Pankaj Chaturvedi, Sanjay Seth, Prakash C Gupta, Ashima Sarin
Tata Memorial Hospital, Mumbai
‘Bans don’t work’ is a common response to measures to restrict or outlaw tobacco supply. Libertarians decry such measures as excessive ‘nanny state’ intervention; others point to the USA experience of alcohol prohibition in the 1930s, often held up as a failed experiment (although the truth is more nuanced; as a public health measure, prohibition was more effective than conventional wisdom holds).
Today, India is proving that prohibition can have a place in public health. Gutka, an industrially manufactured smokeless tobacco product has now been banned in the majority of the country, with encouraging results.
Gutka is made from crushed areca nut, tobacco, catechu, slaked lime and sweet or savory flavorings or fragrance. In December 2014, a former gutka industry owner went public with revelations that harmful chemicals are used as cheap substitutes for flavouring. He turned whistle blower after he was affected by mouth cancer, which necessitated facial surgery, chemotherapy and radiation treatment.
Spurred by attractive packaging in single-dose plastic packs affordably priced at 2-3 cents/pack, and widespread marketing targeted at children and adolescents, the gutka market has rapidly expanded in the last decade to be worth more than US$8 billion. The growth of the industry has caused havoc with public health, especially oral health. According to the Global Adult Tobacco Survey (GATS) India 2009-10, around 13% of males and 3% of females used gutka in India. Among young people aged 15-24, smokeless tobacco use was 23% for males, and 8% for females. Oral cancer is increasing, especially among youth. Use of smokeless tobacco usage is a key risk factor for cancer (mainly oral, oesophageal, and pancreatic), stroke, ischaemic heart disease, type 2 diabetes, adverse reproductive and developmental effects such as stillbirth, preterm birth and low birth weight.
The legal basis for the gutka ban was the Food Standards and Safety Act notified in 2011, section 2.3.4 of which specified that “Product not to contain any substance that may be injurious to health: tobacco and nicotine shall not be used as ingredients in any food product.”At the direction of the Supreme Court, the Ministry of Health and Family Welfare (MoHFW) constituted a high level Expert Committee to collate the evidence on harmful effects of smokeless tobacco and areca nut. In February 2011 the Ministry submitted this report, commonly called National Institute of Health and Family Welfare (NIHFW) Report to the Supreme Court. Several Civil Society NGOs urged the highest court to ban the manufacture and sale of all products found to be injurious to health by the NIHFW health report.
Momentum for the gutka ban, however, came from tobacco victims themselves; survivors of cancers of mouth and throat, widows and families of tobacco victims. Known as ‘Voice of Tobacco Victims’ (VoTV), the campaign featured patients and their family members, supported by their treating oncologists and public health researchers, telling their stories of initiation and addiction to gutka and consequences of disease, financial ruin and agony.
Started in 2011, the target audience for the VoTV was top policy makers, bureaucrats, social influencers, media and politicians. The appeal from patients made direct emotional connections; politicians and bureaucrats made promises and media gave prominent coverage to stories. The VoTV doctors and staff provided scientific evidence, made the advocacy demands very specific, and followed up with bureaucrats and politicians until the objective was met. Ultimately, the first gutka ban was declared by the state of Madhya Pradesh on 1st April 2012. Thereafter, state after state notified the ban. For some states who refused to implement bans, public interest litigations were filed and High Court judgments forced them to declare gutka ban. By the end 2012, 14 of India’s 29 states had notified the ban and in April 2013, the Supreme Court directed all states to comply.
The extent of enforcement of the ban varies a great deal across states, but there have been some common findings by studies. The first major impact assessment report came in 2014, from a study conducted by the Johns Hopkins University Bloomberg School of Public Health and the World Health Organization. Surveys were conducted with 1,001 current and former gutka users and 458 tobacco product retailers in seven states (Assam, Bihar, Gujarat, Karnataka, Madhya Pradesh, Maharashtra and Orissa) and Delhi. Interestingly, 90% of respondents desired that the government should ban the manufacturing, sale and distribution of other forms of smokeless tobacco.
According to the study, there was virtually no retail outlet where pre-packaged gutka was on display. Ninety two percent of respondents supported the ban and 99% agreed that bans are good for the health of India’s youth. Of the respondents who continue to use illegal pre-packaged gutka, half reported they consume less since the bans. 80% believed that ban will motivate them to quit, and nearly half of attempted to do so. Of the respondents that quit since the bans, a substantial proportion in each state (from 41- 88%) reported that they “quit using gutka because of the ban”. The study was a rapid survey in 7 states, rather than a nationally representative survey.
Post the bans, however, most gutka manufacturers started selling two packets: one the same mixture but without tobacco; and, a small packet containing just tobacco, often given free. Users were urged to combine and mix the ingredients of two packets to create their own gutka. This innovation adversely affected the purpose and consequent impact of the ban and was possible due to weak enforcement of the law. However, 11 states took the remedial step to ban the sale of processed and packaged smokeless tobacco and flavored areca nut products.
A concern for public health policy makers and researchers was to determine if gutka chewers switched to smoking following the ban. Studies have consistently shown that there is almost no switch over to smoking. In fact, the whole campaign for gutka ban, aided by other tobacco control measures, seems to have impacted sales of all forms of tobacco. According to the Index of Industrial Production (IIP) data, output of tobacco, declined by 12.1% in March 2015 from a year ago.
The Euromonitor report on Smokeless Tobacco in India published in December 2014, revealed that up to 2010, volume sales as well as value sales of smokeless tobacco were increasing, was more or less stagnant in 2011 and by 2013, there was 84% decline in volume sales and 82% decline in value sales compared to the peak in 2010. Further, compared to 2012-13 figures Euromonitor predicted the decline in sale volume to be 85% and value to be 80%. Euromonitor clearly attributed this decline to gutka ban. Also, for the first time in the history of cigarette industry in India, volume sales have started declining.
These findings assume even greater importance when looked along with economic impact of tobacco use in India. According to report by MOHFW, health care losses due to treatment of tobacco-related illnesses were US$16.5 billion [Rs.1.04 trillion] in 2011. In comparison, in 2013-14, the Government’s earnings from tobacco taxes were US$2.83 billion [Rs.17,800 crores].
The findings here reaffirm the fact that investment into tobacco control policies represent a win-win situation for government, public health and the people and families of tobacco users or potential users. India’s experience shows that prohibition may be a credible tobacco control option in certain situations. In this case, the product was primarily manufactured in one country and cross border supplies could be reasonably controlled. In addition, the ban appears to have led to denormalisation of gutka. By declaring the product as illegal, the consequential massive earned media in the country convinced the public (90%+ approval ratings) that banning this product was good for public‘s health. This also countered the massive brand equity makers had built up around their gutka brands – the “stench” of a banned product led to erosion of the brand values (although possibly for this reason, makers have increased surrogate ad budgets – to revive their brands). The ban has effectively disrupted supply, especially reducing access to children.