Article Text

Conflicts of interest in tobacco control in India: an exploratory study
  1. Neethi V Rao1,
  2. Upendra Bhojani1,
  3. Preetha Shekar2,
  4. Santosh Daddi2
  1. 1Institute of Public Health, Bengaluru, Karnataka, India
  2. 2Padmashree School of Public Health, Bengaluru, Karnataka, India
  1. Correspondence to Dr Neethi V Rao, Institute of Public Health, 250 Masters Cottage, 2 C Main, 2nd C Cross, Girinagar I Phase, Bengaluru 560085, Karnataka, India; neethi{at}iphindia.org

Abstract

Introduction The government of India introduced a tobacco control legislation in 2003 and is a party to the WHO Framework Convention on Tobacco Control. However, anecdotal evidence points to the government's conflicting interests in tobacco control and trade. This research seeks to scope instances of conflicts of interests within the government and analyse how they operate in the Indian context.

Methods We conducted an exploratory study analysing documents over a 2-year period. We scanned media reports related to tobacco, documents of the tobacco industry, information retrieved from governments using the Right to Information Act and relevant websites. The data were analysed through thematic coding.

Results 100 instances of conflicts of interest were found and classified under six categories: public support for the tobacco industry by government institutions or individuals; stakeholding or ownership of tobacco companies by government functionaries; individuals holding positions both in tobacco companies and the government; formal partnerships between the tobacco industry and public agencies; conflicting policies; and incentives available for the tobacco industry. These instances occur at all three levels of government: the individual, institutional and policy levels.

Conclusions Conflicts of interest are rampant in India and operate in many different ways. These conflicts can lead to negative consequences for tobacco control with far-reaching effects. Varied strategies using legal, administrative and legislative tools need to be adopted to manage conflicts of interest.

  • Tobacco industry
  • Public policy
  • Low/Middle income country
  • Denormalization

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Introduction

Nearly one in three adults in India are tobacco users.1 Tobacco smoking was estimated to cause over 0.9 million adult deaths in the year 2010.2 Total mortality from tobacco use would be much higher as 20.6% of adults use only smokeless tobacco, the most common form of tobacco use in India.1

Internationally, the tobacco industry has had a long history of subverting tobacco control policy.3 ,4 The WHO Framework Convention on Tobacco Control (WHO FCTC) article 5.3, in its general obligations, clearly states that “parties in setting and implementing their public health policies with respect to tobacco control, shall act to protect these policies from commercial and vested interests of the tobacco industry,” and offers detailed guidelines for the member parties regarding measures to do so.5 India signed and fully ratified the WHO FCTC in 2004. However, to date, India lacks a policy framework in line with the WHO FCTC article 5.3.

Anecdotal evidence suggests that governments in India have conflicting interests: on the one hand adopting tobacco control measures while promoting the tobacco industry and trade on the other. Bhojani et al6 outlined several links between governments and the tobacco industry in India that could potentially undermine tobacco control. While anecdotes point towards the problematic nature of conflicts of interest (COI) in tobacco control, there has been no published empirical inquiry on this subject. We therefore conducted an exploratory study to scope the extent and the nature of COI within governments with regard to tobacco control in India.

Methods

We adapted an operational definition for COI in tobacco control based on constructs of ‘tobacco industry’ and ‘COI’ as defined in the WHO FCTC,7 and the WHO Roll Back Malaria Partnership,8 respectively. We defined COI as the existence of conflicts between the public duty of an organisation, public official or consultant towards tobacco control and any other interest, which could improperly influence the performance of fiduciary duties and responsibilities towards tobacco control, or result in breach of public trust. A conflict may exist even if no unethical or improper act results from it. These are situations that have the potential to undermine the impartiality and/or fulfilment of duties of the government towards tobacco control.

We broadly defined ‘tobacco industry’ to include all manufacturers, growers, suppliers, processors, distributors and retailers of tobacco and allied products. In India, smokeless tobacco is the dominant tobacco product followed by bidis (tobacco rolled in tendu leaf used for smoking) and cigarettes.1 The bidi industry is highly informal and limited information about it is available in the public domain.

In the absence of prior knowledge about definitive data sources to study COI in tobacco control, we chose to use five relevant information sources. In the following paragraphs, we briefly explain these sources and the data extraction process:

  1. News stories: We sourced all news stories related to tobacco that appeared in print and online media between April 2011 and March 2014 compiled by a media consulting firm. The firm retrieved these news stories from English and regional language publications from 12 cities across India using 19 search terms as part of an ongoing national-level tobacco control initiative (see online supplementary file 1 for details). We read 8109 stories thus retrieved, of which 168 stories were selected.

