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India: death of a simple health warning

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In recent years, health advocates in India have had something of a roller coaster ride. After years waiting for the thing to get going, at last they were up and away, only to feel that empty, falling feeling as they swooped down again, although still above their starting point. This is nowhere better illustrated than with tobacco pack health warnings.

Having at long last got a superb health minister and, having grown a tobacco control lobby worthy of its size and the massive task in hand, hopes were riding high that the federal government would press ahead with some truly world-leading warnings. Special factors had been taken into account, the most obvious being language. India, the second largest country in the world, still has large numbers of people who cannot read or write–40% is the commonly accepted figure. In addition, while Hindi is the national language, India must be the ultimate multi-lingual country: its constitution recognises 22 regional languages, but these also have dialects so, in total, there are more than 100 languages and 200 mother tongues. What sort of health warning could inform the maximum number of people about the unparalleled dangers of smoking?

One answer is to use a graphic image, but with so many who could not read the captions of a disease-specific image whose gory detail might not be recognisable, is there not a universally accepted danger sign that might warn the maximum proportion of Indians? As in so many countries, there is an answer: the skull and crossbones, not just familiar from the flags of cartoon pirate ships, but widely used on containers of poisonous chemicals and other dangerous products and on electrical installations. Together with graphic images of diseased organs, the government included the skull and crossbones in its wish list. But it was not to be.

In a lengthy period of debate, it emerged that the tobacco industry did not just oppose disease-related graphic warnings (though some more than others) but was particularly desperate to prevent the skull and crossbones from appearing. This may at first sight appear surprising, but the manufacturers of bidis, the leaf-wrapped, local product used by millions of lower income smokers, were especially desperate to prevent the government imposing a warning that was particularly effective at reaching their customers.

But how could tobacco interests counter such a simple, universally recognised symbol of poison and danger, especially when it was already part of the government's plans, which meant that an amendment would have to be debated in parliament? The debate generated much favourable comment and media coverage for the government's plans, which should have been quite sufficient for it to stick to its guns. However, a pernicious argument was then wheeled out by industry interests: the skull symbol would be offensive in a religious sense, especially to those people, such as Muslims, who bury their dead.

Public health researchers swung into action. A survey of more than a thousand people not only confirmed that the symbol was the most widely understood to mean danger, especially by less literate, rural people, but also that the religious argument was nonsense. More than nine out of ten Muslims shown the symbol said it would not hurt their religious sensibilities, with only 1.4% saying it would do so. Similar figures for Hindus and followers of other religions showed how baseless it was, but for reasons that may never be known, the industry prevailed and the amendment to remove the skull and crossbones warning was passed. But with proven and growing public and parliamentary support for more effective tobacco control, will the government not show greater political courage and let the roller coaster pick up speed again next time?

India: Mock-up of a health warning with the skull and crossbones, as originally proposed by the government.