A: It is well understood that the tobacco epidemic is moving rapidly from the industrialized world to developing countries.  In the past the epidemic was thought to be basically confined to the industrialized world whereas currently, it seems to be at an equal level in developing and industrialized countries.  Within near future however, the epidemic will decrease or remain stagnant in the industrialized countries but would increase rapidly in the developing world.

The 14th WCTOH attempted to bring this point home that the focus of action in tobacco control now ought to be developing countries.   The Conference set ambitious targets to get major participation in the Conference from the developing countries.  In Mumbai, for the first time in a world conference, the number of delegates from the developing countries exceeded those from industrialized countries. 

Q: What are the next steps for the tobacco control movement, after the conference? 

A: The next steps for the tobacco control movement after the Conference are well delineated in the Conference Declarations (available on www.14wctoh.org).  For example, a major task would be to sustain and accelerate the progress in the implementation of Framework Convention on Tobacco Control that has been ratified by 164 members so far.  The ratification of the FCTC by the USA will be a major step forward in tobacco control movement.

Q: What issues do you see the tobacco control community focusing on in the future?

A: The tobacco control community continues to research, debate and move forward on issues in tobacco control.  For example a major issue that is thought to be ripe for implementation is plain packaging of tobacco products although it has not happened so far in any country. It is important as it is well understood now that the package itself is a major advertisement for the product inside.  Similarly there are issues about illegal trade, duty free sales, cross-border advertising etc.

Q: Is it difficult to get the issue of tobacco control on the agenda in India?  Do you feel as if you are competing with more pressing public health issues?

A: It has not been easy to get the issue of tobacco control on the public health agenda in India. The apparent reasons seem to be more pressing health problems in India of communicable and infectious diseases; reproductive health care, rural health etc.  Real obstacle as everywhere else however, is tobacco industry.  In the past whenever there were attempts to get a focus on tobacco control, either the tobacco industry itself, or its cronies, always tried to divert the attention of public and policy makers by raising such issues.

The Indian Government does derive a reasonable amount of tax revenue from tobacco and people often think that as a reason for a lower priority towards the tobacco control.  It should however be pointed out that tobacco control strategies call for increasing the tax revenue from the tobacco rather than decreasing it.  Moreover almost all tobacco tax revenue in India is derived from cigarette that uses less than 15% of tobacco.  Rest 85% of tobacco remains almost untaxed or has very little taxes.  Although the finance ministry remains unconvinced about the issue of dedicated taxes it should be pointed out that it is not the finance ministry that raises objections on proposed tobacco control policy measures.  Such objections have almost always come from other ministries like Information and Broadcasting, Labor, Commerce, Agriculture, Industries etc.

The most visible obstacles to advancing tobacco control in India are the issues of the employment of bidi workers and to a smaller extent of small farmers and retailers. These issues are exploited by the industry in their fullest effort.

Q: What are the major scientific and policy issues facing the tobacco control community?  What do you think will be the priority moving forward?

A:  In India the major scientific and policy making issue facing the tobacco control community is to advance policies where credible scientific evidence is already available.  For example, although it is now well established that smoking is major factor in tuberculosis epidemic but the tobacco control has not yet received any attention from tuberculosis control programme.  Similarly, the smokeless tobacco in pregnant women in India result in a larger number of adverse reproductive outcomes such as low birth weight babies and still births. Again tobacco finds no mention in the reproductive health programme for women in the country.  The most common and lethal tobacco product in India is bidi, yet there is little tax on it and it remains the cheapest smoking product in the world.

Q: Your research seems to focus primarily on oral cancers, but are other tobacco-related illnesses becoming public health issues in India?  How have other forms of smokeless tobacco impacted oral cancer rates and other tobacco-related illnesses?

A:  Oral Cancers are the most visible cancers and direct consequence of tobacco use.  Oral cancer is amongst the most common form of cancer in India in contrast o everywhere else in the world.  Therefore a larger amount of focus attention is given to oral cancer.  A new form of manufactured smokeless tobacco product, gutka, has created an epidemic of oral sub mucous fibrosis.  It is a pre-cancerous condition and therefore gutka has significantly increased oral cancer among young individuals.

There are several other cancers and a large spectrum of diseases that are caused by tobacco that form major public health problems in India.   My research has addressed a number of these issues through a large cohort study with a long term follow up.

Q: Have warning labels on cigarettes been implemented in India?  If not, do you believe that will happen soon?

A:  The important issue of pictorial warning has gone through the considerable amount of delay, dilution and weakening during the last 3 years.  All tobacco products were supposed to carry the mandated warnings from 31st May, 2009, but implementation has been further weekend by allowing older products without warning to be sold as long as the stocks last.

Q: Do you think that warning labels would have an impact on smoking rates in India, as they have in other nations?

A:  Warning labels on tobacco products (as is true for any other consumer products) are intended to inform the consumer, i.e., smoker, regarding the consequences of tobacco use. Most, if not all, tobacco users in India do not read the textual warning “Statutory warning: Cigarette Smoking may be harmful to health,” first because it is not there most tobacco products other than cigarette and two, because they may not know English.  Also, simple textual messages do not convey the magnitude of health burden associated with tobacco use.

In addition to informing current tobacco users, another useful role of pictorial warnings, as it has been demonstrated in other countries, is related to its ability to prevent “wannabe” or “potential” consumers from becoming tobacco users. According to the GYTS, a small proportion of Indian children aged between 9-13 years initiate the habit to tobacco use (smokeless or smoking). In such a population, the visual impact through graphic images on tobacco products is likely to be retained longer, thereby prompting positive behavioral tendencies.

We, at Healis, conducted a study to determine the impact of graphic labels on tobacco products and inferred that nearly 33% non-smokers will reconsider their decision to smoke, 42% of the current smokers will quit or reconsider their decision to smoke before opening the pack.