Network, Delhi,
HRIDAY, Delhi, Women's Action Research and Legal Action for Women, WARLAW,
Delhi, School of Preventive Oncology , Patna, Bihar.
Surgeons support FCTC: The Association of Surgeons in India recently passed a resolution
supporting the Framework Convention on Tobacco Control (FCTC) and opposing the trans-
national tobacco companies for pushing their products in India, thus increasing, the disease
                      108
burden in the country.
                                                                                         86
4. Community Interventions


The community has been approached in different ways in India. Some examples are given
below:


In Mumbai on World Anti-Tobacco Day, Saturday, May 31st, 2003, the Cancer Patients Aid
Association held a ‘Say No to Tobacco Campaign” event with a discussion on films
glorifying the use of tobacco and tobacco advertising in the electronic media. Participants
included film directors, actors and models, police personalities, the Union Health Minister,
the State Health Minister and a representative of the WHO. Some of the actors confessed to
have given up smoking. The Union Health Minister, in her speech was clear about banning
tobacco promoting advertisements. For another CPAA organised event later in the day, a
special run was held on Marine Drive with the participation of industrialists, actors,
politicians, including the Chief Minister and other prominent citizens.


NGOs plead to young graduates not to sell tobacco: The National Organization for tobacco
Eradication, (NOTE India) and the Goa Cancer Society appealed to graduates and diploma
holders in marketing and sales not to fall prey to “more incentives and more of everything”
advertised by a tobacco marketing company. An advertisement in a leading local daily
newspaper by a leading tobacco marketing company had promised more incentives to the
                  109
sales officers.


Awareness for street children: Cancer Patients Aid Association in Mumbai launched an
intervention program for street children to educate them about the dangers of tobacco. The
programme workers estimate that about 80% of street children, the most vulnerable
children in society, are addicted to gutka. Unaware of its dangers, these children (many of
them orphans or runways) eke out a meagre living in the streets and spend the majority of
their earnings on gutka. Some of them are as young as 8 years old when they start: they
consume it all day long, saying that it helps them forget their hunger and other 'tensions'.


                                                                                         87
The health workers found high rates of pre-cancerous lesions, submucous fibrosis and
                                        110
leukoplakic patches in this population.


Participation by famous sportsmen: The Cancer Patients Aid Association, Mumbai
(CPAA), Mumbai, unveiled canvases signed by famous players from a wide range of
sports, and a cricket bat signed by the Indian team, endorsing the no-smoking message.
“Tobacco is a communicable disease, communicated through advertising and
                111
sponsorship.”


Human chain: The CPAA formed a human chain along busy Marine Drive, Mumbai, on the
eve of World NO Tobacco Day, with volunteers holding anti-tobacco messages from
                      112
5.30pm to 7.00pm.


Rural community awareness programme: Narayan Seva Sansthan based in Udaipur,
Rajasthan and operating in rural areas of that State, had taken the anti-tobacco message
deep into the heartland of the State through its culture specific approach with simple tools
like use of the local language, pictorial reference, posters and catchy slogans in the local
       35
dialect.


School programmes: VHAI along with HOT (Health or Tobacco group of young doctors
from All India Institute of Medical Sciences) educated school children through innovative
techniques like educational talks and competitions. In order to nature leadership qualities,
                                          35
VHAI initiated “Leadership in Health.”


A week-long oral cancer awareness camp was organised by the Rotary Club of Bombay
Hills South. The camp focussed on cancer caused by tobacco - arising from smoking, eating
pan masala, gutka etc. The club held exhibitions and free oral cancer screening at
Churchgate station for three days.



                                                                                         88
Initiative for a smoke free society: The School of preventive Oncology, Patna, organized a
door-to door campaign on the day exhorting people to shun consumption of tobacco in any
                                                                     113
form. Altogether 1857 homes were taken up as part of the campaign.


5. Motivation for Cessation:


An private sector initiative: Alkalis and Allied Chemicals Ltd. of Andhra Pradesh State
encourages its 1,200 workers to stop smoking and drinking alcohol by paying them a
monthly allowance of 215 rupees (US$4.49) for not smoking and another 210 rupees
(US$4.38) for shunning alcohol. The firm said the programme, launched eight years ago,
has been a great success. The allowances, which were paid to the employees' wives, are
stopped if an employee is found to have returned to using tobacco. It costs the firm about
                                         114
510,000 rupees (US$ 10,600) per month.


A voluntary sector initiative: After receiving a lecture from a member of the Cancer
Patients Aid Association (CPAA), a goldsmith company in Mumbai made an immediate
change in its workplace conditions. The reduction in consumption of bidis and gutka was
dramatic, and eight months later the canteen and the office were smoke-free, with the only
smoking area being a narrow ledge in front of the toilets. There was a 50% reduction in the
number of smokers in the office. CPAA said that 42 companies across the country signed
                            115
up for similar campaigns.


Successful school/community Interventional models:
 •   HRIDAY (Health Related Information Dissemination Amongst Youth) SHAN Model
     is a very successful model for urban students. The Institution has been awarded the
     WHO Tobacco Free World Award 2002 for its work to advance the cause of tobacco
                                           116
     control among children and teenagers.

 •   NOTE-India, (National Organization for Tobacco Eradication) an anti-tobacco
     networking organization, had implemented the students and school personnel for
                                                  75, 117
     community intervention model with success.
                                                                                       89
 •   Communication strategies for intervening among rural populations in India in
                                118
     Maharashtra and Gujarat.
                                                          119, 120
 •   Tobacco Behaviour Modification in Kerala State.


6. Student awareness programmes


Celebrities educated youth. The CPAA in Mumbai is trying to teach young people that
smoking is “un-cool, un-sexy and not a requirement to fit in with your peer group”.
Members of the year-old campaign, which includes celebrity models, actors and disc
jockeys, have visited schools and junior colleges to talk about why it isn't cool (desirable) to
smoke. An actor and photographer, Boman Irani, who is currently working on an anti-
smoking photography campaign, said, "It is very important that those in public life should
be conscious that their actions are being followed by young people. They have a social
                                                            121
responsibility not to smoke in ads, photographs or on TV.


A university ban: Lucknow University has banned smoking on the campus, but non-
smokers are concerned because the body responsible for enforcing the ban is only for
                                     122
regulating students, not teachers.


Anti-Tobacco Poster Competition was organised by the Dental Health Foundation and
Gujarat.State Lalit Kala Akademi at the national level. Most of the entries were in Gujarati
and English and displayed messages like, “Stop smoking before it stops you”, “Stop
smoking before it burns you” and “Crush it forever or it will crush your life”, “Play a game
with tobacco if you do not love your life” and other similar messages. The 110 posters
displayed had been judged as the best entries by the jury panel.


On May 31st, 2002, World no Tobacco Day was observed in Delhi by the Cancer Patients’
Aid Association with several activities. A signature campaign for tobacco free environment
was undertaken with the active participation of a number of companies. Sports
personalities participated in a signature campaign for tobacco free sports, the theme of this
                                                                                         90
year's WHO initiative. An inter-school poster competition was held for which Dr. Kiran
Bedi, Chief Patron of CPAA, Delhi was Chief Guest and gave away the prizes. A street
play and a music programme were organised. A detection camp was held for office goers at
               123
Nehru Place.


7. Other initiatives of non-Government institutions


Initiative for alternative crops: Centre for Multi-disciplinary Development Research
(CMDR), Karnataka, had persuaded 100 farmers 100 farmers to shift from tobacco
cultivation to dairy farming and motivate soybean cultivation. This shift from tobacco
cultivation had sustained for three agricultural seasons as per their information. The Centre
had followed up the farm operations of the erstwhile tobacco farmers and also other farmers
in the adopted village. On a close scrutiny of the responses of the farmers in the village it
was noticed that the intervention needed to be sustained for a longer period than only three
agricultural seasons.


Contraceptives from tobacco: Researchers in New Delhi, in collaboration with scientists of
Germany, have got tobacco leaves to produce a chemical that reportedly acts as an effective
                                  124
and cheap female contraceptive.



2.2.3 Strengths and weaknesses of non-government organizations and trusts:


The strengths and weaknesses of NGOs have been ascertained through a process of self-
appraisal as well as informal feedback from peers through the following sources:
 •   Self-reports on strengths and weaknesses of NGOs
 •   Information from peers
 •   Documents from NGOs, WHO, SEARO
 •   Materials on meeting highlights




                                                                                         91
Table 2.3 gives information on NGOs who contributed self-reports:

Table 2.3 Strengths and Weaknesses of Non-government Institutions
Name of NGO                         STRENGTHS                                 WEAKNESSES
1. Action Council Against Tobacco   1.Completely devoted to tobacco           1. No fund raising drive yet so very
            55                      control                                   little core funds.
(ACT-India)
                                    2. Strong scientific and research base.   2. Membership needs to be increased
                                    3. A wide base in India with chapters     manifold.
                                    in different regions and more under       3. Membership base needs to be
                                    development, giving it a truly national   widened to include professionals and
                                    character.                                organization from related disciplines.
                                    4. A strong identity and credibility      4. Little public relation exercises as yet
                                    among researchers and scientists in       therefore low exposure in popular
                                    India                                     media and little awareness among lay
                                    5.Ongoing in-depth interaction with       public
                                    several NGOs having tobacco control       5. Insufficient number of volunteers for
                                    as an objective                           tobacco control activities
                                    6. A track record for a wide spectrum     6. No independent land, premises,
                                    of tobacco control activities including   office or infrastructure as yet.
                                    scientific research, advocacy efforts,
                                    expert group meetings, training
                                    programs and World No Tobacco Day
                                    campaigns encompassing a large
                                    variety of activities.
                                    7. A strong presence and recognition in
                                    international tobacco control
                                    movement including Framework
                                    Convention for Tobacco Control
                                    among leading global tobacco control
                                    organizations.
                                    8. Ongoing interactions with official
                                    bodies such as ICMR, MOHFW,
                                    WHO-India, SEARO, State
                                    Governments etc. in India and with
                                    WHO Geneva, UICC, ACS, OSH,
                                    CDC, Word Bank etc. internationally.
                                    9. Patronage and backing from a highly
                                    prestigious institution - Tata Memorial
                                    Center, Mumbai.




