Indian Society Against Smoking (ISAS) & CNS Tobacco Control Initiative

SUMMARY REPORT of Online Consultation on What more should India do to stop smokeless and smoking tobacco use?
The CNS Tobacco Control Initiative, Asha Parivar, and Indian Society Against Smoking (ISAS) facilitated a time-limited focused online consultation (16-31 July 2011) on Tambakoo Kills electronic discussion forum (eForum) and blog (http://NoTobacco.citizen-news.org). Senior tobacco control advocate Dr Mira Aghi's article made a strong case why India cannot neglect smokeless tobacco use while strengthening response to controlling smoking forms of tobacco. Dr Aghi’s article is available online at: http://www.citizennews.org/2011/07/ban-all-forms-of-tobacco-smokeless-and.html

Guiding question

was: ―What do you think are key measures India can take

to improve responses to control all forms of tobacco - smokeless and smoking both?”

KEY ISSUES
 Weak implementation of existing tobacco control laws both for smokefree and smoking forms of tobacco  Poor enforcement of ban on sale of all tobacco products near schools, and also to and/or by minors  Weak anti spitting/public hygiene laws which are also polluting the environment  Proliferation of hookah bars (where smoking is also rampant), which are very popular amongst students/minors is a cause of serious concern  Bidi smoking very popular in rural/poor population due to low costs and easy availability  Tobacco cessation programmes needed in small towns/rural areas where bidi smoking and chewing tobacco is rampant  Need for targeted interventions to control gutkha (chewing tobacco) use, especially at work/public places, and in children  Government needs to regulate (including contents) of non-tobacco pan masala/ non-tobacco flavoured supari/ candy cigarettes, which act as dangerous precursors to chewing tobacco especially in children and also cause serious health hazards due to spurious contents  Easy and widespread use of tooth cleaning powder which contains tobacco—like ‘gul dant manjan’  Lack of awareness about health hazards of chewing/smokeless tobacco like gutkha, khaini, zarda, mishri  Inadequate measures to encourage use of therapeutic chewables like anise (saunf), clove (laung) and cardamom (ilayachi) for those addicted to chewing tobacco

NARRATIVE SUMMARY
Stricter enforcement of the existing anti tobacco laws is required. We need a stronger political will and government commitment to ensure that smoking in public places is strictly prohibited and that no tobacco products are sold within the stipulated limits of educational premises. Law enforcers will have to ensure that no minor is able to sell and/or buy any tobacco product. Cigarette smoking has declined in public places, but bidi smoking is still very common in the rural/poor populace, especially as bidis are much cheaper (but equally harmful) than cigarettes. This needs priority measures at government/civil society level to tackle the menace. More de-addiction centres should be integrated in existing health facilities of small towns/villages where bidi smoking is playing havoc with public health. Consumption of chewing/smokeless tobacco is increasing at an alarming rate. It is easily available and is cheaply priced. This makes it a popular addiction amongst rich and poor, adults and children. Gutkha chewing is very rampant in poor and underprivileged children. Chewing tobacco is not only harmful for health (causing oral cancer and sub mucous fibrosis among other life-threatening diseases and disabilities); pan/gutkha spitting and littering of gutkha wrappers create environmental pollution/hygiene problems. Even health workers/ activists and social workers, and police personnel are addicted to chewing tobacco. It is unethical and should be taken as misconduct for healthcare workers, teachers and other school employees to chew tobacco while on duty, as it sends out wrong messages to the public and to children and youth. We need stricter laws to control sale and consumption of all forms of chewing tobacco (gutkha, paan masala, khaini, etc). Meanwhile heads of educational, public/private sector institutions should forbid its use during duty hours. There is an urgent need to have targeted interventions to control consumption of gutkha, khaini, zarda, etc, especially amongst children. Some tooth cleaning powders (like gul dant manjan) contain tobacco are used widely, even by children. This is clearly a product that hardly gets under the scanner of public health advocates or policy makers. Online discussion participants said that ‘as they come under the category of tooth pastes locally produced products sometimes do not carry health warnings, and can be bought by anyone from grocery stores.’ This is a serious issue and demands immediate government intervention. Hookah bars/parlours are proliferating even in small towns, and are the latest craze amongst youngsters (chiefly students) who are getting hooked on to them. Very often, these places double up as dens of smoking, in direct contravention of the anti smoking law. There is no law against them, so the administration expresses its inability to take action (In Lucknow, the District Magistrate told Hindustan Times that it is parents’ responsibility to control their students not to use hookah). But they should at least be inaccessible to minors. Unless the government regulates production and sale of dangerous precursors to chewing tobacco-- like sweety supari, "pan masala without tobacco" products and candy cigarettes - it will be very difficult to control smokeless tobacco. Youngsters start by chewing them and then graduate to chewing tobacco. Catch them early - and help them stay away by informing them how dangerous precursor products can be. Encourage use of therapeutic chewables like anise (saunf), clove (laung) and cardamom (ilayachi) for those addicted to

