New Zealand tobacco ban shows the way. Can India act tough, too?

In a radical move, New Zealand, as part of its Smokefree 2025 plan that is expected to be approved sometime next year, will prevent people presently aged 14 from legally buying tobacco products in their entire lifetime. The legal smoking age will also be increased every year.

New Zealand also plans to reduce the amount of nicotine in cigarettes, and cut the availability of tobacco in retail outlets as part of the new restrictions that will come into effect in stages. The island nation is yet to announce details on how it plans to implement the decision.

Only Bhutan, which bans tobacco for everyone, has a stricter policy.

Dr Salkar said New Zealand is a smaller and less populous country than India and might be able to implement it. But the problem is deeper and graver in India, where more than smoking, smokeless tobacco such as khaini, zarda, gutkha, etc., is a bigger issue.

“In some places, tobacco is engrained in our culture. But someone needed to take a step,” Dr Salkar said.

A mega industry

There are many issues and problems when it comes to the Indian context, Dr Salkar explained. “Farmers are dependent on tobacco, it generates employment and is a big industry and a huge revenue earner and that is why the government is a dilemma when it comes to taking similar action in India,” he said.

A study by industry body Assocham says the tobacco sector contributes Rs 1,179,498 crore to the Indian economy and employs an estimated 45.7 million people. These include six million farmers, 20 million farm labour, four million leaf pluckers, 8.5 million workers in processing, manufacturing and export units and 7.2 million workers in retailing and trading, the study said.

According to the website of the Tobacco Institute of India (TII), a representative body of farmers, manufacturers, exporters and ancillaries of the cigarettes’ segment of the tobacco industry, India is a leading tobacco exporter with exports of leaf tobacco and tobacco products generating foreign exchange earnings of around Rs 6,000 crore annually.

Tobacco and tobacco products are also large contributors to the government’s tax revenue. Quoting a Rajya Sabha answer, the TII website says the average annual revenue collection (based on the last three years) from tobacco products was about Rs 53,750 crore.

“Yes, the tobacco industry has huge economic value. However... the health hazard and social harm it does and hence, a gradual and systematic approach is needed to phase out tobacco in the near future,” Dr Salkar said. “We have to save our future generations.”

In India, the use of both smoking and non-smoking tobacco is on the rise, said Dr Tapan Saikia, head of medical oncology and research director, Prince Aly Khan Hospital, Mumbai. “Non-smoking tobacco is being used in various parts of the country in different forms for centuries and is now part of the culture, almost akin to religion.”

There are numerous ways of manufacturing and marketing these products. Contribution of non-smoking tobacco in causing ill health, most significantly cancer of the mouth, has been established beyond doubt, Dr Saikia, who is also visiting professor and constant at State Cancer Institute, Guwahati Medical College Hospital, Assam, said.

Work by Richard Doll and A. Bradford Hill in the 1950s and the landmark paper by Doll and Richard Peto in 1981 on cancer research have been influencing governments in bringing about reforms, Dr Saikia said. “There needs to very strong political and entrepreneurial will to weed out all forms of tobacco use in India. New Zealand has taken a very bold step. It’s a very long-term goal. We hope this will encourage other countries across the world to act in similar manner,” he said.

According to the World Health Organisation (WHO), tobacco kills more than eight million people each year. More than seven million of those deaths are the result of direct tobacco use, while around 1.2 million are non-smokers exposed to second-hand (passive) smoke.

Tobacco use is a major risk factor for many chronic diseases, including cancer, lung disease, cardiovascular disease and stroke, WHO says. In India, it accounts for nearly 1.35 million deaths every year. 

Nearly 267 million people (15 years and above) in India (29% of all adults) are users of tobacco, according to the Global Adult Tobacco Survey (GATS) India, 2016-17. The most prevalent form of tobacco use in India is smokeless tobacco, and commonly used products are khaini, gutkha, betel nuts with tobacco and zarda. Smoking forms of tobacco used are bidi, cigarette and hookah.

Among all states and union territories, the highest prevalence of tobacco use has been reported in Tripura (64.5%) and the lowest in Goa (9.7%). All the seven states from the Northeast with high tobacco prevalence together account for less than 7% of tobacco users in the country, the GATS survey said.

In New Zealand, people have largely welcomed the plan. In nearby Australia, experts and campaigners are debating if such a move can be replicated.

But some critics and opposition parties say the ban will not work and may lead to black marketing of tobacco products. The ACT New Zealand party said "prohibition never worked". "We will end up with a black market for tobacco, with no standards or regulation, and people will be harmed," spokeswoman Karen Chhour told the local media.

Dr Salkar explained that what is happening in New Zealand is a long-term process. “It will lead to two things. Existing smokers will continue and the companies won’t lose their present clientele. But the number of new smokers will decrease and demand will come down gradually, over decades.”