                                                                                                 92
Table 2.3 Strengths and Weaknesses of Non-government Institutions (Continued)
Name of NGO                            STRENGTHS                                 WEAKNESSES
2. Health Related Information          1.Sustainable Growth                      1.Limited Outreach of activities to
Dissemination Among Youth,             2. Innovative Approaches. HRIDAY-         rural youth
                    24, 82             SHAN model accepted as the training       2.Programme Confined to mainly to
(HRIDAY-SHAN)
                                       module by WHO (SEARO)/ Awarded            Delhi but extending to Mumbai, Indore
                                       the WHO Tobacco Free World Award          and Chennai
                                       for 2002. Awarded a prestigious           3.Limited Core Resources
                                       research and capacity building grant      4.Not focused on Tobacco Cessation
                                       from NIH.
                                       3.Capacity Building among HRIDAY
                                       Personnel
                                       4.Strong networking with national and
                                       international organization and with
                                       Other Civil Society Groups
                                       5.Sufficient Funding
3. Consumer Education & Research       1. Consumer related-Legal actions.        Lack in data Collection and
Centre/ Consumer Education &           2. Strong core Resource.                  Research
                              23       3. Advocacy
Research Society (CERC/CERS)

4. Gujarat Cancer and Research         1. Education in general public            1. Weak Advocacy programs
                 23                    2. Early detection of tobacco related     2. Poor Networking
Institute (GCRI)
                                       disease                                   3. Activity Limited to Gujarat
                                       3. Legal intervention
5. Cancer Patients Aid Association     Media, Anti Tobacco advertising, and      1. Lack of Data Collection
        68                             reach to Role Models, Education for       2. Cessation
(CPAA)
                                       general public, Education                 3. Activity limited to Mumbai, Pune,
                                       (school children , mill workers and       Delhi, Bangalore cities
                                       under privileged children), Early
                                       Detection
6. National Organization for Tobacco   1. Very strong historical back ground     1. Poor units in few other states of
                    47                 in Tobacco control in Goa and outside     India.
Eradication (NOTE)
                                       2. Very active in Goa
                                       3. Community Interventions, though
                                       children’s model
                                       4. Media Advocacy
                                       5. Sustained advocacy for policy
                                       making and implementation in Goa
                125                    1. Well received community and            1. A young NGO
7. SWASTHYA
                                       school programs since 8 months only.      2.No sufficient infrastructure
                                       Some success in stopping smoking in       3. Only few part time volunteers.
                                       local trains and platforms in Faridabad   4. Limited advocacy materials,
                                                                                 5. Limited funds
8. Rajasthan Cancer                    1. Good initiatives                       1. Its recent establishment
Foundation                             2. Tobacco Control Advocacy (28           2. Lack of funds.
      126                              sessions).
(RCF)
                                       3. Survey of the State on Tobacco
                                       User.
                                       4. Part of GYTS,WHO, CDC project
                                       in India




                                                                                                    93
Areas of expertise of NGOs:
Determination of the areas of expertise of these organisations was based on their previous
published and presented work:


Types of tobacco control actions taken by non-government organisations:
 •    Total action: e.g., ACT-India, NOTE, POS, HRIDAY
      ‘Total Action,’ in tobacco control includes sustained advocacy, intervention in day-to-
      day life and activities at all levels. For the Indian community it is a most critical
      component as the population suffers from so many myths and beliefs and varieties of
      tobacco products used.
 •    Advocacy: e.g., ACT-India, CPAA, NOTE, HRIDAY SHAN, VHAI, POS, SALAAM
      BOMBAY, INGAT, ACASH, IMPACT
 •    Judicial Intervention: e.g., CERC, VOICE, POS, CLEAR,VHAI
 •    Educational intervention for youth in urban areas: e.g., SALAAM BOMBAY,
      HRIDAY SHAN, NOTE, POS, INGCAT TASK FORCE
 •    Educational intervention for youth in rural areas: e.g., POS, NOTE
 •    Community intervention e.g., ACT, POS, CERC, GCRI, CPAA
 •    Tobacco related consumer movement - e.g., CERC, VOICE, ACASH
 •    Advocacy material development - e.g., PATH Canada, CPAA
 •    Tobacco related social movement - e.g., TISS, CPAA, SB
 •    Media Advocacy - e.g., ACT-India, CPAA, NOTE, HRIDAY SHAN, VHAI, POS,
      SALAAM BOMBAY, INGAT, ACASH, etc.


Strengths of NGOs:


1. Expertise in tobacco control: Some NGOs have developed expertise in some aspects of
     tobacco control.
2. Selfless life-time devotees: A few people devoted solely to this cause.
3. Organisations devoted solely to tobacco control: A handful, like ACT, HRIDAY, POS,
     and ISAS are involved solely in tobacco control.
4. Idea generators: A few people are providing ideas to move the work forward.
                                                                                      94
5. Young and enthusiastic people: There are some young entrants in tobacco control.
6. Support from important positions: A few people in important positions in some
   institutions are ardent supporters of tobacco control in India.
7. New devotees: A few people have recently given up their stable jobs becoming devoted
   full-time to tobacco control.
8. Organizations with a broad base in India: There are a few, e.g., ACT, POS, ICS, Prajapati
   Braham Kumamari Organization, and VHAI. However, they do not all work solely in
   tobacco control.
9. Some organisations have strong core resources: E.g. Only CERC, VHAI, VOICE, CRY
   and FBIS have strong core resources.


Weaknesses of NGOs:


1. The general weakness of almost all the organizations is a low level of action, both in
   litigation and mass based action on the streets and in rural areas.
2. There is absence of NGOs having a broad base of tobacco control throughout India.
3. Few NGOs solely devoted to tobacco control in India.
4. Many NGOs have no infrastructure and are without seed money and have limited funds,
   especially for anti tobacco activities, anti tobacco advertising. Important institutions like
   ACT and HRIDAY have no strong core resources.
5. Many NGOs are one-man structures.
6. There is poor networking amongst most anti-tobacco groups, leading to a lack of
   guidance and coordination of action.
7. There is a need to develop expertise for research, planning, designing, implementing
   need-based interventions, fund-raising and in working with all those sectors requiring to
   be activated for effective tobacco control.
8. For some there is a lack of good lawyers expert in the tobacco scene at local, national and
   international levels.




                                                                                         95
Non-Government organisations with untapped potential to work in tobacco control:


The following are organisations not actively participating in tobacco control that could be
sensitised to work well for tobacco control in India:


       1. Associations of health professionals
       2. Associations of school personnel
       3. Associations of students (student unions)
       4. Labour unions
       5. Associations of media personnel




2.2.4 Suggested mechanisms to strengthen non-government institutions


In this subsection it is discussed how these institutions could strengthen their current
activities and become involved in developing and implementing new strategies for
comprehensive tobacco control. An assumption is that it is important to match requirements
and needs to expertise and resources. This section has been prepared basically from the
inputs from renowned tobacco control advocates in India on this issue. Basically four
mechanisms have been suggested:


 •   Increased use of collective and individual approaches by NGOs
 •   Resource Development for NGOs
 •   Capacity building of NGOs by mutual training in their respective weak areas
 •   Sensitising potential institutions


1. Increased use of collective and individual approaches by NGOs
Collective functioning (Working together): In February 2002 at the instance of advocacy
Institute at CDC tobacco advocates in India considered coordinating their activities according
to the expertise available, to maximize the attainment of the objective of tobacco control.
Thus they provisionally prepared a platform called, ‘Indian Coalition for Tobacco Control’
                                                                                           96
          78
(ICTC).        A later platform, called the Advocacy Forum for Tobacco Control (AFTC)
performed an advocacy role for the passing of the comprehensive tobacco control bill.


Individual efforts: In addition to the collective functioning individual efforts (in media
advocacy, use of personal influence in persuading policy makers, and community cessation
efforts, etc.) will make tobacco control reach more effective.


In India NGOs need to work on these essential components of tobacco control:


 •   High level of community mobilization beginning with awareness generation:
     Institutions should create awareness in the public by making the anti-tobacco
     movement broad based by involving in their campaign against tobacco, people with
     mass appeal like spiritual leaders and respected social workers. They should organize
     public programs at regular intervals. They should influence legislators to impose new
     taxes on tobacco products or increase existing taxes on tobacco products and compel
     them to enact laws and implement banning sale of any new product containing tobacco.
     There is lack of awareness in the public about the existing regulations and rights in
     getting those legislations enforced. This kind of awareness need to especially provided
     to NGOs dealing with public issues and grievances such as consumer bodies,
     environmental groups, health organizations and social justice NGOs.
 •   Simultaneously contact the different electronic and print media throughout the year to
     create awareness and a movement.
 •   Manpower is a crucial component of tobacco control and is at present insufficient.
     Organizations and individuals should increase the number of people participating in the
     field of tobacco control and transform the organizations into effective action groups.
 •   Improve networking and sharing of resources and strengths; bridging gaps in each other
     by training each other in their respective weak areas.
 •   Form an effective coalition over the long term; perform joint advocacy; plan strategies
     jointly and using them in a regularized, phased manner.
 •   Carry out continuous advocacy on implementation, taxation, smuggling and
     advertisements.
                                                                                         97
 •   Create local sub units thereby increasing reach; divide localities area-wise and educate,
     motivate and mobilise youth from the respective areas into anti-tobacco activities.


2. Financial Resource Development (Funding) for NGOs
There is a need for the development of funding for NGOs involved in tobacco control by
WHO and other international organizations.


Financial resources: Financial resources are crucial for the capacity building of the NGOs,
for them to be effective action groups. This point has been highlighted by most of NGOs are
at constraints. They need to be resourced in matching of requirements, needs and expertise of
individual organizations.


Need-based resource provision: One example for resource allocation matching with
requirement may be support for school intervention in the north-eastern states, as tobacco use
among students in these states has been reported to be very high.
Equal distribution: All sizes of NGOs need to be provided with resources. Small NGOs in
need of seed grants must be supported depending upon their level of activity.


Resource provision for boosting level of activity: Funding should be provided for action at
the local level, state level, regional level and at country level. Country level grants should be
for capacity building of NGOs in specialized fields and those for local level grants should be
given for special community intervention.


Resource provision based on expertise: Individuals or organizations should be supported on
the basis of their expertise in different fields of tobacco control and their need.


3. Capacity building of NGOs


Gaps in different organizations can be bridged by mutual training (and assistance of
international organizations) in their respective weak areas:


                                                                                          98
Capacity building for fund raising: Analysis of funding routes of NGOs in India indicates
that many either do not have capacity for fund raising or they do not adopt the principles of
self fund-raising. This issue needs to be seriously addressed.


Workshops on Tobacco for Various Sectors: In many situations, different associated sectors
may not be aware of the magnitude of the problem and of the possible solutions for tobacco
control. Issues of law enforcement, awareness generation and seeking compensation for the
victims of tobacco are some areas where training is needed. It would be necessary to organise
information sharing programmes in consultation with the full involvement of different
sectors, to inform them of different facets of tobacco and its control. The faculty for such
programmes would necessarily have to be inter-disciplinary, carefully selected from fields of
health, economics, media, education, sports, youth affairs, agriculture, finance, law, labour,
etc. Such workshops should be followed up by periodic interaction and seeking their
cooperation to initiate activities related to that area.


4. Sensitising potential non-government institutions


In India, some institutions like associations of health professionals, associations of school
personnel, associations of students (student unions), labour unions and associations of media
personnel need to be sensitised on tobacco control as they have a strong potential for tobacco
control. Government and non-government institutions need to put equal efforts in sensitising
them.




                                                                                         99
Chapter 3


Policy Implementation and Gaps in Tobacco Control


This chapter has been written under two broad subheadings:


3.1 Implementation of Tobacco Control Policies
3.2 Gaps in the Implementation of Tobacco Control Policies, Suggested Mechanisms to
     Address Them and Recent Steps Taken




3.1 IMPLEMENTATION OF TOBACCO CONTROL POLICIES




Implementation has always been considered the responsibility of the State Government and
its local functionaries, like municipal office bearers, the Food and Drug Administration, the
Police and the rural Panchayat Sanghs. However, participation from NGO's and individuals
                   68
are also needed.        Another way of looking at this is that civil society bears part of the
responsibility of monitoring policy implementation and perhaps even of implementation
itself, through individuals and organizations.


The well documented work in this regard of the States of Goa and Maharashtra are
provided here as examples:


 •   In enforcing the Goa Prohibition of Smoking and Spitting in Public Places Act, 1999, the
     police in Goa pulled down glossy posters of cigarettes put up by tobacco companies in the
     city. The UK's BBC recorded the event in a documentary film showing, the cynicism of
     the major global tobacco companies, and anti-tobacco campaigns in India. Goa has
                                              127
     practically no cigarette advertising.          It is likely that the success in Goa of
     implementation of the Goa Act, 1999 is related to the strong presence of the National
                                                                                              100
      Organisation for Tobacco Eradication (NOTE India). Its general secretary stresses on the
                                                              47
      importance of sensitising the law enforcing officers.

 •    In September, 2000, the Government of Maharashtra set up a 12-member coordination
      committee to implement its decision to ban the sale, consumption, distribution and
      advertisement of gutka within 100 metres of educational institutions. It also submitted
                                                                     128
      a proposal to the Union Government to ban the sale of gutka.




3.2 GAPS IN THE IMPLEMENTATION OF TOBACCO CONTROL POLICIES
     AND MECHANISMS TO ADDRESS THEM


Gaps in the implementation of tobacco control policies and the new mechanisms needed to
address them are discussed in this chapter, under the three categories of players involved in
tobacco control as follows:
3.2.1 The Community (Civil Society)
3.2.2 Government Institutions
3.2.3 Non-government Institutions


     Gaps: Under each of the above mentioned players, three categories of gaps, general,
     supply side and demand side.


