Legislation to control tobacco use in developing countries has lagged behind the dramatic rise in tobacco consumption. India, the third largest grower of tobacco in the world, amassed 1.7 million disabilityadjusted life years (DALYs) in 1990 due to disease and injury attributable to tobacco use in a population where 65% of the men and 38% of the women consume tobacco. India's antitobacco legislation, first passed at the national level in 1975, was largely limited to health warnings and proved to be insufficient. In the last decade state legislation has increasingly been used but has lacked uniformity and the multipronged strategies necessary to control demand. A new piece of national legislation, proposed in 2001, represents an advance. It includes the following key demand reduction measures: outlawing smoking in public places; forbidding sale of tobacco to minors; requiring more prominent health warning labels; and banning advertising at sports and cultural events. Despite these measures, the new legislation will not be enough to control the demand for tobacco products in India. The Indian Government must also introduce policies to raise taxes, control smuggling, close advertising loopholes, and create adequate provisions for the enforcement of tobacco control laws.
The past decade has seen a significant paradigm shift in tobaccorelated policies that has led to a significant curtailing of the use of tobacco in many countries. However, nearly all of these advances have occurred in industrialized countries. Unfortunately developing countries' policies have lagged far behind (1), and tobacco consumption in these countries continues to rise (2, 3). The Indian Parliament recently introduced a multifaceted tobacco control bill (the Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Bill of 2001). This paper summarizes tobacco use and its consequences in India, examines the major legislative control measures that preceded this comprehensive legislation, and discusses additional measures required to successfully curb tobacco use in India.
History of tobacco use in India
The Portuguese introduced tobacco to India 400 years ago and established the tradition of tobacco trade in their colony of Goa. Two hundred years later the British introduced commercially produced cigarettes to India and established tobacco production in the country (4). Today, of the 1.1 billion people who smoke worldwide, 182 million (16.6%) live in India.
Tobacco consumption continues to grow in India at 23% per annum, and by 2020 it is predicted that it will account for 13% of all deaths in India.
Tobacco use in India is more varied than in most countries. Only 20% of total tobacco consumption is in the form of cigarettes . A common alternative to traditional cigarettes is the bidi, a handrolled, filterless tobacco cigarette. Tobacco is also used in the hookah ( a traditional water pipe), as pan masala or guthka (a chewing tobacco containing areca nut), as chutta (a clump of tobacco smoked with the lighted end inside the mouth), and mishri (a powdered tobacco rubbed on the gums as toothpaste) . Bidis account for the largest proportion of tobacco consumption in India, at about 40%.
In India an estimated 65% of all men and 33% of all women use some form of tobacco (6). While the prevalence of smoking among men and women differs substantially 35% of men and 3% of women both use smokeless tobacco products to approximately the same extent. Health consequences of tobacco consumption in India
In 1990 approximately 1.5% of total deaths in India were tobaccorelated, and the nation amassed over 1.7 million disabilityadjusted life years (DALYs) due to disease and injury attributable to tobacco use . Tobaccorelated cancers account for approximately half of all cancers among men and onefourth among women , and it is estimated that 8.3 million cases of coronary artery disease and chronic obstructive airway diseases are also attributable to tobacco each year . Treating these three tobaccorelated diseases cost approximately US$ 6.5 billion in 1999.
Smokeless tobacco is an important etiological factor in cancers of the mouth, lip, tongue, and pharynx. It is not surprising, therefore, that India has one of the highest rates of oral cancer in the world. These rates are steadily increasing and oral cancers are occurring more frequently among younger individuals . Annual oral cancer incidences in the Indian subcontinent have been estimated to be as high as 10 per 100 000 among males.
India's tobacco industry and market
India is the world's third largest tobaccogrowing country. In 1992 it produced 7% of the world's total unmanufactured tobacco and 14% of the world's total manufactured tobacco in the form of cigarettes and bidis .
The overall contribution of the tobacco industry to India's large agricultural sector it employs twothirds of the country's labour force is small. Approximately 3.5 million people are employed in tobacco cultivation in India, representing less than 0.5% of the agricultural labour force and 0.31% of the total labour force (12). In contrast, cigarette manufacturing is a mechanized production process and generates fewer jobs . However, manufacturing of tobacco products other than cigarettes (bidis and various forms of chewing and smokeless tobacco) largely takes place within the unorganized sector, providing employment for what is estimated to be millions of women and children who work at home .
Bidi manufacturing is the largest tobacco industry in India. In 1998, a total of 858 billion bidis were sold in India and sales are projected to reach 1031 billion by 2007.
Guthka and pan masala have become increasingly popular with young people. These mixes, containing areca nut, tobacco and flavoured additives, are sold in colourful small sachets for as low as half a rupee (ca US$ 0.01) . This rapidly growing cottage industry uses aggressive marketing and advertisements and has successfully secured a large market .
The cigarette market was worth an estimated 60 billion rupees (US$ 1.7 billion) in the late 1990s . While four Indian companies, Indian Tobacco Company (ITC), Godfrey Phillips Limited, Golden Tobacco, and National Tobacco, control the cigarette market, foreign multinationals hold stakes in three of them . Interestingly, these cigarette companies face significant competition from the unorganized bidi manufacturers which are largely protected from high taxes because of their status as smallscale industry.
Tobacco legislation in India
Effective tobacco control in other parts of the world has been achieved via multipronged strategies focusing on reducing the demand for tobacco products (1618). These strategies include the following: raising taxes; publishing and disseminating information about the adverse health effects of tobacco, including adding prominent health warning labels to products; imposing comprehensive bans on advertising and promotion; restricting smoking in workplaces and public places; and extending access to nicotine replacement alternatives and other cessation therapies .