So farmers and tobacco companies will get time in this process to shift to other businesses and companies can diversify, Dr Salkar said. “In India, we see companies such as ITC already diversifying into other businesses.”

“It is difficult to deter existing smokers. But we can stop non-smokers from joining the club by targeting them at an early age. And that is what New Zealand intends to do,” Dr Salkar added.

Multiple factors come into play in substance abuse, very similar when it comes to smoking cigarettes and bidis, or using gutkha and other forms of tobacco, Dr Samir Parikh, director, Fortis National Mental Health Program, Fortis Healthcare, said. “You are looking at exposure that comes through family, media, peer pressure, friends, seniors, etc. So when you start using a substance, biology takes over and you become habituated. You cannot withdraw, and (you) start defending what you are doing,” he said.

But if we only look at banning as a solution, it may not work fully because it is also important to bring in media literacy, social skills training, life skills, and teach youngsters how to deal with peer pressure in schools and colleges. “We need to act on prevention and teach youngsters how to resist,” Dr Parikh said.

Laws in place in India

In India, laws are already in place to regulate the sale of tobacco products. The Cigarettes and Other Tobacco Products Act, 2003 (COTPA, 2003) is an Act of Parliament to prohibit the advertisement of, and regulate trade and commerce in, and production, supply and distribution of cigarettes and other tobacco products in India.

In recent years, many states have banned the manufacturing, sale and distribution of gutkha and pan masala mixed with tobacco, a major cause of oral cancer in India. There is also a ban on the production, import, distribution and sale of electronic cigarettes.

In 2007-08, the government of India launched the National Tobacco Control Programme (NTCP) to bring about greater awareness about the harmful effects of tobacco use and about the tobacco control laws and ensure their effective implementation.

Proper implementation, however, remains a concern, experts point out. In many states, gutkha users have switched to twin-sachet (pan-masala and chewing-tobacco sold separately to circumvent the law. In many places across India, the use of chewing and raw tobacco, or piped tobacco (hookah), is part of local culture.

Some state governments attempted a tobacco ban vigorously but its implementation has been extremely difficult, Dr Saikia said. “Regardless of such failures, the society and the regulatory authorities must continue to innovate and minimise tobacco use.”

Dr Salkar said on the one hand, the government tell us to stop smoking and is running a national tobacco eradication programme, and on the other hand, it shows how to increase tobacco production. “There cannot be double standards. The government has to dismantle the Tobacco Board,” he said.

The website of the India Tobacco Board, which falls under the Union Ministry of Commerce, mentions its mission: "To strive for the overall development of tobacco growers and the Indian Tobacco Industry."

“We need strong political will if we want to eradicate this menace. The government has to decide if it is serious about tobacco eradication. It is difficult but if the government is serious, it is possible,” Dr Salkar said.

Small steps do matter

The need of the hour in India is to properly implement and toughen the existing laws and raise more awareness about the health hazards of smoking and tobacco among the people, experts say.

Binoy Mathew, program manager, Voluntary Health Association of India, a federation of 27 state associations, says what New Zealand has done is a welcome move but in India, we already have a comprehensive law and the government in the process of the amending COTPA to make it stronger.

There are plans to increase legal age of smoking from 18 to 21 years and ban all kinds of tobacco ads from all mediums, Mathew said. Designated smoking rooms in restaurants and other public places will be removed and fines for violation will be increased.

“If all that happens, it will be a positive move. The last GATS report shows all-India prevalence has come down to 29% from much higher. This shows that the laws are working,” Mathew said.

Dr Salkar said a small region like Goa, which strictly implements The Goa Prohibition of Smoking and Spitting Act 1997 to ban smoking in public, can initiate this process to ban tobacco and be a model state. 

“No farmer in Goa is into tobacco. There are no tobacco industries in Goa. If Goa can show the way, and over the next 10-20 years, show a decline in cancer cases and other COPD (chronic obstructive pulmonary disease) diseases because of a decline in the use of tobacco, other states can follow,” Dr Salkar said.

Dr Devdutt Sail, secretary of NOTE, said their primary focus is on stopping the initiation of young, new smokers. “The tobacco industry knows that current customers will eventually stop due to tobacco-linked diseases, and so it keeps on enticing young adults by surrogate and indirect advertising.”

In India, according to Dr Salkar, if we are able to prevent a person from smoking till the age of 35 or 40 by means of awareness or prohibition, it will help immensely. A man who hasn’t smoked till that age is unlikely to pick up the habit, he said. 

“A teenager generally picks up smoking due to peer pressure. A youth or a person who has begun his career picks up smoking in the company of colleagues or at parties.  So if we stop people in the age group of 15 years from smoking for 20-25 years, we can achieve a lot,” Dr Salkar said.

Separate queries sent to email addresses of senior officials mentioned on the Tobacco Institute of India and the Tobacco Board websites went unanswered.