     Suggested Mechanisms: Under each gap are elaborated the suggested mechanisms needed
  to address them and lastly,


≈ Recent steps: Recent steps taken towards closing the gaps are mentioned at the bottom of
     the sections on each of the three types of players.


All this information is schematically shown in Tables 3.1, 3.2 and 3.3 below:




                                                                                       101
Table 3.1a Gaps in tobacco control in the community in India and suggested mechanisms to fill them, along
          with recent steps taken towards filling them.
         Gaps:                      General                  Supply Specific        Demand Specific
Player :
The Community                         Poorly Informed;           Dependency on          Many use tobacco
                                      Unmotivated;               tobacco for            Awareness
                                      Weak Opposition            livelihood.            generation
                                      Health Personnel not       Awareness and          programmes
                                        involved                 alternative skills     Cessation clinics
                                      Awareness                  training for
                                      generation                 tobacco workers.       Underactivity of
                                      programmes for the     ≈ New livelihoods:         NGOs
                                      public, schools and        like at Dinesh         Volunteer
                                      health personnel           Bidi, Kerala           recruitment.
                                      Mobilisation of
                                      public and health                                 Lack of PILs.
                                      community,                                        Motivational &
                                      entertainers                                       practical
                                                                                         training for
                                                                                         initiating PILs




                                                                                                  102
Table 3.1b Gaps in tobacco control in government institutions in India and suggested mechanisms to fill them,
along with recent steps taken towards filling them
         Gaps:                      General                    Supply Specific         Demand Specific
Government Institutions                  Policy Gaps                Conflicting           Unequal taxation of
                                         Complete the rules         objectives &          products
                                         for the compre-            policies              Address taxation
                                         hensive Act, 2003.         Clear non-con-        Duty-free imports
                                         National policy            flicting policies     Legislate against
                                         unit & action plan                               duty-free imports
                                         Socially balanced          Tobacco Devel.
                                         legislation                Board                 No de-addiction
                                         Lack of political          Phase out              facilities
                                          will, priority            tobacco with          Mechanism for
                                         Take policy                alternate crops       funding Cessation
                                         seriously                                        Clinics &
                                         Lack of                    Government            Compensation of
                                          coordination with         responsible for       Victims
                                          NGOs                      welfare of
                                         Coordinate more            citizens              Tobacco
                                         with NGOs                  Create alternate      advertising,
                                         Multi-sectoral             employment for        promotion, warnings
                                           Approach                 tobacco workers       Close loopholes in
                                    ≈ Consultations                                       advertising; enforce
                                                                    Smuggling             new law (Act, 2003).
                                        Corruption                  Control
                                                                    Smuggling.            Inadequate health
                                        Time lags in                                      warnings
                                          legislation,              Unequal laws          Improve warning
                                          implementation            among States, in      labels – enforce
                                                                    tobacco               New Act, 2003.
                                        No Central Agency           production,
                                          – for monitoring          storage, sale and     Lack of tobacco
                                          and law enforce-          labour laws;          policy for schools &
                                          ment                      Extend laws to        colleges, except 100
                                        Specific agency/          all States & UTs        yd. Rule in new Act,
                                       focussed authority                                 2003..
                                           Nodal agencies           Restrictions on       Youth Education
                                           Clear chain of           package size and
                                           command                  contents for          Inadequate public
                                    ≈ Creation of a                 cigarettes, cigars    education;
                                           National Tobacco         and 22 other          Public Education
                                           Cell in the MOH          products           ≈ Some Public Edu-
                                           for planning and         dropped.               cation
                                           coordination             Restore
                                                                    packaging             Few tobacco
                                        Lack of monitoring          restrictions          laboratories;
                                          and follow-up;            Time lag for          Tobacco Research
                                           Monitoring               justice to            Laboratories (create
                                           Follow-up action         victims.              them)
                                        Inadequate Regional         Expand judiciary ≈ Some Research
                                          legislation                                     High tobacco
                                        Strong support to           Tax-free exports      toxicity.
                                       FTCT in region               Tax exports           Reduction of tar and
                                    ≈ Ratification                                        nicotine levels

                                                                                                    103
Table 3.1c Gaps in tobacco control in non-government institutions in India and suggested mechanisms to fill
them, along with recent steps taken towards filling them.
         Gaps:                      General                  Supply Specific          Demand Specific
Non-government Institutions             Information not         Tobacco industry          Insufficient
                                        readily available        flouts policy            public awareness
                                         Networking; infor-       Strong                  initiatives
                                         mation sharing           opposition              Public Education
                                                                    o PILs            ≈ Public Education
                                       Lack of research             o Media
                                        initiative                     advoacy            Youth Education
                                         Research, e.g.,            o Litigation
                                         Strategic                   for                  Lack of tobacco
                                         Mapping                     compensation         cessation
                                        Study attitudes and          for indivi-          intiatives
                                        reasons for tobacco          duals and            Set up Cessation
                                        use locally                  class actions        Clinics
                                                             ≈ A few PILs             ≈ Some tobacco
                                       Lack of monitoring & ≈ Limited pleas on            cessation clinics
                                        follow-up                taxation issue           set up
                                        Remind authorities                                Start community-
                                         & industry of           Constant                 based cessation
                                         policies                lawbreaking              programmes
                                                                 Remind
                                       Lack of community          authorities
                                        mobilisation              & industry of
                                       Community                  policies
                                      Mobilisation           ≈ Some Advocacy
                                       Sustained Motivation ≈ Initiatives for
                                                                 alternative crops,
                                       Lack of youth             alternative liveli-
                                        mobilisation             hoods and uses.
                                       Youth Mobilisation

                                     Unplanned approach
                                      Strategic planning

                                    Poor networking
                                     among NGOs and
                                     Absence of strong
                                     NGO lobby
                                  ≈ A few Meetings/
                                      consultations
                                  ≈ Creation of the
                                     Indian Coalition
                                     on Tobacco
                                     Control, worked on
                                     the FCTC.
                                  ≈ Advocacy Forum
                                   for Tobacco Control
                                   (AFTC) created for
                                   advocating
                                   comprehensive Bill
                                    Manpower shortage
                                    ‘Recruit’ and
                                     motivate volunteers
                                                                                                    104
3.2.1 The Community


   Poorly informed people and consequent lack of motivation for tobacco control:


The 1975 Act was a step towards tobacco control, however, it made no significant dent in the
smoking prevalence because 1) the warnings were limited to cigarettes, which are consumed
much less than bidis; 2) the printed warnings were only in English, understood by only a
                                               26
small proportion of the literate population.        Thus the warnings did little to inform the
public.
          According to tobacco control activists, there is a lack of awareness and unchanged
                                                                                            23, 68
social attitudes, as education of the public has not been a priority of the Government.
There is also a lack of awareness in the public about the existing regulations and rights.
Overall, the population, including the adolescents has not been reached. The proper degree of
motivation has shown great success in India, where small initiatives have been
              129
undertaken.         Underlying this assertion is the assumption that motivation comes from at
least in part from awareness and knowledge.
          According to a tobacco control activist, there is not much effort from the Government
side to disseminate warning messages about tobacco as they do for the immunization of
children or even sometimes for common diseases like diarrhoea and very few NGOs are
working on this issue. NGOs and the Governments are more concerned with maternal and
child health, common diseases and now AIDS. Cancer is not on the priority list, nor the many
                                                                                129
other non-communicable diseases associated with tobacco besides cancer.
          Public education is required to raise the consciousness of the people about the new
Act and its rationale. A combination of regulation (to confer the right of non-smokers to a
smoke free environment) and community mobilization (to assert and respect that right) is
needed to ensure smoke-free public places.


   Suggested Mechanisms: Public tobacco awareness programmes;
                                School/college tobacco awareness programmes;
                                Campus counsellors; Reporting NGO activities in the
                                                                                             105
                                media to attract volunteers.


        If the country had a concrete program for covering school children at an early age and
trained them in anti-tobacco counselling, the tobacco control effort in India would see some
           129
success.         From studies on the smoking behaviour of more than 4500 children (aged 11 to
14 years) in 30 of Delhi’s schools, it is clear that tobacco smoking is increasing significantly
among children and is a serious cause of concern. Health education interventions do make a
difference, but the tobacco industry’s targeting of the youth needs to be resisted tooth and
                                        24
nail in the interest of their health.


        Counsellors need to be provided on college campuses, especially those of medical,
dental and other professional institutions. It is important to ensure that new students are
informed on the first day of the availability of counselling for ragging, tensions of studies and
college life and of the importance of avoiding/quitting tobacco, which should not be viewed
                                   130
as a healthy coping mechanism.


≈ Recent steps: Community and youth interventions – e.g. HRIDAY SHAN,
                    Delhi, for student youth.


Community awareness interventions: Successful community intervention trials in several
states over the years and the new tobacco cessation clinics show that people can and will give
up tobacco if properly motivated, even illiterate persons.
        HRIDAY-SHAN of Delhi conducts awareness generation programmes for school
going children, which the organisation believes will help them grow up into full-fledged
citizens with the awareness of the evils of tobacco. Not only will they refrain from using
                                                                                              23
tobacco, but they will be instrumental in persuading their parents to give up tobacco use.


    Lack of interest and involvement among medical fraternity and other health personnel.




                                                                                         106
Very few health personnel have publicly expressed their opinions about tobacco use or filed
any PIL, or participated in lobbying the Government. The medical fraternity has limited
awareness and other priorities. It needs to be sensitised.


    Suggested Mechanisms: Awareness programmes for health personnel;
                                 Mobilisation of the health community; approach
                                 professional associations.


        According to some, tobacco control activists need to approach professional
associations and write articles on tobacco control issues for professional journals, appealing
to them to get involved and suggest ways professionals can take action.


    Lack of opposition to prohibited behaviours:


Many problems of implementation remain unopposed. Cigarette addicts smoke in public
places as this behaviour remains mostly unopposed. Sale and use of gutka is still occurring in
Maharashtra, where the ban on the production and sale of gutka has been legally banned with
no judicial stay. This is evidenced by continuing appearance of gutka packets littering the
streets in some areas.


    Suggested Mechanisms: Community mobilisation – the public, health providers,
                                                              and entertainers.


        After the passage of the Cigarette and Other Tobacco Products Act, 2003, the current
Health Minister opined that enforcement was an area where social pressure could prove more
                                 81a
effective than the law itself.
        It is necessary to build a vigilant civil society to provide effective monitoring and
prompt reporting of violations under the existing laws. Mobilize support from the
entertainment industry and obtain celebrity endorsements of anti-tobacco policies. Involve
youth icons in spreading anti-tobacco messages. Mobilise the community through media
advocacy, health camps, etc.
                                                                                          107
≈ Recent steps: In May 2003, CPAA held a World No Tobacco Day in Mumbai with
celebrity personalities from the film world, politics, industry and the police where the
use of tobacco in films and advertising was denounced and those who had quit using
tobacco spoke out.

                                    8
   Tobacco related livelihoods


At least 3.56 million people depend on tobacco for a living in India, either in cultivation and
processing, manufacture or trade, as calculated by data from the NSS 50th Round (1993-94).
8d, 131                                             8d
          The tobacco industry claims 26 million.


   Suggested Mechanisms: Awareness and skills programmes for tobacco workers
                                for alternative livelihoods.


≈ Recent steps: CMDR programmes in tobacco growing areas of Karnataka; Dinesh
Bidi Cooperative, Kerala, alternative livelihoods programme; Studies on new
livelihoods by ILO, World Bank, NGOs.


New livelihoods: A considerable number of workers from the Dinesh Cooperative bidi
factories in Kerala have successfully entered new occupations producing processed food
                          132
products at the factories.