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chewing tobacco. Moreover non-tobacco containing chewing pre-cursor products are made of spurious contents that cause serious health hazards and thus warrant stricter measures in interest of public health and social justice. Our policies and social behaviour need to be ethical and in the interest of public health to counteract the tobacco industry’s tactics of selling lethal products to unsuspecting customers. Some pertinent questions raised by the respondents were:-(i) How are children able to sell and buy Gutkha? (ii) Are we informing children and young enough about dangers of chewing tobacco like Gutkha? (iii) Are we having sensitive programmes to help people who chew tobacco? Awareness Programmes reaching out to children and/or general public need more attention. Government, parents, teachers will have to work in close collaboration to prevent youngsters from succumbing to the charms of the lethal poison called tobacco.

RECOMMENDATIONS
 More resources should be earmarked for advocacy initiatives to sensitize politicians, government officials and seek inter-ministerial collaboration to streamline and harmonize control of all forms of tobacco use with other health and development government programmes  Law enforcers are not strictly implementing existing tobacco control laws. Unless we increase monitoring and evaluation of tobacco control laws at all levels, and enforce existing laws optimally, not much will be achieved in terms of desirable public health and social justice outcomes. Existing tobacco control laws must be stringently implemented at all levels.  Laws to control all forms of tobacco use among children and young people must be enforced strictly without delay. Government notifications and other legal requirements should be completed without any further delay. It is important to reduce number of children and young people who initiate any form of tobacco use in all settings (urban, rural)  No form of tobacco must be sold within 100 yards of any educational institution – this law must be implemented without delay  No form of tobacco must be sold by/to minor children/ young people. Law must be strictly enforced and training, monitoring and evaluation should be robust to ensure proper compliance  Since bidi smoking and chewing tobacco are major forms of tobacco consumptions in India, tobacco control measures specific for these two forms of tobacco use should be stronger, strictly implemented and closely monitored for optimal public health outcomes. For instance, stronger pictorial health warnings should be printed on bidi and chewing tobacco packs, taxes on bidi and chewing tobacco, cessation programmes sensitive to bidi and chewing tobacco, regulating content, manufacture and sale of bidi and chewing tobacco, ensuring the ban on their sale within 100 yards of 3|What more should India do to stop smokeless and smoking
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any educational institution is in place and teachers, healthcare providers, law enforcers and other adult professionals do not use these forms of tobacco while on duty must be ensured among other required measures.  Government-run and civil society’s Tobacco control programme must join hands with environment advocates in the government and civil society at large – to strengthen anti-spitting laws and pollution caused by gutkha or chewing tobacco sachets  Chewing tobacco in public places should account as cognizable offense as it sends out wrong and misleading messages for children and young people, and cause environmental pollution and health hazards to others due to spitting.  Stricter measures to ban/ regulate sale of tobacco containing tooth cleaning powder should be in place. Stronger pictorial warnings emphasizing tobacco as one of its contents ban on sale to or by minor, increasing taxes, and cessation programmes should be in place to control this form of tobacco use.  Strong measures to control hookah bars and parlours are needed. Bombay High Court order and other measures are not enough to control hookah parlours across the country. Clear policy directives and legal framework should be defined at the earliest to curb hookah use and restrict their access or availability to minors. The sale of Hookah in open market is another serious cause of concern. Sale of hookah should be strictly regulated and banned to/ by minors just in case of other tobacco forms.  Regulating content, manufacture, sale of non-tobacco forms of chewing pan-masala or sweet supari or candy cigarettes is important and policy and legal measures should be taken to control these pre-cursors to tobacco use and also because they cause serious health hazards on their own too
All comments are available online at: http://www.citizen-news.org/2011/07/online-consultation-what-more-should.html Shobha Shukla, Professor (Dr) Rama Kant, Rahul Kumar Dwivedi, Bobby Ramakant Indian Society Against Smoking (ISAS), Asha Parivar and CNS Tobacco Control Initiative
C-2211, C-block crossing, Indira Nagar, Lucknow-226016. India M: +91-98390-73355 | F: +91-522-2358230 | E: bobby@citizen-news.org | W: NoTobacco.citizen-news.org For more information, please contact:

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