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DEPARTMENT OF GLOBAL HEALTH & SOCIAL MEDICINE COURSEWORK COVER SHEET

Module Title and Code: (eg Introduction to Global Health - 4SSHM001)


Key Concepts in Global Health -5SSHM001

Candidate Number:
X04195

Coursework Title (including the essay number – e.g. 1st or 2nd assessed essay):

Tobacco Control in India

Submission Date:
31/03/2017

Word Count:

2000

PLAGIARISM DECLARATION:
I have read and understood the College regulations and guidance on plagiarism.

I certify that the work I am submitting is my own. In addition, I have not submitted this
piece of work for assessment elsewhere, either within King’s College London or outside it.
I also certify that I have acknowledged any quotation from the published or unpublished
work of other persons and the sources of all material I have consulted.
Tobacco Control in India

Introduction:

The burden of non-communicable diseases (NCDs) in the global south has been
increasing and has arguably surpassed the burden of infectious disease (Reubi, 2016). If
NCDs are not addressed, this burden “will cost low-income and emerging powers 7 trillion of
cumulative GDP losses by 2030” (Sullivan p.1, 2016). The rise in NCDs has been partially
attributed to globalisation, whereby products and habits travel from the global north to the
global south. Part of this process has involved the spread of tobacco consumption, which is
now one of the greatest risk factors for chronic disease in the global south (Reubi, 2016).
In this essay I will analyse how tobacco use is being responded to in Indian public
policy. I will argue that the policies that have been produced are not local solutions, but are
replicas of models seen within the global north. To do this, I will begin by looking at the
impact that tobacco has had upon the Indian population, and then I will go on to review the
current tobacco policies that are in place. My review of tobacco policies will reveal that
tobacco policies often fail to take into consideration the cultural perceptions of tobacco use,
they do not respond to the ways in which tobacco is specifically used in India and by whom,
and these policies often overestimate the capacity of government infrastructures. I will
conclude this essay by suggesting ways in which policies should be formed in India, urging
policy makers to create local solutions to local issues.

The Tobacco Situation in India — current policies and frameworks for intervention:

“The Next Epidemic”:

Tobacco use is responsible for 16% of deaths in India, having one of the highest
mortality rates in the world (World Bank, 1999; WHO, 2017). Morbidity attributed to
tobacco is equal to that of what is seen in the UK and the US (WHO, 2017). Tobacco use is
most common among the poor, the illiterate, and the younger generations (Global Oncology,
2014; World Bank, 1999; WHO, 2017). With high rates of tobacco associated mortality, and
the demographics that tobacco use is associated with, tobacco interventions provide a
valuable opportunity to address a large portion of India’s burden of disease and to alleviate
health inequalities (Global Oncology, 2014).

The National Tobacco Control Programme:

India has recently attempted to address the tobacco epidemic by implementing the
National Tobacco Control Programme (NTCP). Under this framework, the Ministry of Health
of India has established six policies (NTCP, 2017):

1) Prohibition of smoking in public places


2) Prohibition of direct and indirect advertisement
3) Prohibition of tobacco sales for minors
4) Mandatory warnings and displays of contents on tobacco products
5) Prohibition of sales of tobacco products within 100 yards of educational
institutions
6) Imposing a sin tax on tobacco products

Despite these efforts, the NTCP has failed to significantly reduce tobacco usage on
most fronts. In the following section, I will explain how these policies fail to take into
consideration the nuances of the India context.

Solutions from the Global North for Problems in the Global South:

The cultural perceptions of tobacco in India are often supportive of tobacco use.
Tobacco is not seen as a dangerous product which can have negative health effects, but as a
correlate of positive social status among lower socio-economic groups (Shaukat, 2014). This
perception results because of poor education among lower socio-economic groups (World
Bank, 1999; WHO, 2017). The positive cultural perception of tobacco undermines many
policies that are implemented. Prohibition laws, which rely on the police force, are not
“uniformly possible as … violations remain [a] low priority” (Shaukat p. 15, 2014).
Second, the tobacco policies that have been enacted often fail to take into account the
ways in which tobacco is used, and who is using tobacco. At least 40% of tobacco
consumption in India is attributed to smokeless tobacco (SLT), or chewing tobacco (Arora
and Madhu, 2017). Prohibiting smoking in public places, although arguably having some
impact, does not account for SLT. A failure to regulate SLT results in the rise of
communicable disease, whereby diseases such as tuberculosis are often spread from spitting
SLT (Arora and Madhu, 2017). Another aspect is how warnings on tobacco packages and
anti-tobacco media campaigns fail to cater to the correct audience. One study of a rural
population was able to demonstrate that “only three [participants] could interpret [the
warnings] correctly” (Gaidhane et al. pp.1, 2011). When creating policies, it is important for
governments to target the specific users of tobacco — often the poor and illiterate — and to
adjust to the dynamics of the Indian tobacco epidemic — often including SLT and other
smoking tobacco variants.
Finally, the Indian government simply does not have the capacity to implement many
of their regulatory policies. Tobacco advertisements are often publicised on unregulated
public billboards and other forms of Indian media which are challenging for the government
to monitor (Shaukat, 2014). Additionally, imposing a sin tax on tobacco products has been
effective, but has been challenging to apply universally to all tobacco products (Mckay et al.,
2015; Shaukat, 2014). In addition to the common smoking packs as seen in the global north,
the Indian tobacco market also contains ‘binti’ cigarettes — a local, cheaper version which is
more damaging to the user’s health — and a variety of chewing tobaccos (Mishra et al.,
2012). Sin taxes were originally imposed on smoking and chewing tobacco, and tobacco
usage fell among the higher socio-economic classes; however, the poor began buying cheaper
tobacco in the forms of binti and unregulated chewing tobacco (Shaukat, 2014; Arora and
Madhu, 2017; Mckay et al., 2015). These purchasing habits have led to negative impacts on
the health of the poor, and lead to larger health inequalities.
The policies that have been implemented have been solutions that have echoed what
have been seen in the global north, and have failed to take into consideration the contextual
nuances of the Indian tobacco epidemic. Policy makers should take notes from social
scientists who speak of ‘local biologies’: when diseases travel, so do the ways that diseases
are interpreted and responded to, demanding different policy solutions based upon the local
context (Rubei, 2016; Lock, 2001; Livingston, 2012).
Indian Solutions for Indian Problems — a localised framework of intervention:

To begin to craft interventions for tobacco control in India it is important to


understand the context of the tobacco epidemic. The most at risk groups for smoking are the
poor and illiterate; within these groups, it is up to four times more likely that tobacco habits
begin between the ages of 10-18 (World Bank, 1999; Shaukat, 2014; WHO, 2017). This
means that the most cost-effective interventions will most likely be in youth living in urban
slums, where there are higher tobacco access rates and more accessible youth for intervention
(Mishra et al., 2012). As these policies are designed it is also important to keep in mind that
national government infrastructure is weak, meaning emphasis should be placed on low-cost
programs run by local, state and community governments (Shaukat, 2014).

Adolescent Focused Interventions for Tobacco Cessation:

To date there have been a number of tobacco control interventions focusing on


adolescents. There are two common mechanisms by which interventions can take place:
community interventions and school interventions (Perry et al., 2009; Harrell et al., 2016).
Community interventions have been shown to decrease overall tobacco use by up to 26%,
while school interventions have been shown to decrease overall tobacco use by up to 17%.
Despite the initial difference in cessation rates, there are some nuances within these programs
that may make school interventions more favourable from a cost-benefit analysis.
In the structuring of community interventions programs they often rely on extensive
infrastructure to make the programs a success. For example, the ‘ACTIVTY’ intervention
analysed one community and ensured that within that community tobacco prohibition laws
were strictly enforced (Harrell et al., 2016). Despite the positive results of this, the model
would be hard to scale, particularly with a weak government infrastructure (Shaukat, 2014).
School interventions programs, although having initial lower cessation rates, appear
to have a higher cost-benefit ratio and to be both sustainable and scalable because they can be
built into school curriculums (Mckay et al., 2015). Additionally, school interventions also
have higher cessation rates for chewing tobacco, an often hard to come by result. School
programs include tobacco education in the classroom curriculum, posting tobacco warning
posters around the school, parental involvement and peer-led activism (Perry et al., 2009).
Although successful, these programs still face a number of challenges, particularly in curbing
chewing tobacco usage. It is important to think of school-based interventions as only one part
of a multi-strategy approach.

A Bottom Up Governance Approach:

To complement school-based intervention programs, there are a variety of solutions


that local governments can implement. To compare to the NTCP, I recommend that
government initiatives happen from a bottom up perspective, being led by the community and
local governments. This will take strain off of weak national government services, and allow
for more catered approaches to the populations’ needs.
First, local governments should impose sin taxes. To do this, they should use the
national government’s framework that is already in place as a guiding template. Then, local
governments should take the time to modify sin taxes based upon their local contexts.
Depending upon the state, there are different availabilities of tobacco products (Shaukat,
2014). If local governments are to evaluate these contextually dependent markets, sin taxes
can be imposed that would be able to avoid the previous failures of sin tax where tobacco
users bought cheaper, lower quality products (WHO, 2017; Shaukaut, 2014). Suggestions
have initially included taxing tobacco products at rates that will make all tobacco products of
equal prices; however, the exact mechanisms would have to vary based upon the specifics of
the tobacco market that the tax is being imposed upon. Additionally, this approach would
complement the challenges that occur within school-based interventions; specifically, this
would provide an opportunity to disincentive adolescents from purchasing chewing tobacco
(Harrell, 2016).
In addition to taxing, governments should consider methods on how to incentivise
public officials, specifically the police, to prioritise the implementation of tobacco prohibition
laws. Most recently, the national government has written to the head of the police force in
each state asking for police to play a larger role in tobacco prohibition (Shaukat, 2014). In
some states, the monthly police review boards have begun to dedicate time to discussion of
tobacco prohibition. In states where this has occurred tobacco prohibition has been
implemented more strictly as police see it as a priority of the government’s agenda (Shaukat,
2014). Efforts like these should be multiplied across other states, and should be insisted by
local governments compared to a request on behalf of the national government.
Finally, it is worth considering whether local community led approaches would have
an impact. In the past these have been used to stimulate ideological change around
stigmatised topics. For example, in Kerala there were established local maternity picnics and
discussion groups to support expecting mothers and to destigmatise aspects of maternal care
(Marmot, 2006). Research should be done to investigate if local led initiatives such as these,
perhaps even integrated into school programs, could have a positive impact on tobacco
cessation.

Conclusion:

Moving forward, India needs to develop Indian solutions to the Indian problem of
tobacco use. If India continues to import policies which mirror those of the global north, they
will fail to fully address the burden of tobacco in India. This essay has shown how the current
policies for tobacco control in India often do not take into consideration the individuals that
are using tobacco and the types of tobaccos used, they often overestimate the capacities of
government infrastructures, and they fail to overcome the cultural barriers that are in place.
Indian tobacco policy should focus on groups that are most at risk — young adolescents —
and should implement community led, bottom up government approaches, to ensure the most
effective forms of intervention.
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