Exploratory studies on new livelihoods: The World Bank and the International Labour
Organization (ILO) have conducted/funded exploratory studies on alternative livelihoods for
home-based women beedi workers. They have concluded that alternative home-based or
community-based work likely to be accepted would include food processing, forest produce
processing, tailoring, tutoring, and paranursing, according to the level of education and
interests of the women. Otherwise in many of the areas where bidi work is carried out, many
new employment opportunities are opening up, but since they are not based in the villages

                                                                                        108
where these women live and carry out their domestic responsibilities, these women would be
                                                          132, 133
unlikely to travel daily to access these opportunities.


    Many tobacco users:


As mentioned earlier, there is a high prevalence of tobacco usage in India, differing from
region to region. Apart from tobacco industry, each individual using one product proclaims
its advantages over other tobacco products and such individuals promote it everywhere.


    Suggested mechanisms: Public awareness campaigns and tobacco cessation clinics.


≈   Recent steps: Public awareness interventions and tobacco cessation activities of the
twelve centres.




    A lack of consumer applications (PILs) on tobacco related harms and losses.


    Suggested mechanisms: More PILs need to filed


≈ Recent steps: A PIL recently filed by a cancer patient, a surgeon and the Consumer
Education & Research Society, Ahmedabad (See chapter 2). Many more such are
needed.


3.2.2 Government Institutions


According to the media reports despite anti-smoking regulations enforced in Delhi, Goa and
                                              68
Kerala desired results are not satisfactory


    Conflicting objectives and policies among agencies of the Union Government. E.g.:

                                                                                    109
   •   Large investment of public funds in tobacco industry
   •   Insufficient provision of law on tobacco advertisements
   •   Insufficient initiative for alternative crops
   •   Permission to new trans-nationals for entering the country
   •   Insufficient initiative to check smuggling
   •   Not demanding funds from tobacco industry for control of tobacco epidemic
   •   Insufficient counter advertisements


       India faces a conflict of objectives of various sectors connected with tobacco. While
the Ministry of Health and Family Welfare is convinced about the need for tobacco control
measures and has taken many administrative steps for reduction of tobacco use, other
government sectors have been working for its promotion, encouraging the tobacco industry.
       The Directorate of Tobacco Development, in collaboration with the State Department
of Agriculture, primarily aims at planning, coordinating and supervising development
including training in improved methods of tobacco cultivation to the farmers and marketing
programme of tobacco at national level. The Indian Tobacco Development Council,
constituted in 1966, serves as an advisory body for this purpose. The Central Tobacco
Research Institute is conducting research on improving the yield and quality of tobacco. A
multi-centre project by Indian Council of Agricultural Research helps in tobacco-related
agronomy, plant breeding, soil chemistry, entomology and plant pathology. The Indian
Council of Agriculture Research has also carried out some research on alternative uses of
tobacco and alternative crops. The main functions of the Tobacco Board, constituted in 1976
are the regulation of production of Virginia tobacco, ensuring fair and remunerative prices to
the growers, maintenance and improvement of existing markets, and development of new
markets for Indian tobacco outside the country. While the Tobacco Board is concentrating on
Virginia tobacco, the interests of non-Virginia tobacco are being looked after by the National
Cooperative Tobacco Growers Federation, Limited, since 1983.
       On a more encouraging note, however, the All India Co-ordinated Research Project
on Tobacco, of the Indian Council of Agricultural Research, carried out at the Gujarat
Agricultural University, Anand Campus, found that comparison of net realization from
                                                                                         110
tobacco in Gujarat with other crops grown in Middle Gujarat revealed that irrigated castor
and irrigated cotton fetched better profit per hectare than tobacco. Rotation of tobacco crop
with other crops also provides more remuneration than producing only tobacco crops in the
field. However, one anticipated problem in substitution of tobacco with other crops was the
difficulty of finding a substitute in rain-fed areas in view of the drought resistant nature of the
tobacco crop. Alternate uses of bidi tobacco mentioned included extraction of nicotine
sulphate to be used as pesticide in orchards; pharmaceutical grade organic acids and
solanesol; food grade tobacco leaf protein; and pentosans for production of ferfural, an
                      134
industrial solvent.
       The agricultural sector is wary of upheaval to tobacco farmers in the event of major
tobacco control initiatives. The labour sector points out the difficulty of finding alternative
employment for millions of bidi rollers and tribal populations dependent on tendu leaf
collection. The prospect of reduced revenue in slow economic conditions is considered
impractical by the financial sector. While there have been dialogues between health and other
sectors on tobacco control measures, there has been limited progress towards development of
a concerted programme for tobacco control and for development of a national policy on
tobacco.
       Experience shows that once the tobacco business is well established it is difficult to
dislodge it from the financial picture of the country. It tends to create contradictions and
differences within the various agencies of the government by playing the economic
instability card. An example is the 'M/S Kastoori Manjan Vs the Union of India case' where
the Health Ministry of India supported a ban on chewing tobacco as a result of its extremely
harmful health consequences. The Ministries of Commerce, Agriculture and Labour
vehemently opposed the ban when the ban threatened to hurt economic interests. The clash of
opinions between the Ministries of the Government has been the reason why, even long after
the ban was recommended, its implementation remains a matter of contention within the
government structure. A need to improve communication amongst various stakeholders is
                                                        35
being increasingly felt by tobacco control advocates.
       In 1975 the Government set up a Tobacco Development Board for promoting tobacco
by offering direct subsidies and a price support system to farmers and dropped restrictions on

                                                                                           111
                                                                          135
package size and contents for cigarettes, cigars and 22 other products.         However, direct
subsidies have been discontinued and only a price support system remains.
       An MP stated regarding enforcement of the comprehensive Bill: “This Bill should be
enforced for the welfare of the people this can only be done by the united efforts of the
                                                                                                   81a
Agriculture Department, Commercial Department, I&B and all other related Departments.


   Suggested Mechanisms: Improved communication amongst various stakeholders;
                                 Clear non-conflicting policies.


a. Laws are needed at national and State level to prohibit production and marketing of any
new product to be taken into the mouth or smoked, of which tobacco is one ingredient. Give
authority for clearing the marketing of the products for human consumption to the Food and
                          47
Drugs Administration.          Repeal The Tobacco Act and other laws promoting production and
                           47
distribution of tobacco.        Eliminate price support to growers and promote crop substitution
more vigorously (although efforts in this direction have been found fairly ineffective in some
                                          136
countries in controlling tobacco use.


b. Phase out tobacco (and areca nut) with alternate crops: It is essential that incentives and
education for the farmers are provided to persuade them to plant alternative crops, preferably
              23
cash crops.        Implementation of successful alternate crops/alternate product related
                         68
businesses is needed.
c. The anti-tobacco stance is that India must no longer consider tobacco growing as an
instrument of development, as reported recent in regard to the State budget of West Bengal.
In the financial year 2000-2001, Rs. 804 crore was proposed to be spent from the State
budget on development in the six districts of north Bengal. According to a news report, this
amount was to include Rs. 40 crore to be spent by the recently constituted North Bengal
Development Board. In Siliguri, the State Finance Minister called upon the tea companies to
                                                                                  137
invest in agro-industries in North Bengal, particularly pineapple and tobacco.          In 1998,


                                                                                            112
tobacco had replaced some of the area planted with jute and other fibre crops, coarse grains
and cereals as shown by a significant increase in the aggregate Area Replacement Index
(ARI). This indicates a 'potential danger' of tobacco replacing not only food crop areas, but
                                             138
also important commercial crops like jute.


d. Create alternate employment for tobacco workers: The labour sector, which is intimately
connected with bidi rolling, can work out a plan along with welfare sector for appropriate
rehabilitation of bidi workers. Given a positive social atmosphere and personal incentive (the
need to avoid expenditure on tobacco products due to higher taxation) most tobacco users can
quit their addiction.


e. Licence tobacco manufacturers: It has been suggested that all tobacco manufacturers
should be licensed, and launch product diversification.


f. Restore packaging restrictions on package size and contents for cigarettes, cigars and other
products (see ‘conflicting objectives’ under policies of government institutions.).




≈ Recent steps: A crop holiday declared in one area.


A crop holiday declared: In Andhra Pradesh, one of the largest tobacco producing states,
                                                                                 135
there has been a crop holiday for two years, meaning no production of tobacco.           This
shows farmers can manage without producing tobacco. In addition, it has been reported that “
contrary to fears expressed in different quarters, the State Trading Corporation is poised to
rake in a handsome profit in tobacco sales this year, thanks to the crop holiday being
observed in Maharashtra, Andhra Pradesh and Orissa for the year 2000-01. The crop holiday
has spurred the traders to turn frantic buyers, which has brought much-needed buoyancy to
the market. STC, which reluctantly entered the market in 2000, fearing losses, is happy with
the turn of events. Cigarette major ITC and its suppliers are the largest buyers having bought



                                                                                          113
45m kg, followed by Godfrey Philips India and its suppliers who purchased about 8m kg.
                                                                                  59
The remaining quantity has been purchased by local traders and exporters.”


   Weak policies and policy gaps at least until recently – until the Act, 1993 was passed,
   there was no comprehensive policy; lack of political will and corruption, tobacco use by
   implementers of tobacco control laws:


Tobacco control advocates in India want tobacco control policies to apply to all tobacco
            55                                                                         23
products.        They wanted early enactment of the latest Bill through Parliament,         but they
                                                      67
have been apprehensive of wavering political will          and the lack of priority for tobacco
control.


   Suggested mechanisms: Enactment of current bill was the main priority till recently
  achieved; development of rules for implementation of the new Act is a current
  priority; development of a national policy unit and national plan of action; socially
  balanced legislation are further suggestions.


The new Act, 2003 now forms the basis of a strong and clear national policy. Government
and non-government agencies need to put their best efforts for its implementation. It contains
measures to control both the demand side (bans on advertising and event sponsorships;
restriction on smoking in public places; better warning labels) as well as the supply side (ban
                      25, 55
on sale to minors)             .


A National Policy Unit and National Plan of Action: It has been suggested that these should
                                   69
be developed in the country.


A Fund for a Tobacco Cessation Programme: A suggestion that came up during the debate in
the Lok Sabha on the comprehensive bill was that “if we want to implement this enactment,
we have to create a fund and the people, who are addicted to cigarette and tobacco, should be
                                         81a
helped by having some counselling.”
                                                                                              114
Socially balanced legislation: It has been stated by tobacco control activists that it is
important to keep in mind at all times what tobacco does to all the sectors of society and how
and then visualise objectively what society would be like if tobacco were totally eliminated.
It is important to design legislation according to this vision, after working out all the details
                    73
and implications.        According to the Annual Survey of Industries (ASI) in 1993-94, about
5.25 lakh workers found employment in the production of various tobacco products. And
                                                                         14
according to the Labour Ministry, there are 4.4 million bidi workers.         The new Act, 2003
purposely does not directly affect producers of tobacco and manufacturers of its products,
except in the area of advertising. The effect on demand for tobacco is expected to be gradual.


       ο Establish a scheme of incentives to tobacco farmers who shift to other
                     47
           Crops.

       ο Create alternate employment opportunities to people engaged in bidi rolling,
                                                               47
           tendu leaves collection, tobacco farm labourers.         Successful model programs
           should be duplicated in all other states, like alternate business propositions to
                                   68
           beedi making units.
                                                      47
       ο Phase out growing of tobacco in stages.


   No clear chain of command; delayed implementation.


Anti-tobacco activists complain that existing laws and policies are also not properly
               73
implemented.        They say that the main reasons behind this are a lack of a clear chain of
command, lack of political will and bureaucratic cooperation, corruption, as well as high
rates of tobacco use prevalence among policy implementers and media personnel.
       If one finds someone smoking in a public place, is bothered by it, he may request the
person to stop smoking. However, there are no indications as to what to do next if the smoker
does not comply.          The official staff nearby simply shrugs – they feel it’s not their
responsibility.
                                                                                            115
An case: There is no monitoring authority in Goa to monitor the implementation of "The Goa
Prohibition of Smoking & Spitting Act, Act No. 5 of 1999". However the police have acted
sporadically by fining people smoking in public places.




