The World Health Organisation (WHO) has estimated that India has the second largest number of smokers in the world after China (1). According to the National Family Health Survey-3, 2005-06, 57% of adult men and 3.1% of adult women used one or more tobacco products (2). The Global Youth Tobacco Survey 2006 estimated that in India 17.3% of boys and 9.75 % of girls in the age group 13-15 are using a tobacco product. In poor households, up to 10.5% of the household income is spent on tobacco (3).

According to the report Tobacco control in India, 800,000-900,000 Indians die annually due to diseases attributable to tobacco-50% of cancer deaths, 40% of all health-related problems, and a majority of cardio-vascular and lung disorders in the country. WHO predicts that nearly one million Indians will die from smoking alone in 2010 and 70% of these deaths will be premature (4).

India spends Rs 30,000 crore annually to treat tobacco-related diseases, an amount which is four times the revenue generated by the tobacco industry. A total of Rs 25,000 crore is collected as excise duty on tobacco-related products. Only 1% of this-Rs 25 crore-is spent on tobacco control activities (5).

The government of India has, from time to time, taken measures, including legislation, to control tobacco intake. The Cigarettes and Other Tobacco Products Act (COTPA) enacted in 2003 is intended to discourage the consumption of tobacco (6). The salient features of the Act are:

• Prohibition of smoking in public places.
• Prohibition of direct and indirect advertisement.
• Prohibition of sale of tobacco products to minors below 18 years.
• Prohibition of sale of tobacco products within 100 yards of educational institutions.
• Mandatory depiction of specified pictorial health warnings on all tobacco product packs.
• Mandatory depiction on tobacco packs of tar and nicotine content along with maximum permissible limits.

The first four provisions have been implemented in India in the last few years, but they have not been strictly enforced. Despite the ban on advertisements, surrogate promotion campaigns and disguised advertisements are rampant in India. Non-tobacco products are promoted with brand names of tobacco products and non-tobacco brand names are used for tobacco products (4). Nobody is punished for violating tobacco laws. Tobacco advertisements are not banned at the point of sale.

The last two provisions of the Act listed above have been delayed for some years. There is reason to believe that this is because of pressure from tobacco industry.

Pictorial warnings on tobacco products

They say a picture can speak a thousand words. Pictorial warnings and images are meant to help users to visualise the nature of tobacco-related diseases. They should make them aware that tobacco use can cause serious illnesses and can kill the user. The pictorial warning should be strong to be effective and should repel the user. It should occupy 50% of the principal display area and should be clearly visible.

In a country like India with its multilingual and multicultural communities, a pictorial warning can break cultural, regional and language barriers. Moreover, when a large proportion of the population is illiterate, written warnings may be ignored, which is why pictorial warnings are necessary. It is a good public health strategy which costs the government and the public nothing because the cost of the colourful package warning will be met by the tobacco companies (7).

In 2003, India, together with 150 other countries, became a signatory to WHO’s Framework Convention on Tobacco Control at the 56th World Health Assembly, and is required to follow the WHO protocol for tobacco control activities. The use of pictorial warnings on tobacco product packets is one of the WHO’s declared six "M POWER" strategies designed to combat tobacco use in its member countries during 2008 (8).

M POWER strategies are: 1. Monitor tobacco use and control activities. 2. Protect people from the hazards of tobacco. 3. Offer help to people who intend to quit tobacco. 4. Warn people about the hazards of tobacco. 5. Enforce against all tobacco promoting activities including sponsorships. 6. Raise the price of tobacco products to decrease consumption.

Countries such as Brazil, Thailand, Singapore, Hong Kong, Chile, Australia and Canada have effectively implemented pictorial warnings on tobacco product packets. The impact was found to be strongest on people with low education and low economic status (7).

Under COTPA, statutory warnings were introduced on all tobacco products in 2005. But it was evident that this measure alone was not sufficient to reduce the use of tobacco. The government therefore notified rules on pictorial warnings on July 5, 2006. However, the actual implementation of these rules has been postponed repeatedly, apparently because of pressure exerted by the tobacco companies.

India signed the WHO Framework Convention on Tobacco Control on September 10, 2003. It was ratified on February 5, 2004 (7).

July 2006: The government issues a notification of the specific pictures to be used by tobacco companies within seven months.

January 2007: Tobacco companies seek more preparation time. The government extends time to June 2007.

February-May 2007: The companies object to the use of a picture of a corpse which indicates that smoking can kill. A Group of Ministers (GoM) is formed to take a decision on the matter. The GoM asks the government for a further extension till July.

July 2007: The GoM decides to use the symbol for death-a skull and crossbones – as the picture, supported by the health minister Anbumani Ramdoss (who got an international award from WHO for his tobacco control activities in 2007).

August 2007: Parliament amends the bill making the use of the skull and crossbones picture optional, not mandatory. The court sets a deadline of December 1, 2007 for pictorial warnings to be implemented.

September 2007: The GoM withdraws the pictures of the skull and crossbones and the corpse, citing cultural and religious reasons.

December 2007: The court allows the government another extension till March 17, 2008.

February 2008: the GoM proposes that cigarette and beedi packs are to carry a photograph of an x-ray plate of the chest of a man affected by cancer (though understanding the significance of these pictures will require the help of a radiologist). Packets of chewing and smokeless tobacco products will carry the image of a scorpion, depicting cancer (though usually the crab symbolises cancer).

March 10, 2008: The ministry of health issues guidelines and notifications. The date for implementation of pictorial warnings is shifted to June 24, 2008. The picture must occupy 40% of the space on the packet (instead of the earlier notified 50%) and the warning should be changed every 12 months (9). The messages "smoking kills" and "tobacco kills" is to be printed on beedi, cigarette and smokeless tobacco products in English and regional languages.

The date was later extended to November 30, 2008, a deadline announced in national and regional newspapers in a full page advertisement. But in the last week of November the health minister extended the deadline to May 31, 2009. Thus it was postponed for the seventh time (10).

The right of an individual to maintain a healthy life has to be enabled by the government. Using strong pictorial warnings is an evidence-based measure to warn the user and thus empower the consumer. By weakening the warning we are denying the individual the right to a healthy life. Tobacco is the only lethal product that has no safe limit and that is legally marketed to consumers around the world.