Tobacco control advocates in India who have been active for more than two decades, together with a few ageing colleagues from the west, will remember the sweat and toil of trying to kick-start a self-sustaining and viable Indian tobacco control movement in the 1980s. The switch-back ride from optimism to disappointment, the new dawns and false starts, the workshop sessions shouted against noisy air conditioners, the sheer hard work, heat and dust of it all – in those days it seemed an impossible dream to reach the present situation. However, there is now a real will at federal government level, led by one of the world’s most outstanding health ministers, and many skilled, experienced and well informed health advocates constantly monitoring developments and lobbying for progress. India is a very different place now, a fact recognised by its successful bid to host the next world conference on tobacco and health.

Among the more visible evidence of change recently was an incident on the front line of the ongoing battle for comprehensive tobacco control legislation. Unlike most big tobacco consuming nations, India’s biggest health problem comes from the much greater amounts of tobacco consumed orally, in several forms, than is smoked in cigarettes. In addition, the ubiquitous bidis, the cheap, hand-rolled, traditional smoking products, cause massive damage to the health of the poorest sections of this vast country. In the past, cigarette manufacturers have not been averse to implying in their marketing communications that Indians who suck or chew tobacco, as well as bid-smokers, should trade up to the higher “quality” offered by cigarettes. In the old days, advertisements portrayed cigarette smokers typically as successful, better paid and more educated members of the burgeoning new middle-class, the millions of consumers being swept along in the country’s incoming tide of economic prosperity.

Thus, while other countries have to contend mainly with resistance to public health progress from the big cigarette companies, India faces additional foes – the formidable smokeless tobacco and bidi industries, both, especially bidi manufacturers, armed with the political bludgeon of far higher employment numbers than the ever more capital intensive cigarette manufacturers.

Predictably, therefore, the union (federal) health ministry’s efforts to implement new tobacco product labelling rules are being constantly countered by a wide range of tobacco industry opposition. The arguments may be exactly the same ones familiar the world over – that it will take at least 6 months to import new printing cylinders and fit them to their machines, for example – but the numbers bandied about on the employment argument are much larger than in most countries.

So it was that in March, the bidi industry stepped in with an aggressive advertising campaign demanding “justice”. In particular, it asked politicians to drop the proposed requirement of a skull and crossbones to be printed on all tobacco packaging, including bidi wrappers – in fact, a highly creative and neat solution to the problem of conveying the true risk of tobacco to illiterate users. It also demanded that tobacco control measures be “practical” (for which read ineffective) and protect employment in the industry; and that the two-thirds increase in excise duty on bidis proposed in the federal budget for 2007–8 be withdrawn. The ad played the employment case to the full, highlighting the huge numbers of tribal people employed growing the trees whose leaves are used as wrappers for bidis, as well as the large number who hand-roll them, mostly women (but without mention of children – bidi production is often a family affair).

India: when the bidi industry ran newspaper advertisements trying to persuade politicians to dilute proposed tobacco control legislation (above), health advocates responded.

At this point, ACT-India, one of the members of the Advocacy Forum on Tobacco Control (AFTC), a loose network of organisations working on tobacco control for the past half decade, realised it was time to fire back with a like for like ad of their own. In lightning time, they came up with a counter advertisement in the Hindustan Times, one of the leading newspapers in the capital, New Delhi, and in another well respected paper in Mumbai. Their ad, like that of the manufacturers, made prominent use of some large numbers, but in this case, they measured the horrific figures for mortality and morbidity caused by tobacco in India. Large bullet points told of 4.4 million new cases annually of tobacco induced heart disease, 3.9 million from lung disease, and 200 000 from cancer. Total tobacco-induced mortality was prominently announced in the stark headline, “Sadly, they speak of justice when tobacco kills 10 lac (1 million) Indians every year”.

India: this man in his 30s has been chewing paan masala since he was 11 years old. [photo: Gemma Vestal]

By happy coincidence, or kind editorial placement, the same page in the Delhi paper reported a speech by an international cancer expert, predicting that cancer cases would double by 2030. Best of all, there was also a picture of a skeleton holding a cigarette in its hand, something the near-empty coffers of the health advocates could not have run to even if they had thought of it; but years of effort to educate journalists, among other opinion formers, may be paying off at last. The outcome of the government’s struggle is awaited, but in the meantime, it is clear that when trying to do the right thing, it can draw on the support of a well coordinated tobacco control movement