   Suggested mechanisms: Specific authority at each level to monitor and follow-up;
  targets set for 2010 and 2030; fight corruption.


Creation of a clear chain of command for tobacco control enforcement: This is required for
addressing the problem of non-compliance. Besides at union level, a specific
agency/focussed authority with assigned responsibility for implementation and monitoring
tobacco control laws at state, district and block levels is required. This type of structure also
needs to be formulated among non-governmental agencies (most suitably under national
coalition of NGOs-ICTC) too for better implementation. The Government at both Union and
State levels need to put their best efforts towards follow-up. For example, the Government of
Goa has recently proposed to constitute a special cell for implementation of Anti-Tobacco
Act.


More ideas:
   Set targets for reductions in tobacco use for the years 2010 and 2020 and monitor
   progress.
   Enforce bans on tobacco use in government buildings and services controlled by the
   Government (like transport).
   Focus on developing interventions in communities across the country, and monitor them.




                                                                                          116
Some specific policy issues:


a. Improper taxation policy:


   Unequal taxation of different products: Cigarettes are taxed much higher than bidis and
   smokeless tobacco products.


Faulty Taxation Policy: An account of tobacco taxation policy of India suggests that it has
not been governed by the health hazards of these products. The rates of taxation have been
generally in line with the guiding government concern that the people in the lowest strata of
community should pay lesser taxes. The smokeless tobacco products, commonly used among
rural masses, are not taxed. Bidis, which are known to be used by people in lower economic
strata, were not taxed till early 1990s, but currently are being taxed lightly. The non-filter
cigarettes attract a much lower tax than filtered cigarettes, and cigarettes companies aim the
sale of highly taxed cigarettes towards the higher socio-economic groups of the society. The
Ministry of Finance tried to keep the prices of certain tobacco products cheaper for low-
income groups. The fact was never considered that a higher tobacco use rate among lower
strata would also result in higher occurrence of tobacco related diseases in these strata. It is
important to note that the total amount spent by patients (as well as by the Government) on
treatment of tobacco related cancers in India does not differ significantly according to socio-
                   163
economic strata.         A reason for no tax on unmanufactured tobacco has invariably been
that this is an unorganized sector and it would not be practical to impose tax on it. However,
the bidi industry also belongs to a scattered small industrial sector. The operational problems
related to tax collection would remain the same irrespective of the taxation level. Thus, the
rationale for a low tax on bidis may not be associated (only) with logistics. There has been no
interaction of financial experts with tobacco experts from other specialities, including health,
regarding taxation on tobacco products.


   Suggested mechanisms: Address taxation: Equal taxation on all products;
                               Taxation must address inflation;
                               Divert part of tax to de-addiction;
                                                                                          117
                             Withdraw and curtail tax-free exports and duty-free
                             imports.


                                                                                         55
Activists stress that taxes on all tobacco products need to be increased substantially        and
revenues used for tobacco control programmes. It has been suggested that countries need not
make a choice between higher cigarette tax revenues and lower cigarette consumption, as
                                     136
higher tax rates can achieve both.


   1. A well conceived taxation strategy should assess its likely implications and inter-
       sectoral or multi-sectoral plans should be prepared to match the imbalance likely to
       result from it. For example, if an increase in taxes on bidis is implemented, likely
       implications may be a shift of tobacco users from bidi smoking to smokeless
       tobacco use, i.e., cessation of bidi smoking (desired outcome by health sector), a
       reduction of bidi tobacco production in medium term, and increasing unemployment
       rate among bidi rollers. Experience from elsewhere suggests that may not be any
       reduction in revenue for a long time.
   2. To avoid upheaval by the increased taxation on bidis, it would be important for the
       finance sector to tax smokeless tobacco products to render them equally costly. If
       increase in taxation of smokeless tobacco products has immediate or short-term
       operational problems, the agriculture sector would need to plan appropriate
       measures to avoid increase in production of smokeless tobacco. Even if people wish
       to shift to smokeless tobacco use, the increase in its demand and static supply would
       result in increase in prices, forcing people to consider tobacco cessation as the
       practical approach. The commerce and agriculture sectors should remove the
       facilities provided to farmers for tobacco cultivation and sale of their produce.
   3. As taxation affects the market for tobacco products, address alternate employment
       as already elaborated.
   4. In case of tobacco taxation, the Ministry perhaps had been using the general
       principles a applicable to other products. A greater interaction with specialists from
       other sectors like, health, commerce, agriculture, labour welfare, police, border

                                                                                              118
       security force, foreign affairs, etc., would help the assess the real magnitude of
       hazards due to tobacco use and the positive influence which can be generated by a
       rational.
   5. Some system should be devised for a financial levy on the Tobacco companies. The
       funds so collected should be utilised for the treatment, de-addiction and
                                                            23
       rehabilitation of the victims of tobacco products.
   6. Increase pleas on taxation: The limited pleas on taxation issue from non-government
       organizations active in the field of tobacco control so far have not yielded the
       desired effect on taxation policy on tobacco. It may not be entirely correct to blame
       the financial experts for a disproportionate tobacco taxation policy.
   7. A portion of the taxes from tobacco products should go toward funding cessation

       clinics, health care and compensating victims.




   Tax free exports and duty-free imports of tobacco products:


   Suggested mechanism: Withdrawal and curtailment of tax free exports and duty
                            free imports.


Withdrawal of tax-free exports Withdrawal of tax-free exports: The facility of tax-free
exports should also be withdrawn from tobacco products.


Curtailment of legal channels of tobacco imports Curtailment of legal channels of tobacco
imports: The legal channels of tobacco imports like the duty free import under the Baggage
Rules, duty free shops at international airports, the duty free imports by agents on behalf of
embassies and naval ships, and duty free import of cigarettes for re-export etc., also need to
be curtailed.




                                                                                            119
b. Tobacco advertising and promotion.


Advertisments and promotion: Tobacco advertising has been banned in state-controlled
electronic media and government publications, but continues unrestricted in newspapers,
magazines, posters, billboards, and in videocassettes of Indian films. Promotion through
sponsorship competitions, promotion of items such as clothing etc., is not yet banned. The
Cable TV network Regulation Act 1995, was amended to prohibit tobacco ads on cable TV
channels. However there are certain enforcement issues since some of these channels are
being aired from overseas.
        "The Goa Prohibition of Smoking and Spitting Act, Act No. 5 of 1999" prohibits
advertisements of tobacco products in newspapers, magazines published in the State of Goa.
However, newspapers and magazines published outside Goa and sold in the State are not
affected. This leads to the ban on tobacco advertisement becoming ineffective.
     Suggested Mechanisms: Ban all types of advertising - close loopholes; make
                              strong FCTC provisions against trans-national
                              advertising.


Ban all types of advertising and close loopholes: Anti-tobacco activists believe that Union level
legislation is necessary in order that a ban on tobacco advertising is effective all over the
                                                                                        55
country. A safeguard against brand stretching and surrogate advertising is required.
Surrogate tobacco products like pan masala are advertised on T.V. Channels other than the
National ones. Legislation is necessary to stop tobacco advertisements on all T.V. channels
                                              47
including indirect/surrogate advertisement.


Mechanisms to ban tobacco advertising:
 •    Withdrawal of tax-free exports: The facility of tax-free exports should also be
      withdrawn from tobacco products.
 •    Ban should cover entire nation
 •    Ban should be extended to all types of media – print, electronic, billboards, etc.

                                                                                           120
•   It should cover all types of advertisements (direct and surrogate)
•   Enforcement of Advertisement from overseas channels should be high lighted in
                                           14
    FCTC which will resolve these issues.
                                                                           139
•   High fines need to be imposed for violation of all advertising bans.




                                                                                    121
c. Inadequate health warnings – now will be improved under the Act, 2003.


Insufficient Health Warnings on Tobacco Products: Most of these limitations have been
addressed by the new Act of 2003. However, there needs to be monitoring of its
implementation and action has to be taken against defaulters; the printed warning on cigarette
packages on which the rest of the label is only in English, will legally be only in English,
thereby reducing its reach.
       There are a number of American judgements where the courts have held that a
simple warning that is repeated over the years is not enough to warn the consumers as it has
lost all its meaning and awarded huge amounts of money in compensation to the victims
                                        23
who have suffered health damages.


   Suggested Mechanism: Improve warning labels.


Strong and effective warnings: Like other places in the world, the simple warning on tobacco
products: "Tobacco is injurious to health", needs to be replaced with a strong and effective
                                        23
warning like: "Tobacco Kills You”.           It is hoped that the new law, requiring a skull and
                                              25
cross bones, will give the desired effect.




   Tobacco industry continues to flout tobacco control policy:

The greatest difficulties are due to the strong muscle power of the shameless tobacco
            73
industry.        The industry applies all sorts of evils for non- implementation of tobacco
control policy. The companies bribe or try to bribe at all levels of policy enforcement. The
devious commercial tactics used by the tobacco industry, like surrogate advertising, event
                                                                 67
sponsorship, make tobacco control difficult to implement.             In Madhya Pradesh the
tobacco industry is also taking great advantage of the delay in enactment of comprehensive
tobacco policy and is displaying all types of promotions and advertisements.



                                                                                              122
Commercial tactics of the shameless tobacco industry:


Tobacco Advertising: The power of advertising as a function of consumer choice and
market expansion has long been recognized and exploited by the tobacco companies. They
                              140
are the largest advertiser.         Tobacco Advertising in India alone contributes Rs. 300-400
crore to the Rs. 8000 crore-strong Indian advertising industry. Manufactures of gutka and
other oral tobacco products are catching up with their increasing advertising budget, as is
evident from the increasing print and television advertisement of chewing tobacco products.
The data clearly indicate the astronomical figures the cigarette companies spend annually
                                         141
on advertising their various brands.


News papers and Magazines: There are no estimates available on the advertising
expenditures of cigarette and gutka companies, though they are frequently seen in all the
local dailies and television channels. A very recent phenomenon has been the cigarette
companies sponsoring the sports page of newspapers in the wake of the proposed ban on
                                           142
tobacco sponsorship of sports events.            Except for health-related magazines, few have
any policy prohibiting advertisement of tobacco products. Disturbing reports on Gutka
advertising spotting the cover pages of school notebooks are pouring in from Nagpur
                          143
District in Maharashtra


Outdoor Advertising: International and domestic cigarette brands compete with each other
in billboard advertising while oral tobacco brands resort to transport vehicles. Point of sale
                                                                                          144
advertising flourishes adjacent to schools and colleges as also in restaurants and kids.


Promotional Activities: Sponsorship of sports and cultural events: The last decade of the
past century witnessed the tobacco companies vying to conquer sponsorship rights of
various sports and cultural events. Subsequently, the Indian cricket team came to be
sponsored by Wills, the flagship brand (ITC) until its recent withdrawal in March 2001. For
every test match that India played, WILLS (ITC) doled out Rs. 33 lakh, for every one-day

                                                                                           123
match, it paid Rs. 32 lakh. The major Tennis tournaments in the country were sponsored by
                                                         145
Gold Flake and boat racing by Four Square cigarettes.          On the cultural front,
Manickchand, who catapulted the tobacco market with their Gutka brands, has patronized
Filmfare Awards giving away the annual film awards. Ironically, the national bravery
awards recognizing heroes for courage, adventure and spontaneous physical action is being
sponsored by Red and White cigarette brand, capitalizing on the positive image and good
will the event fetches. In several parts of India, major State festivals like Ganesh Chaturthi
and Navratri have come to be celebrated with grate fanfare at the behest of Gutka
           146
companies.


Surrogate Advertising in Television: Gutka companies like Simla, Goa 1000 and Pan Parag
skirt the ban on tobacco advertising in Television channels by resorting to surrogate
advertising in the name of Pan Masala bearing the same brand name. Cigarette companies
do it like through transmitting tobacco sponsored cultural events as in the case of Red &
White Bravery Award.