  2. Tobacco industry documents: We analysed websites and 34 documents of 14 Indian tobacco companies including all the companies listed on the national stock exchange and a few smokeless and bidi companies purposively selected based on the availability of their documents in the public domain (see online supplementary file 1). These documents included annual reports for the financial years 2011–2012 to 2013–2014 and links on company websites.

  3. Asset declarations by parliamentarians: The Association for Democratic Reforms, on their website,9 compiles the self-declarations of assets that election contenders in India are mandated to make public. We analysed 15 867 declarations filed by the contenders of the last two rounds of general elections to the lower house of the Indian parliament (8198 for the year 2009, and 7669 for the year 2014). We analysed asset declarations by the 138 members elected to the upper house of the Indian parliament during the same time period.

  4. Information received through use of the Right to Information Act, 2005 (RTIA):10 We filed 29 applications with relevant government departments at the state and national levels as well as government-run companies (see online supplementary file 1). These applications sought to understand any partnerships and/or exchanges (financial or otherwise) between government agencies and the tobacco industry for the period between April 2011 and March 2014.

  5. Questions in the parliament: We searched questions raised in the lower house of parliament using the search term ‘tobacco’ for the period between April 2011 and March 2014, as made available on the website of the Indian Parliament. We retrieved 79 responses for analysis.

We conducted targeted Google searches to supplement the data retrieved from the aforementioned sources. The relevant documents were organised and coded using QSR NVivo software. We did not use any specific theoretical framework but the operational definition for COI to arrive at the ways COI occurred from the sourced data. The first author did the initial data coding. The codes and classifications were then discussed among the research team. As per our operational definition, we only included individuals who were considered to have a fiduciary duty towards tobacco control by having a role in tobacco control policy making/implementation. However, irrespective of their duties, we included cabinet ministers as their actions reflect the government's vision/intentions. We included all government organisations and policies across sectors.

Results

We found 100 instances of COI through varied sources of information. The complete list is provided in online supplementary file 2. These instances characterised six major ways in which COI happen in tobacco control in India: political and government leaders publicly supporting the tobacco industry; Individuals assuming prominent positions simultaneously within the tobacco industry and public sector bodies; governments investing in the tobacco industry; formal/informal partnerships between governments and the tobacco industry; conflicting policies within governments; and governments providing privileges to the tobacco industry. Table 1 provides a few illustrative examples of each type of COI.

Table 1

Categories of conflicts of interests (COI) in tobacco control in government in India with illustrative examples

Another way to look at these COI instances is according to the levels of government at which they occur: (1) individuals; (2) organisations/institutions/departments and (3) policies. Looking at the instances of COI through such a perspective facilitates thinking about potential interventions and ‘entry points’ to prevent/manage COI within governments.

Note that these ‘categories’ are not mutually exclusive ways in which COI happen in tobacco control. Policy conflicts at the macro-level, in particular, trigger pathways for COI at the meso-level and micro-level. For example, the members of the Tobacco Board of India, a government agency, include parliament members, government officials and tobacco traders. The statutory status of the tobacco board mandates frequent interaction between government representatives and the tobacco industry, specifically to promote tobacco. Information obtained under RTIA revealed that on average more than one meeting per week happened between officials of the ministry of commerce and industry and a tobacco industry representative between 2011 and 2014. This is in contradiction to the government's obligations under FCTC Article 5.3, which specifically requires minimising interactions between government and the tobacco industry and making them transparent.

Apart from the results described here, some instances of ‘potential’ COI were identified but, due to a lack of clarity of their exact mechanics, we erred on the side of caution to not list them as COI. We also excluded some known examples (eg, political parties receiving financial donations) since those instances preceded the time frame considered in our study. We also excluded instances of COI that were outside the purview of our definition of COI within governments. For example, members of parliament who did not have a fiduciary role in tobacco control were not included. Similarly, tobacco industry representatives were found to wield a lot of clout in industry associations like the Confederation of Indian Industry and the Federation of Indian Chambers of Commerce and Industry, who have influential voices in policy making.11 However, since these agencies did not share the government's tobacco control commitments, they were not included in our analysis.

