Even well-informed people shake their heads in disbelief when they hear that tobacco killed 100 million persons in the 20th century and is projected to kill a billion in the 21st century. It is only when they are told that these are authentic estimates from the World Health Organization (WHO) that the terrible truth begins to sink in. Even then, they are jolted when they learn that tobacco killed 6 million persons globally last year — a toll that will rise to 8 million annually between 2025 and 2030.
Where India has really fallen short is in the use of taxation to push down tobacco consumption. A rise in the price of its products will bring down tobacco use.
The world responded to this threat by adopting the Framework Convention for Tobacco Control (FCTC) in 2003. This first ever public health treaty developed under the auspices of the WHO proposed several measures that countries must adopt to reduce the prevalence of tobacco consumption. The treaty has been ratified by 177 countries. The United States, Argentina, Indonesia and Switzerland are among the notable exceptions.
The most important tobacco control measures recommended by the WHO are: raising taxes; comprehensive ban on all forms of tobacco advertising, sponsorship and promotion; smoke-free public and work places; cessation services to help people quit the habit and strong health warnings. Many countries have implemented one or more of these measures but very few have effectively used the full arsenal to bring down the foe.
Raising taxes has been found to be the most effective intervention since consumption declines when price increases. This effect is especially strong in persons with low disposable incomes — the poor, young persons and many women. South Africa tripled the excise tax on tobacco and halved its tobacco consumption in a 11-year period. Philippines recently raised tobacco tax sharply and will use 70% of the increased revenue to fund universal health coverage.
India has done well in some areas of tobacco control but needs to do much more in others. The law enacted in 2003 bans all forms of tobacco advertising other than at the point of sale. Through the combined efforts of the government, civil society and the judiciary — sometimes in concert and sometimes in conflict — direct advertising has been curbed. Surrogate advertising is still resorted to by a recalcitrant tobacco industry that seeks to defy, delay or dilute any regulation. The restrictions placed on the depiction of tobacco consumption in cinema or on television are way ahead of the rest of the world.
The recent ban on ‘gutkha’ is also a much needed move to contain the menace of smokeless tobacco, which has become the leading form of tobacco consumption in the country. Children and women are especially vulnerable victims of this habit, which is the leading cause of oral cancer. However, the enforcement of this ban needs to get stronger, as also the ban on smoking in public places. Pictorial health warnings on tobacco product packs too need to be more prominent and hard hitting. It is time India mandates plain packaging, like Australia, to remove the promotional effect of colourful tobacco packs.
Where India has really fallen short is in the use of taxation to push down tobacco consumption. Bidis are virtually out of the tax net and oral tobacco too has received the light touch treatment. The cigarette segment too should be subjected to higher taxes. A sharp rise in the price of tobacco products, across the board, will bring down consumption while differential treatment will result only in product or brand switching.
There are now concerns that the decline in tobacco consumption will be slower than needed, even if all countries effectively implement the FCTC. Kenneth Warner, a global leader in tobacco control, cautions us: “…barring more effective tobacco control, global smoking prevalence will remain between a fifth and fourth of all adults for at least the next 20 years. Unless something dramatically different occurs, smoking will continue to be Public Health Enemy #1 for decades to come, killing millions of people every single year”. By 2030, over 80% of all tobacco related deaths will be in low- and middle-income countries.
The United Nations (UN) and the WHO have set a target of 30% reduction in the prevalence of tobacco consumption by 2030. Some countries have been more ambitious and have set a target of reducing such prevalence to less than 5% — New Zealand and a group of Pacific Island Nations (2025), Finland (2030), Scotland (2034). Bhutan has already banned the sale of all tobacco products. Tasmania has announced a ‘Tobacco-Free Millennium Generation’ policy, wherein no one born after 2000 will be ever sold tobacco legally. Singapore is likely to follow suit.
In the context of the evolving post-2015 development agenda of the UN, tobacco needs to be viewed not only as a threat to health but also an enemy of sustainable development. Tobacco degrades the environment by extensive deforestation (wood fuel is burnt for ‘curing’ tobacco leaf) and paper use for packaging (cigarette machines use four miles of paper per hour). It is also a crop that consumes nutrients and water at a rate faster than most other crops and causes soil erosion. It requires an extensive use of pesticides. In a world that is increasingly threatened by food insecurity, can we waste 4 million hectares of arable land on a killer crop? The world over, the poor consume tobacco more frequently and tobacco consuming families sink into poverty. Any development agenda that intends to reduce global poverty cannot ignore the threat of tobacco.
With what we know now, we have a duty to protect present and future generations from the many harms of tobacco. We need strategies to make the 21st century the very last period in human history where a person dies of a tobacco-related disease or a tree is killed to produce 300 cigarettes. Hence, the call to design the ‘end game’, so that we can finally declare closure on the tobacco epidemic. The tobacco industry cannot be tamed — it has to be timed out. K Srinath Reddy is president, Public Health Foundation of India.