Contests: The Wills "Made for Each Other" campaign of the Eighties with lucrative offers
including a holiday abroad had courted much controversy over glamourizing and
                                                       147
minimizing the dangers of smoking filter cigarettes.         In December 1999, Four Square
brand from Godfrey Phillips India, an affiliate of Philip Morris Inc. ran the "Gold in Gold"
contest offering Gold gift options, on the stipulation that the entrants in the contest, besides
                                                                                         148
being tobacco users, were to collect 4 inserts from Four Square Gold cigarette packs.


Product Placement in Movies: Several leading filmmakers and popular film stars have
fallen prey to this hidden trap and have indirectly promoted cigarette brands by consciously
placing cigarette packs or brand names/logos in movie scenes as was observed in movies
                                                                    144
like God Mother, Tere Mere Sapne, Chasme Baddur and Katha.




                                                                                          124
Free sampling: Earlier, tactic of initiating the young with tobacco use was restricted to
handing out free samples of cigarettes. Recent press reports from Nagpur indicate that even
                                                                        143
Gutka sachets are being given out freely near schools and colleges.           Strategically, youth
in outfits, bearing tobacco brand names and logos are engaged in these promotional
campaigns. In Mumbai, several discotheques and restaurants witness regular Benson&
Hedges promotional activities including giving free samples.


Brand Stretching and Diversification: perceiving an imminent ban on tobacco advertising,
several tobacco companies are promoting other consumer products, which bear the same
brand name or logo as their popular tobacco products. These logos or brand names can
easily be spotted on clothing, sports apparel, hats, trays, posters and stickers affixed to
sports vehicles and backpacks. Examples include Four Square sports gear, WILLS holiday
and casual wear. The Indian Tobacco Company, already holding investments in the hotel
and tourism sector, is on a spree to set up 125 lifestyles stores selling apparels in the
country in the immediate future. The plans include spreading out to greeting cards business
and experimental kitchens. It is also starting to sell wheat flour. Manickchand, the domestic
Gutka major has diversified its products to tea powder, windmills and construction
         149
industry.


Corporate Philanthropy and Public Promotion: The earthquake that ravaged parts of Gujarat
have well been exploited by Gutka manufactures by distributing food packets along side
gutka packers to build up their social image. All the major gutka firms are activity engaged
in supporting local youth clubs in organizing their annual sports events and religious
festivities. The India Tobacco Company claims that they invest in education, immunization
and family planning programmes in communities attached to their factories.


Government-patronized Tobacco Promotion: While the government is responsible for the
health and well being of its citizens, it is lamentable that it often acts as a vehicle of tobacco
promotion. The obvious examples are the BEST buses plying in Maharashtra and the
Railway station premises and bus also across the country displaying huge tobacco

                                                                                            125
hoardings. Doordarshan, the national television channel transmits advertisements of
Cavenders Cigarette brand disguised as adventure gear as also sports and cultural events
                                   146
sponsored by tobacco companies.


Trends in Tobacco Advertising: Following the announcement of the recent Tobacco
Products Bill proposing a ban on tobacco advertising there has been an upsurge in surrogate
advertising and sponsorship of entertainment events. Recent marketing figures indicate that
while the market spending on tobacco products declined by 2% over the year, the spending
on tobacco brands grew by 28%. This is illustrative of the increasing reliance of tobacco
companies on sponsorships, restaurant and hotel programmes, public and direct relations
and direct marketing programmes these days.


Impact of Tobacco Advertising and Promotional Activities: In a study conducted in Goa
among students immediately after watching tobacco-sponsored cricket matches, 15-20
percent students felt that smoking and Gutka improves memory. Some students even felt
that if you smoke, you will become a better cricketer. A 1992 review of 19 studies of
cigarette advertising by the British Department of Health revealed that advertising does
have a positive impact on consumption. A 1995 study indicates that advertising is more
likely to influence teenagers to smoke than even peer pressure while a 1996 study published
in the journal of Marketing found that teenagers are three times as sensitive as adults to
cigarettes advertising. The escalating annual advertising budgets of tobacco companies
themselves are enough proof of the impact this component of marketing has on increasing
consumption rates.


The Multi-sectoral strong tobacco lobby: The tobacco industry is very strong and has
developed a lobby, which includes, among others, very strong political personalities. Some
politicians also own a part of the industry and thus have vested interest for it to flourish. So
                                                                                     73
as a result they oppose any action, which favours tobacco control in the country.




                                                                                          126
 •    Cigarette Lobby (Multi--national and National)
 •    Gutka Lobby
 •    Strong Snus lobby
 •    Bidi lobby
 •    Some politicians


 Suggested mechanisms: Timely and strict policy implementation and meting out of

                          Justice - central monitoring agency as mentioned above,

                          with the authority to discipline erring Government

                          agencies.


     Smuggling


                                                            68
Smuggling and corruption are not sufficiently controlled.        Lower excise duties in the
neighbouring SAARC member nations of Nepal, Bangladesh and Myanmar (Burma) are said
                                                             150
to be an inducement to smuggling of cigarettes into India.         Tobacco and tobacco
products (Cigarettes) smuggled from Nepal and Myanmar cost much less than domestic
products. One kilogram of raw tobacco smuggled from Myanmar cost Rs. 250 as compared
to Rs. 350 for local Indian tobacco. A pack of 20 cigarettes, smuggled from Myanmar cost
Rs. 7 as compared to approximately Rs. 20 for a pack of 20 comparable sizes Indian made
                                                                              44
cigarettes. There is a growing grey market for foreign branded cigarettes.
        Smuggling of tobacco and tobacco products negates the effect of tobacco taxation in
                                                                                              8d
terms of tobacco control as well as on revenue collection and loss of foreign exchange.            As
stated by the Chaiman of ITC in 1999, "Conservative estimates indicate that smuggling in
cigarettes is causing an unaccounted outflow of foreign exchange upward of Rs. 5,000
million and the related loss of revenue to the exchequer that would otherwise accrue on
equivalent domestic manufacture. This contraband trade is estimated to be growing at an
                                                   151
alarmingly high rate upwards of 20% per annum”.
                                                                                         127
        The tobacco industry, represented by Tobacco Institute of India, has asked for short-
term stoppage on increase in excise duty rates followed by uniform and moderate increase
across all slabs of cigarettes. The industry has also asked for single point taxation for
cigarettes and withdrawal of additional excise duty share of states levying luxury taxes on
              44
cigarettes.


    Suggested Mechanism: Create a South Asian regional policy (FCTC); strategic plans;
                              reduce corruption.


Mechanism to control smuggling of tobacco and tobacco products: Smuggling of cigarettes
should be better controlled, as it has grown considerably in recent years. An estimate of the
sale value of contraband cigarettes entering India 1998 at US$ 227 was made by industry
sources. A senior tobacco industry executive made the following comment to the press in the
year 2000: “The contraband trade is growing alarmingly at upwards of 20 percent per annum
and is estimated to be causing export of value form the Indian economy of around Rs.1000
crores and the loss of revenues to the Exchequer that would otherwise accrue from equivalent
                         15
domestic manufacture.         The level of smuggling in any country has been judged to be
                                                   136
proportional to the level of corruption therein.         If that is the case, and then it would
appear that the level of corruption in India is growing and badly needs to be curbed. Effective
control measures for smuggling included focussing on large container smuggling, placing
local language warnings and tax stamps in prominent places, increasing penalties, using
licensing and tracking of containers and increasing export duties to restrict trade.


Strategic plans to counter smuggling: The police and border security forces would need to
develop strategic plans to check increased tobacco smuggling in the wake of increased
taxation to check on any tobacco product. NGO may also play a role by interacting with
them and educating them.


        1. Placing local language warnings and tax stamps in prominent places,


                                                                                              128
       2. Increasing penalties, using licensing and tracking of containers and increasing
           export duties to restrict trade
                                                                                       136
       3. Multilateral tax: Multilateral tax increases help combat smuggling.                The
           foreign affairs sector along with health, finance and commerce sector need to
           interact with neighbouring countries, to implement similar rational tobacco
           taxation structure which would make tobacco products equally expensive in these
           countries.


   No Central Agency for monitoring and law enforcement:


No specific agency/focussed authority has been assigned responsibility for implementation
and monitoring tobacco control laws, although this had been recommended in 1991 by the
National Conference. The police are expected to implement the laws, but they are not
                                          55, 68
effective, at least over the long term.            The enactment and amendment of laws in India
are relatively easy, compared to their enforcement. Although there are many laws and
statutes, enforcement is very poor, partly due to the inefficiency of the enforcement agencies
                                                   23
and in some cases even due to corruption.               There is a lack of a nodal agency for tobacco
                                                                           67
control that can coordinate state, central and international efforts.


   Suggested mechanisms: Creation of a specific national regulatory authority with
                                 nodal agencies in all ministries, multi-sectoral approach.


Creation of national tobacco regulatory authority on tobacco: A single national authority on
tobacco control is needed with representation from the Government, academia, health
professionals and NGOs to propose and implement policies and monitor compliance with
legislation and for establishing and regulating standards of tobacco product constituents and
             55, 67
emissions.            Sweden, for example has constituted a National Tobacco Control
         152
Council.       An umbrella body of opinion makers from varied fields needs to head a national
                                                                                              68
anti tobacco Secretariat for formation and implementation of rules and regulations.
                                                                                                   129
Central Office/Nodal Agency on Tobacco Control: The activities related to tobacco control
are many and the coordinators cannot be expected to do full justice if it is just one of their
responsibilities. Planning of cost-effective programmes requires full-time thinking and
complete dedication on all aspects of tobacco. Therefore, creation of a central office on
tobacco control with adequate facilities under the PMO is highly desirable. The office may
monitor tobacco use status, tobacco production and trade practices; plan and evaluate cost-
effective intervention programmes; interact with sectors associated with tobacco and
undertake liaison work for initiation of their activities; initiation and coordination of inter-
sectoral (not necessarily with health sector) and Multi-sectoral programmes for tobacco
control; undertake /commission research in support of tobacco control; prepare periodic
reports.


Multi-sectoral Approach: Convene a multi-sectoral consultation on tobacco control
involving Central and State agencies and civil society groups to draw up a national plan for
                                              67
tobacco control for phased implementation.         The WHO, India advocates that NGOs
working against tobacco work together along with NGOs working on health issues, with a
focussed IEC and mass media plan to effectively combat the tobacco menace in the
           14
country.


Discussions within Parliament: Parliament or legislative assembly can be considered as top-
most plank for any multi-sectoral activity. Approach discussions highlighting multi-sectoral
approach and pointing out the specific roles of different sectors are likely to result in
maximum benefit. Discussion of the issue in any parliament committee may also result in
recommendations for various sectors. The advantages are 1) That it could question any
sectors and their decisions are acceptable to every sector; 2) That discussions will sensitise;
3) That internal discussions may consider some realistic remedial measures.


State-level advocacy: Activate state-level advocacy to overcome the jurisdictional
restrictions on policies regulating to oral tobacco products and bidis.

                                                                                            130
≈ Recent steps: Creation of a National Tobacco Cell in 2001 in the MOH for the purposes of
inter-agency coordination.


A National Tobacco Cell was created: In the National Conference on Tobacco or Health held
in Delhi on July 27 and 28, 1991, a recommendation was made that a National Tobacco
Control Commission (NTCC) should be established to co-ordinate all tobacco related
activities. According to the report of the meeting, it should, on one hand deal with the
various ministries like Commerce, Agriculture, Labour, Education, Law, Youth affairs
Environment and Social Welfare and on the other hand co-ordinate the working of all
existing Governments as well as NGOs including financial support to NGOs. The report also
envisioned that the NTCC should be established as a parliamentary committee with sufficient
executive powers and administrative and financial support for implementing the National
                                                                   69
Plan of Action and presents its annual report to the parliament.