These demand reduction strategies are typically accomplished through national legislation. In India, health legislation has been historically (and perhaps more practically) enacted at the state level. National legislation has been reserved for major issues requiring countrywide uniformity .
India has a short history of tobaccorelated legislation. The first national level bills were introduced not to curtail but to build a foundation for the tobacco industry and enable it to be competitive on the international market. Early attempts to enact tobacco control legislation were insufficient and only recently has there been significant impetus to come up with a multifaceted national control measure .
Protobacco legislation dates back to 1975 with the Tobacco Board Act, introduced to develop the tobacco industry . It facilitated the regulation of production and curing of tobacco, fixed minimum prices, and provided subsidies to tobacco growers; the objective was to develop the Indian tobacco market and make the industry export competitive . Similarly, the Tobacco Cess Act of 1975 was enacted to collect duty on tobacco for the development of the tobacco industry . Antitobacco advocates have criticized these Acts because they nurtured the tobacco industry through subsidies and loose export policies .
India's first national level antitobacco legislation was the singlefaceted Cigarettes Act of 1975, which mandated health warnings on cigarette packets and on cigarette advertisements . This Act prescribed all packages to carry the warning "Cigarette smoking is injurious to health" in the same language used in the branding on the package. The text was to be a minimum of 3 mm in height, irrespective of the dimensions of the surface on which it appeared or of the dimensions of the brand name . While this Act was a major step in tobacco control, it did not apply to noncigarette tobacco products. In February 2001, Indian Prime Minister Vajpayee's Union Cabinet introduced the Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Bill, a multifaceted antitobacco legislation to replace the Cigarettes Act of 1975 . Smoking in public places would be outlawed, the sale of tobacco to persons below 18 years of age would be prohibited, and tobacco packages would be required to have warnings the same size as that of the largest text in English or the local language. The proposed national Bill would prohibit tobacco companies from advertising and sponsoring sports and cultural events. Significantly, this Bill covers most tobacco products including not only cigarettes, but also cigars, bidis, cheroots, cigarette tobacco, pipe tobacco, hookah tobacco, chewing tobacco, pan masala, and guthka.
The consequences of violating the laws under the Bill are far more stringent than with the original 1975 Act. Defying the ban by smoking in public places such as streets, parks or government complexes will be fined up to 200 rupees (US$ 4). The same fine applies to vendors who sell tobacco to minors (under18yearolds). A secondtime offence will result in a fine of 100 000 rupees (US$ 2000) and imprisonment for up to 3 years .
Additional steps to curb demand
While this multifaceted bill is a big step for India in controlling tobacco use, its effectiveness depends on additional major measures. Essential measures to comprehensive tobacco control through demand reduction are the following: increased tax on all tobacco products; control of smuggling; closure of all advertising avenues; and creation of an infrastructure for enforcement of laws.
Taxation and smuggling
The tobacco industry in India is subject to a range of taxes imposed by the Federal and State Governments. According to an industry report, taxation on cigarettes accounts for around 55% of the average price of a packet of 20 cigarettes . The same report estimated that total excise duty generated by tobacco products was around US$ 1424 million in 1998; nearly 82% of that amount came from the sale of cigarettes (1. These data highlight the minimal contribution of the unorganized sector to excise revenue. Bidis, in particular, have a far lower excise tax than cigarettes . Furthermore, the Indian Government has limited ability to collect excise from the unorganized sector as it consists of scores of small producers.
Closing all advertising avenues
The proposed legislation may prove less effective at controlling tobacco advertisement since it has ignored some avenues of advertising and promotion. Two developing countries, Brazil and Thailand, have recently passed legislation that may be effective in this area.
Although Brazil has a big economic stake in tobacco , producing nearly as much unmanufactured tobacco as India and being the world's lead exporter of tobacco leaf, Brazil enacted measures in 2000 that outlaw all television, newspaper and magazine advertising of tobacco products, and event sponsorship by cigarette companies . The measures also require placement of graphic health warnings on cigarette packages. While the effects of Brazil's stringent advertising laws remain to be seen, the government has demonstrated the political will to control tobacco use despite the industry's important role in the national economy. Enforcement
The Thai experience also demonstrates that legislation is not enough. Although Thai laws are comprehensive, a major problem has been their enforcement. A 1996 Thai survey showed that 97% of 15yearolds were able to purchase cigarettes even though the law states that tobacco products are restricted to those over 18 years of age. It is also apparent that pointofsale advertising and brandstretching are also escaping Thai law due to the lack of enforcement . Building an enforcement infrastructure in India appears to be essential to the success of tobacco control and is a much needed government priority. Politics and economics of tobacco control
The tobacco lobby has argued that tobacco control measures can negatively impact the economy by creating massive employment loss. Simulation of the net impact of tobacco control on the Indian economy has not been adequately investigated, making it difficult to assess accurately the effect of control measures. However, studies from other countries demonstrate that employment losses occur in the sectors that are immediately associated with cigarette production; however, these losses can be outweighed by increases in employment in all other industries, particularly in labourintensive service industries . Jobs lost in retailing tobacco are likely to be replaced by jobs in retailing other products people can purchase with the money formerly spent on tobacco .
Future national comprehensive tobacco control legislation in India will require better understanding of the political economy. As the third largest agricultural producer of tobacco, slowing this industry down will not only require concerted political will and sustained commitment, but will also require careful investigation of the involved stakeholders.