Discussion

This paper offers a synthesis of evidence demonstrating the government's continued involvement with the tobacco industry in India despite its stated tobacco control commitments. Since our study relied on publicly available information, it was not always possible to derive causative links between COI and their negative effects on tobacco control policies. However, there are many examples in India signifying the negative impacts of COI in governments.

The most direct form of COI constituted stakeholding by elected leaders and government officers in the tobacco industry while they were part of the tobacco control policy-making processes. Such COI were directly implicated in the delay and dilution of pictorial health warnings in India when the group of ministers and the parliamentary committee on subordinate legislation deciding on tobacco pack warnings had members with stakes in the tobacco industry.11–14

When government representatives participate and become dignitaries at events organised by tobacco companies or when government agencies partner with tobacco companies for public events, they lend legitimacy to the tobacco industry. There are several examples of such happenings in India. Such events help the tobacco industry in brand building and accessing high-placed policymakers. COI are problematic even when no demonstrable wrongdoing results, since they create public mistrust and the potential for improper action. The High Court of Karnataka observed that the appearance of logos of government agencies alongside those of tobacco companies creates a public impression that the government supports the industry and amounts to indirect promotion of tobacco by the government.15

Historical industry communications reveal how governments have facilitated avenues for diversification and tax benefits for the tobacco industry driven by COI.16 Large tobacco companies have been able to diversify into sectors such as fast-moving consumer goods and hospitality that can be used to leverage their tobacco operations. Internationally, public health efforts have successfully pressurised tobacco companies such as RJ Reynolds and Philip Morris to separate their tobacco business from other sectors.17 ,18 Large institutional investors including reputed universities have in the past divested their tobacco related investments.19 So far, no policy measures have been taken in India to induce isolation of the tobacco industry in India.

There have been some developments in India to introduce policies that prevent/manage COI in tobacco control. However, such efforts are yet to materialise in concrete policy frameworks.

Efforts by public health activists in India led to the High Court of Karnataka directing the government, in the year 2010, to formulate a code of conduct for public officials/agencies to prevent tobacco industry interference in tobacco control.15 In its annual report to the WHO FCTC for the year 2012, the Indian government reported the preparation of such a code, which is yet to be notified and operationalised.20 In India, civil servants and parliamentarians are subject to service rules and codes of conduct. However, these rules do not address the variety of COI identified in our study and are poorly enforced. A broader legislative proposal to prevent and manage COI in all government sectors was introduced as a private member's bill in the parliament but was not discussed and not adopted.21 More recently, amendments have been proposed to the national tobacco control legislation to include provisions in line with the FCTC article 5.3. However, these amendments are yet to be discussed and decided on by the parliament. We believe that considering the multisectoral nature of public health in general and of tobacco control in particular, there is a need to mandate the health impact assessment of any major programmes or policy proposals across various sectors. That will help identify potential conflicts of those policies with public health (and tobacco control) goals.22

Apart from legislation, there may be several ways in which existing policies could be amended or expanded to address COI issues in tobacco control. These measures could be seen as tangible actions incrementally leading to an overall framework for prevention and management of COI. This needs to be accompanied by persistent sensitisation of public officials, and civil society involvement to denormalise the tobacco industry in public policy.

What this paper adds

  • As a party to the WHO Framework Convention on Tobacco Control (FCTC), India is obliged to implement policies to protect tobacco control measures from the vested interests of the tobacco industry.

  • Anecdotal evidence has pointed to conflicts of interest for the government of India leading to delays and/or dilutions in tobacco control measures.

  • To date, no empirical inquiry has been published around the WHO FCTC article 5.3 related issues in India, making a case for appropriate policy frameworks.

  • This study maps the extent and nature of conflicts of interest in tobacco control in India within a period of 2 years.

  • Results presented extend the scope of conflicts of interest and suggest points of intervention to mitigate their negative impacts on public health.

Acknowledgments

The authors would like to thank the Campaign For Tobacco-Free Kids for financial support for this study (India-G-46) as well as facilitating researchers’ access to media compilations related to tobacco. They thank our colleagues for useful inputs and remarks at various stages of the study. They also thank the anonymous reviewers for their inputs in improving the manuscript.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors NVR and UB were involved in the design, planning, interpretation of findings, writing and revised the manuscript. NVR did the primary data collection and analysis and wrote the first draft of the manuscript. PS and SD assisted in data collection. All the authors read and approved the final version of the manuscript submitted to the journal.

  • Funding This work was supported by the Campaign For Tobacco-Free Kids grant number India-G-46.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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