In February 2001, a dedicated cell was set up as a joint effort by the Ministry of Public
Health and Family Welfare and the WHO, India, to devise strategies and coordinate all the
tobacco control activities; to execute of a comprehensive anti-tobacco IEC plan; 4.To
undertake research on key policy issues of tobacco economy and legislation; To establish and
                                                        14, 50
strengthen the network of tobacco cessations clinics.


   Unequal laws among States, in tobacco production, storage, sale and labour laws:


An unequal level of laws and regulations in the different states makes for weak policy and is
                                              68
a major contributor to poor implementation.        Bans on the sale and use of chewing tobacco
products are deemed ineffective if other states do not ban their manufacture, as stated the
Madhya Pradesh Chief Minister. A state-level ban by few states only may encourage illicit
                                                                                                 89
inter-state trade in the commodity and boost crime. Hence a ban at union level is required.



                                                                                           131
       The bidi industry has a history of shifting production to areas where labour laws are
least likely to be implemented, thus, if tobacco control efforts redirects the employment of
these workers into other livelihoods in one area, the authorities need to be alert to the
industry locating a new labour force elsewhere.


   Suggested Mechanism: Extend anti-tobacco legislation to all States and Union
                                  Territories.


       Tobacco control activists wanted to extend anti-tobacco legislation to all States and
Union Territories with full coverage of all tobacco products including oral tobacco, bidi etc.
                                  67
under the control measures.            This is expected to occur once the Cigarettes and Other
Tobacco Products Act, 2003 is notified. Some activists also want a nationwide ban on
production, sale, advertising, storage of tobacco products and other ingredients responsible
for causing oral diseases and a bill to be passed to the same effect with strict implementable
                         47, 68
rules and regulations.            The other view is that this is too drastic a measure given the
economic significance of tobacco and that it would not be enforceable in the near future.




   Inadequate South East Asian Regional legislation:


There is no South East Asian Regional treaty on advertisements and taxation.


   Suggested mechanisms: A regional treaty, give strong support to the FCTC.


Give strong support to FCTC: The country has recently ratified the Framework Convention
on Tobacco Control (FCTC). The issue of a regional treaty on advertisements and taxations
can be addressed by the FCTC. India needs to voice this in the appropriate forum/fora. Gutka
is a major regional problem – it is traded across borders as well as made locally.




                                                                                              132
   Lack of coordination with NGOs. A feature of tobacco control activity in the country has
   been that the Government and NGOs work separately.


   Suggested mechanisms: Prioritise coordination with NGOs to achieve goals faster.


≈ Recent steps: As mentioned above, the recently created National Tobacco Cell has been
envisioned by some to coordinate not only tobacco related activities among the government
institutions, but also with NGOs. Coalitions are formed when the need for advocacy arises.


   No treatment for de-addiction in the Government health system or inclusion in health
   insurance policies issued by Indian companies:


   Suggested mechanism: Create tobacco cessation clinics and suggest inclusion of
                             coverage in public sector health insurance.


Treatment for de-addiction: The health sector would need to create tobacco cessation clinics
that would utilize techniques appropriate to the social set up in different areas. Coverage of
expenses should be allowed under Med-claim Policies. In foreign countries and more
particularly in the USA, treatment for de-addiction involves hospitalisation as indoor
patients. It is therefore quite expensive. Besides the medicine, there are a lot of group and
other therapies to help the patient to overcome depression or to strengthen his will power not
to revert to smoking or tobacco addiction once again. There is no provision in India for
reimbursement of such expenses in insurance policies for Mediclaim issued by Indian
                                                               23
companies. A campaign should be launched for this purpose.




   Time lags for legislation and implementation:


Ban without legislation: Bans on smoking in public places are not effective. The example of
Chandigarh was cited in the Indian Express: In Chandigarh, smoking is prohibited in
hospitals, educational institutions, railway stations, bus-stands, auditoriums and public
                                                                                         133
offices. However, hospital employees can be seen smoking outside emergency rooms;
students smoke outside college libraries and canteens; passengers smoke at bus stands. No
one is checking – the ban is not enforced. Union Territory Deputy Commissioner M.
Ramsekhar maintains: “It is true that the Administration has imposed the ban. Smoking in
public places is an offense under Section 144 of the Chandigarh Police Code. But, in the
                                                                        153
absence of legislation not much can be done to implement the ban.”            In another
example, the Allahabad High Court ordered a ban on the manufacture and sale of flavoured
chewing tobacco and pan masala. The Supreme Court stayed the Allahabad HC order in
                 154
Uttar Pradesh.         Politicians took advantage of a similar situation in Madhya Pradesh,
where the State Government deferred its action on this issue, ignoring the Madhya Pradesh
High Court.


Legislation without implementation: The Delhi Government found it difficult to implement
the Delhi Prohibition of Smoking and Non-smoker health Protection Act 1996. A writ
petition was filed in the year 2000 charging that sections 8 and 9 of the Act pertaining to the
sale of tobacco products to anyone younger than 18 years of age and the sale of such
                                                                                      24
substances in the vicinity of educational institutions were not being implemented.


   Suggested mechanisms: Formulate strategy for timely disposal of complaints;
                                advocacy to address this issue.




   Limited policy for schools and colleges:
Absence of tobacco control policy in schools: Although the Government of India instructed
all schools having CBSE curriculum prohibiting tobacco use by students, school personnel or
anyone else coming to the school. But only schools governed by the Central Government
(Central Schools, Navoday Schools, Railway Schools) implements it partially. Ban on sales
of tobacco and tobacco products within 100 metres of schools is also prohibited in some
places. But is practically difficult for the schools in market area and is not truly implemented
widely. The schools governed by state governments do not have a school policy in most of

                                                                                           134
the States in India and tobacco use by students and school personnel are reportedly very high.
A comparative study of schools with and without tobacco control policy showed a significant
difference in the level of current tobacco use among students and school personnel between
these schools. Tobacco use among students in general colleges, medical colleges and dental
colleges have been reported high from different corners of India. Data from the Global Youth
Tobacco Survey in 20 States of India have shown that curricular teaching about tobacco is
very low. Therefore these schools need a curricular program on tobacco with utmost urgency.
Data from the Global School Personnel Survey in 16 States of India have shown that
although most of them are tobacco users, 8 out of 10 school personnel want to have a policy
prohibiting tobacco use by students and school personnel in school premises. Four out of five
school personnel want training at ground level to raise their awareness and to teach students
                                                                         155, 156, 157
about the harmfulness of tobacco. Such training is nonexistent today.


   Suggested mechanism: Extension of school policy to all schools in India;
                             formulation of a policy for all colleges.




   Low priority to public education on tobacco:


The Governments, both of the Union and of the States has never given a high priority to
public education about the dangers of tobacco.


   Suggested mechanisms: Re-start ‘Radio DATES’; initiate television spots;
                             display anti-tobacco billboards in all public places.


Integration of Anti-Tobacco Control with other Programmes: As said in Maharashtra, no
public health programme will succeed unless it is integrated with the general health services
and all the health staff at all levels are involved. This requires conducting training
                                                                                  45
programmes for them with the assistance of the Medical and Dental Colleges.



                                                                                         135
       Sometimes it may be easier to initiate programmes on tobacco control by combining
it with other existing or proposed programmes. A common example of intra-sectoral
collaboration (health) is combining tobacco awareness programmes with education on
alcohol and drugs. This has been successfully achieved in the collaborative programme,
                                                                                              158
"Radio DATES", between All India Radio and the Indian Council of Medical Research.
Such combinations may become cost-effective and sometimes may be more acceptable to
programme managers or to the community. One example of such continuing collaboration is
the Sri Lanka's coordinated programme for promoting a healthy drug-free lifestyle.
Recommendations from a workshop in 1996 paved the way for formation of a national
coordinating committee on alcohol, tobacco and other substances, with representatives from
                                                                159
all major organizations working in the area of prevention.            The coordinating committee
has been meeting monthly for the task of formulating a national programme. A country
profile for Sri Lanka has been prepared on alcohol and tobacco. The suggestions and
guidelines provided by this committee have been helpful in gaining support for tobacco
control from different sectors. Combination of tobacco education as a part of healthy lifestyle
programmes for cardiovascular diseases has also been popular in certain countries, including
Finland and India. Opportunities for tobacco awareness may be available while educating the
public about deforestation, religion or even general hygiene.




   High toxicity of Indian tobaccos:


Indian non-cigarette tobaccos, like bidi tobaccos, are high in content of tar, nicotine and
                160
nitrosamines.         Sixty-eight percent of Indian tobacco is dark, and air or sun cured,
                                                           15
showing a preference in the country for strong flavours


   Suggested mechanism: Labelling instructions for tar and nicotine; heavy punishment
  for tobacco items.




                                                                                             136
Reduction of tar, nicotine and nitrosamines: Tar, nicotine and nitrosamine levels could be
reduced in all types of tobacco products.




   Lack of tobacco surveillance and research laboratories:


Tobacco surveillance and research laboratories: There is a need for the establishment and
strengthening of national and regional laboratories as independent agencies for surveillance
                                                               67
of tobacco products for their constituents and emissions.


   Suggested mechanism: Establish more tobacco laboratories using taxes on tobacco.


Some funds from tobacco taxation could be set aside for this purpose.


   Time lags for justice to tobacco victims:


Lack of a mechanism for a speedy and efficacious remedy for the victims of tobacco from the
             23
Judiciary.        India’s judicial system, like those of other developing countries, is grappling
with population pressure. This goes to the advantage of the tobacco industry, that takes cover
under the delays in judgement. This allows them time to carry on their activities and
consolidate their position in the market. An advertising strategy of the ITC was challenged
by VOICE in the court in 1984, but the judgement was delayed. Meanwhile, WILLS
                                                                                      35
expanded its market and was successful in sponsoring the Indian Cricket Team.




                                                                                             137
   Suggested mechanisms: Budget should be allocated to expanding the judicial
                             system to handle this as well as the many other matters
                             before it.




3.2.3 Non-government Institutions


   Information is not readily available to non-government organisations.


Information needs to be provided to NGOs dealing with public issues and grievances such as
consumer bodies, environmental groups, health organizations and social justice NGOs. This
would help to get legislations enforced.


   Suggested mechanism: Information sharing.


Share information: Create a comprehensive and authoritative source of information on
tobacco use that all can cite and use in advocacy work. Network for information sharing –
create a directory of NGOs in tobacco control.


≈ Recent steps: Recent creation of the Indian Coalition on Tobacco Control and its
successor, Advocacy Forum for Tobacco Control, a networking and advocacy body,
supporting the FCTC (See Chapter 2).




   Poor networking among NGOs and other non-government organisations; absence of a
   strong NGO lobby:


   Suggested mechanisms: Facilitate networking.




                                                                                     138
Effective and Sustained Networking by Non-Governmental Organizations (NGOs): The
NGOs have an important role in various activities related to tobacco. Besides health-related
NGOs, it is important to tap the potential of NGOs working in non-health sectors. A network
of NGOs could discuss and plan various activities for tobacco control and assign specific
duties to NGOs working in specific sectors for their cost-effective implementation. Different
NGOs could take up responsibilities for advocacy and lobbying for their respective sectors.
In view of their great potential, these should be supported in their tobacco control activities.
The International Agency on Tobacco and Health Bulletin can be more widely used for
sharing information.


   Suggested mechanisms: Create and publish an authoritative source of
                              Information/ use IATH Newsletter; network for information
                              sharing; Create an NGO directory.


          Create a directory of organizations and individuals conducting tobacco control
activities, within the Government and the voluntary/private sector Focus more attention on
the dangers of tobacco in the mass media, TV, press, with the involvement of the
Government, NGOs and corporations.


   Lack of research initiative: Research on the demographics and attitudes of tobacco users
                                        161
   toward its consumption is limited.


   Suggested mechanisms: Study attitudes toward tobacco use.
                             Perform ‘Strategic Mapping’ in each area;
                              Study cessation behaviour using various interventions;
                              Study alternative crops and employment options;
                             Document all activities for future reference.


