Cancer, who cares!

Images of a scorpion and lungs X-ray havent quite succeeded in keeping people away from cigarettes or chewing tobacco (gutka). Some interpret the scorpions image as a new brand, zodiac symbol or a decorative add-on, a survey in Mumbai has found. The lungs X-ray image was construed as waterfall, butterfly and even the small intestine. These findings establish the health ministrys notification to tobacco companies to carry pictorial warnings showing the ill effects of tobacco stand ineffectual.

In the notification issued in May the health ministry had asked tobacco companies to reserve 40 per cent of packet space for pictorial warningsscorpion on gutka packets and a diseased lung and its X-ray image on cigarette packets. Our survey found that images occupied 5-10 per cent of a gutka packet space.All warnings were in English and no picture of a diseased lung could be found on any of the cigarette packets, said Prakash C Gupta, director of Healis-Sekhsaria Institute for Public Health. The institutes survey was aimed at tracking the notifications implementation.

The survey included 615 adults all over Mumbai. People could not relate the pictorial warnings to any health implications, said Lalit J Raute, the lead researcher. Crab, and not scorpion, is the symbol of cancer. The confusion is genuine, Raute added. People were also shown images of a diseased mouth and a weak child as a result of passive smoking, which the health ministry initially proposed in 2006, but did not include in the May notification. About 45 per cent of the respondents said the excluded images sent the message, loud and clear.

Images need to be stronger
Public health experts alleged the Indian government was not serious about regulating and monitoring the sale of tobacco products, served the interests of the tobacco lobby and indulged in delay tactics. In July 2006, the government issued a notification of the specific pictures companies need to print on the packets. A series of extended deadlines followed, and a diluted notification was passed this year (see box).

Gupta said packet warnings can communicate effectively and threatening images command attention. Canada, Brazil, Singapore and Mauritius have had success. Their images have helped smokers quit and prevent people from taking up the habit, said Geoffrey T Fong, principal investigator of International Tobacco Control Policy Evaluation Project, a collaboration of tobacco-control researchers. The least India could do is make images more effective, Fong said. He added since the tobacco industry was aware of how effective these pictorial warnings were it tried to prevent, weaken and delay their introduction.

There might be hope still. Effects of pictorial warnings are to be reviewed by the government each year. The Mumbai survey report is with the health ministry. The first review is slated for early 2010.

With inputs from Nidhi Jamwal

India signed the WHO Framework Convention on Tobacco Control on September 10, 2003. It was ratified on February 5, 2004 (7).

July 2006 The government issues a notification of the specific pictures to be used by tobacco companies within seven months.

January 2007 Tobacco companies seek more preparation time. The government extends time to June 2007.

February-May 2007 The companies object to the use of a picture of a corpse which indicates that smoking can kill. A Group of Ministers (GoM) is formed to take a decision on the matter. The GoM asks the government for a further extension till July.

July 2007 The GoM decides to use the symbol for death-a skull and crossbones - as the picture, supported by the health minister Anbumani Ramdoss (who got an international award from WHO for his tobacco control activities in 2007).

August 2007 Parliament amends the bill making the use of the skull and crossbones picture optional, not mandatory. The court sets a deadline of December 1, 2007 for pictorial warnings to be implemented.

September 2007 The GoM withdraws the pictures of the skull and crossbones and the corpse, citing cultural and religious reasons.

December 2007 The court allows the government another extension till March 17, 2008.

February 2008 the GoM proposes that cigarette and beedi packs are to carry a photograph of an x-ray plate of the chest of a man affected by cancer (though understanding the significance of these pictures will require the help of a radiologist). Packets of chewing and smokeless tobacco products will carry the image of a scorpion, depicting cancer (though usually the crab symbolises cancer).

March 10, 2008 The ministry of health issues guidelines and notifications. The date for implementation of pictorial warnings is shifted to June 24, 2008. The picture must occupy 40% of the space on the packet (instead of the earlier notified 50%) and the warning should be changed every 12 months (9). The messages "smoking kills" and "tobacco kills" is to be printed on beedi, cigarette and smokeless tobacco products in English and regional languages.

The date was later extended to November 30, 2008, a deadline announced in national and regional newspapers in a full page advertisement. But in the last week of November the health minister extended the deadline to May 31, 2009.

Source http//www.issuesinmedicalethics.org/172co105.html