India presented itself as a true global leader when it made the critical decision to ensure pre-tested graphic health warnings cover 85% of the surface area of tobacco packs sold in India. The initial announcement in October 2014 was met with resounding applause from the 200 governments and institutions assembled in Moscow for international negotiations at the Conference of Parties to the Framework Convention on Tobacco Control, and it received public praise from national and international leaders and health experts in the ensuing months.

An urgent need

India was praised because of the proven cost-effectiveness of graphic health warnings and because of the example its decisive action would set for other countries. India is home to the largest youth population in the world, but she will only realise her potential demographic dividend if she can protect her citizens from suffering from disease and premature death during what should be their most productive years. Currently, there are one million premature tobacco-related deaths in India every year and an annual health cost of $22.4 billion. India’s youth face the highest (and increasing) rates of oral cancer in the world. The death clock ticks relentlessly.

Graphic health warnings sound a ringing alarm each time a tobacco user – whether current or prospective – reaches for that tobacco pack. The images warn of the imminent and real danger of using the product, replacing the glamorous and misleading images of Marlboro men and Bollywood divas that the tobacco industry seeks to peddle. These images empower individuals to make a more informed choice about what they are doing to themselves and others when they use tobacco. They dissuade youth from initiating tobacco use and encourage quitting among current tobacco users. In a country with low literacy and little formal education, the images have the potential to improve millions of lives.

Delaying tactics

The tobacco industry knows this, which is exactly why it has sought to delay and derail large graphic health warnings in India and many other countries – interfering in the implementation of good, proven public policy. Were it not for the serious consequences of this interference, the tobacco industry’s arguments against graphic health warnings would almost be amusing. They claim that these warnings don’t influence behaviour, and in the same breath argue that there will be an increase in illicit trade. They bemoan that such warnings will result in the loss of livelihoods, and then they shut down production in their own factories. They claim that India shouldn’t have to implement large graphic health warnings when other countries aren’t doing so, ignoring the reality in neighbouring countries like Nepal (90%), Thailand (85%), Sri Lanka (80%) and Myanmar (75%). The tobacco industry’s arguments are shifty and inconsistent. Most importantly, they contradict the evidence.

In India, as in other countries, the poor farmer and worker has been presented as the face of the industry. Their poverty and desperation is mercilessly exploited and put on display through industry advertisements, wasteful litigation, organised protests and demonstrations. The true puppeteers – the wealthy owners and middle-managers of the tobacco industry – stay cloaked. Similarly, the influence and resources of multinational tobacco giants like British American Tobacco and Philip Morris – the names behind some of India’s biggest tobacco companies – cannot be ignored. They have a vested global interest in deterring other countries from following India in adopting large graphic health warnings, whatever the cost.

Warnings will help India’s poor

In India as in so many other countries, the poorest are most likely to bear that cost. Tobacco is a killer, victimising the workers and farmers as much as the users of the product itself. Paid subsistence wages, comprised primarily of women and children who suffer from horrendous working conditions, the majority of tobacco farmers and workers eke out a pitiable living. Unknown to them, the very handling of tobacco results in nicotine absorption and causes grave illness. Exploited in their ignorance, maintained in their poverty, the truth is kept hidden from the tobacco farmers and workers. Graphic health warnings will help to show them the reality.

Tobacco creates a poverty spiral in India – with tobacco-related ill-health and family expenditure being diverted from nutrition and education – estimated to push 15 million more people into poverty every year. There is a real body of evidence for this: The World Health Organisation has estimated that in low and middle-income countries, like Nepal and Egypt, and in low-income households, about 10% of household expenditure is on tobacco. The WHO has also reported that homeless children in India spend a significant proportion of any money available to them on tobacco, often prioritising it over food. Yet, even as they continue to proclaim to be on the side of the poor, the profits keep ticking upwards for the tobacco industry.

The reduction of tobacco use in India will not only save lives through improved health, increased economic activity and reduced health costs. It will also allow the currently exploited tobacco farmers and workers to switch to healthier, more economically viable alternative activities. Even in the most positive scenario, a reduction in the prevalence of tobacco use will only happen gradually, allowing time for governments and currently employed tobacco workers and farmers to make the transition.

The Ministry of Health and Family Welfare has stayed strong in the face of interference by the tobacco industry. Tobacco control activists continue to champion the 85% Graphic Health Warning Bill, challenging the industry’s untruths. Most recently, the Ministry of Health and Family Welfare, with technical support from Vital Strategies, unveiled a tobacco control mass media campaign, titled Tears You Apart, that describes the health, financial and emotional burden faced by tobacco users and their families. A social media campaign, with a running Death and Profit clock highlights the numbers of lives lost in India because of tobacco consumption, and the profits made by the tobacco industry in the same period. At the time of writing, it stands a little over 10 lakh deaths since graphic health warnings, which were initially to come into force from April 1, 2015, were delayed.

It is too heavy a burden to bear. India must continue to rebut the industry’s misleading arguments and enforce 85% graphic health warnings now.

Nandita Murukutla is country director, India, and director (global), research and evaluation; policy, advocacy and communication, Vital Strategies.

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