Strategic Mapping: ‘Map’ producers and consumers locally and share the information
nationally to form a complete picture. Tobacco ‘mapping’: Strategic tobacco ‘mapping’ is a
strategy to pinpoint where the key stakeholders on the supply and demand sides are located:
                                                                                          139
tobacco producers, consumers and nonusers are found. Prevalence surveys can form a part of
this exercise. Planning can be based on targeting each of these groups with information about
the harmfulness of tobacco, alternative livelihoods and government assistance for the
transition out of the tobacco industry. In each State, producers, i.e., farmers, agricultural
labourers, producers of fertilizers, tobacco curers, tobacco processors, bidi rollers, bidi
packers and factory owners, unions, betel leaf growers, cigarette workers and industrialists
can be identified and located. Allied industries can also be targeted with information: tendu
leaf collectors, cigarette paper producers, areca nut producers and processors, matchbox
makers, cigarette lighter makers, advertisers, transporters, as well as wholesalers, retailers
and sales managers. The same can be done with consumers of different types of products.
Government offices connected to the tobacco industry include Customs and Excise,
Consumer Affairs, Health, Labour, Trade and Commerce, International Trade, Law and
Justice, Education, and Environment. Such mapping exercises have been reported from
Vietnam for tobacco control purposes. Since the regional pattern of tobacco growing,
processing, manufacturing, and marketing is different than the consumption pattern, the inter-
regional transfer of income and differences in employment opportunities, tax revenue, and
                                                          8d, 136
foreign exchange earnings become a matter of concern.


A broad tobacco map of India would include the following:


Consumption: Tobacco use prevalence is high everywhere, but highest in the Northeastern
                                                                                   50
States, high in the East, and lowest in the Southwest, according to NSSO data.


Cultivation: Andhra Pradesh is the largest tobacco-producing state in India followed by
Gujarat and Karnataka. Andhra Pradesh and Gujarat, together account for two thirds of the
                                                                                                 8d
total area under cultivation of tobacco and 75-80 percent of total tobacco production.
Cultivation of the different varieties of tobacco is concentrated in well-defined areas, e.g.,
FCV tobacco is mainly cultivated in the coastal districts of A.P. and in the transition zone of
Karnataka. Bidi tobacco is cultivated mostly in Kheda and Vadodara Districts of Gujarat,
Kolhapur and Sangli Districts of Maharasthra, and Belgaum Districts of Karnataka. The areas

                                                                                           140
important for cigar and cheroot tobacco are Andhra Pradesh and Tamil Nadu. In the latter
state, much of chewing tobacco is grown. Important areas for chewing tobacco as well as
hookah tobacco include Cooch-Behar and Jalpaiguri Districts in West Bengal, Farrukhabad
and Etah Districts in Uttar Pradesh and Vaishali. Samastipur, Purnea and Muzaffarpur
Districts in Bihar.


Manufacturing workforce concentration: The largest tobacco manufacturing workforce is
engaged in bidi making and is mainly located in Madhya Pradesh, Andhra Pradesh, and
              8d
Tamil Nadu,        yet there are concentrations of such workers in other states also, including
Karnataka, Kerala, Maharashtra, Gujarat, West Benngal, Orissa, Bihar, Uttar Pradesh,
                         6
Rajasthan and Assam. Apart from climate, geology and infrastructure, the differences in
labour laws among states are also partly responsible for these differences. The bidi industry
has a history of shifting production to areas where labour laws are least likely to be
implemented, thus, if tobacco control efforts help to redirect the employment of these
workers into other livelihoods in one area, the authorities need to be alert to the industry
locating a new labour force elsewhere.


Other research areas would include:


Study cessation behaviour using various interventions: Health facilities can test and
document various behavioural interventions, evaluating them according to the objectives and
disseminate the findings.


Study alternative crops and employment options: there is a need for developmental NGOs in
rural areas where tobacco is grown/processed to study alternatives to tobacco in the local
economies. Some work has been done by the ILO and some NGOs in this aspect.


Study alternative tobacco products, like cessation products, natural pesticides, etc.




                                                                                          141
   Lack of monitoring and follow-up of initiatives:


Many successful models of different aspects of tobacco control worldwide and in India, just
like for any public health endeavour, have shown that follow-up action in implementation is
the most essential component of tobacco control, otherwise the control mechanism fails
(mostly due to follow-up action by the tobacco industry). Both government and non-
government institutions lack in follow-up action.


   Suggested mechanism: Remind authorities and industry of the policies.


Non-government agencies need to remind policy implementers as well as lawbreakers in
society of the policies and follow them up regularly. The Government or the local level
implementer may have other priorities but non-governmental institutions involved in tobacco
control need to follow-up implementation at all levels.




   Lack of community mobilisation efforts:


   Suggested mechanism: Increase community mobilisation efforts.


After public education comes mobilisation which can be used effectively for better law
enforcement. With the proper information, the public could be persuaded to boycott
                                    130
grocery stores that sell tobacco.         This would also help to take care of the practical
difficulty with the ban on sale and storage of tobacco products within 100 meters of
educational institutions – some of them are located in market areas, where tobacco is freely
available in the shops.


                                                      130
Grocery stores that sell tobacco can be boycotted.          or targeted with information.




                                                                                            142
   Inadequate youth mobilisation efforts:


   Suggested mechanism: ‘Sustained motivation’ programmes.


          Successful models like school intervention through HRIDAY-SHAN Model,
community intervention by the school children’s model in Goa, community intervention
using the NSS team model in Kerala, behavioural approach in Mumbai and the Bhavnagar
district of Gujarat need to be sustained and further applied to larger area.
          A youth training programme for tobacco prevention among youth peers can be an
effective health education strategy. The Youth As Teachers (YAT) programme trains senior
secondary students to teach smoking and illicit drug use prevention to their friends and
                               162
children in their community.
          Students of colleges where instructors smoke or chew tobacco could boycott the
classes for a brief period and not refer patients to them to symbolize their protest against
                                     75
tobacco use (Vaidya 2000 e-mail).




    Unplanned approach: NGOs often do not plan their activities very far in advance.


   Suggested mechanism: Strategic planning ; plan with forethought and clear aims,
                            measurable goals and objectives; access training for
                            NGOs in planning.




   Manpower shortage in NGOs:


   Suggested Mechanism: Motivate volunteers from the community;
                             disseminate information on activities through the media
                             to attract volunteers and other resources



                                                                                         143
   Tobacco industry continues to flout tobacco control policy (as mentioned under
   Government Institutions – policies):


   Suggested mechanism: Strong opposition to the tobacco industry.


The essential components of strong opposition to tobacco industry include:
     •    Strong public opinion against evils of tobacco industry need to be addressed by
          informing the public of the true story of the multi-national and national tobacco
          industry killing millions of people globally and in India
     •    Strong media advocacy on the Framework Convention on Tobacco Control.
     •    Public interest litigations
     •    Target bureaucrats, politicians and film makers with information
     •    Move into consumer courts for compensation
     •    The tobacco industry's targeting of the youth needs to be resisted tooth and nail in
                                          24
          the interest of their health.


Public litigations/consumer activism: NGOs should use Consumer Courts to seek
compensation for the victims of tobacco products and their family members. Where a number
of persons are affected, class action suits should be filed, for saving the cost of litigation and
                                                  23
deriving benefit for a large number of victims.


   Constant law breaking on the part of the public and lack of implementation by
   Governments:


   Suggested mechanism: Strong opposition to lawbreakers.


         Non-government Institutions as well as individuals need to put their opposition on
lawbreakers in all places and in all circumstances. A few more examples of types of
opposition needed:

                                                                                           144
 •    The Government escapes implementation. It should be strongly opposed by individual
      institutions or collectively by many institutions. There are examples of implementation
      after strong opposition, as mentioned earlier in the document.
 •    If one finds someone smoking in a public place, he or she should be requested to stop
      smoking and if the smoker does not comply, the nearest level of implementer should be
      informed and so on.
 •    If anyone finds walls stained with tobacco quid in an office, attention must be drawn
      towards this and must be informed to the head of the department of the office or to other
      proper authority.
 •    If anyone finds contraband cigarettes or cigarettes without proper statutory warnings the
      local authority must be informed.




     Insufficient Public Awareness initiatives:


                                                                                 67
Mass and targeted health education programmes to reduce demand are lacking.           Only a
handful of NGOs, Government agencies and committed individuals at the local levels are
involved, reaching only a limited segment of the diverse Indian population. Till date, due to
the disjointed nature of these efforts, negligible results have been achieved and no perceptible
attitudinal changes among tobacco consumers have been seen. No strategic media plan has
been made to counter the aggressive media efforts of the tobacco industry. Research on the
demographics and attitudes of tobacco consumption is also limited. A focused counter
advertising media plan on the negative health/social aspects of tobacco consumption is
                                                             135
needed to sensitize policy makers and the public at large.


     Suggested mechanisms: More public and youth awareness initiatives, cessation
                             clinics and community-based cessation programmes.


More public education needs to be provided about tobacco use and environmental tobacco
smoke exposure – in the workplace, at home, in eating-places and in modes of transport. In

                                                                                        145
the example of the State of California, even the proportion of homes where indoor smoking is
allowed has decreased after public education, according to evaluation studies. Changes in
public attitudes would be a prerequisite for the community mobilization needed to enable
                                             67
better enforcement of enacted legislation.        Community-based health education activities
need to be promoted, as grass-roots work helps to create public awareness. These can be in
the areas of psychology, medicine and social work for de-addiction programmes.


Anti tobacco awareness should be a part of education for all children every year from class
5th onwards. Successful model programs should be duplicated in all other states, like the
Hriday-Shan Youth program. Budget should be allotted by the Government for anti tobacco
awareness campaign via the media, bill boards, bus panels, trains, railway stations and other
areas that come under the jurisdiction of the Government.


Special education and awareness should be imparted to the medical teaching faculty and
                                                          69
made a part of their education system (Kapdia, 2002).          A few points for health education
that came out of a meeting in the United States that could be relevant in India are as follows
                 152
(USPHS 2000).

 •   Get parents to restrict smoking at home
 •   Counter advertisements
 •   Target youth to not take it up and middle aged for quitting
 •   Create social pressure for not using tobacco


More ideas for awareness generation that emerged from the Tobacco Control Research
Meeting sponsored by the World Bank and organized by TIFR in Delhi in April, 2002:


       •   Publish reports on the major issues in tobacco use and control in local languages
           across the country;
       •   Prepare a series of articles on various tobacco issues, in all local languages and
           submit to newspapers all over the country


                                                                                         146
         •   Make documentary films showing tobacco harms both to workers and users; in all
             local languages and shown on TV.
         •   Sensitise non-smokers to demand a smoke-free environment.


Tobacco cessation clinics: Many more tobacco cessation clinics need to be set up.


≈ Recent steps: In order to help people who are addicted to various forms of tobacco to
quit, 12 cessation clinics have been set up across the country with the support of WHO.
These clinics will give a combination of psychological support, counselling and
pharmacological treatment to the tobacco users who want to stop using tobacco. A special
emphasis is paid in these clinics to youth as they are vulnerable to all forms of substance
         46, 50
abuse.            It has been suggested that nicotine reduction therapy needs to be made available
                                                                                           152
to the masses. Cessation products could be subsidized and disseminated more widely.


•   For more related information, see also Chapter 2 – Initiatives of Non-Government
    Institutions.




                                                                                           147
NEXT STEPS



•   Ensure good rules framed for the new Act;

•   Continue and strengthen joint action by NGOs as needed.

•   Impart training to school personnel in tobacco control and

    start curricular and extra-curricular teaching of youth;

•   Generate public awareness about the hazards of tobacco, how

    to quit using it and the comprehensive Act, 2003.

•   Promote ratification of the FTCT by all nations in the South

    Asian Region




                                                               148
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