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RF_PH_9_SUDHA

// PAN MASALA

A Thing to Chew Ou
Manufacturers protest an imminent ban on chewing tobacco
B I- a’ government committee has its way,
I your favourite pan masala pouch could

■ soon disappear from your neighbour­
hood pan shop. It has recommended a
blanket ban on the manufacture, distribu­
tion, stocking and sale of all forms of che­
wing tobacco including pan masala, gutka
and plain and zafrani zarda.
The proposal was mooted by the expert
committee appointed by the UF govern­
ment, in its meeting of September
1997. Last month, it was deci­
ded, in principle, to ban these
products on health grounds.

300 companies and a its 1,200 crore turn­
over in the organised sector, says the gov­
ernment is acting in haste and under the
influence of mnc cigarette companies who
have been the direct sufferers of the pan
masala and gutka revolution in India. They
claim the cigarette industry has lost 25 to 30
per cent of their market since the beginning
of organised chewing
tobacco manufacture
in India 12 to 15 years
ago. "It's funny that

on Food Standards under the
Directorate General of Health
Services (dghs) meets in New
Delhi on April 13, after
which a public ann­
ouncement will
be made.
The ban's
triggered by
the
govern­
ment accumulat­
ing substantial evi­
dence that non-smo­
king tobacco causes
cancer of oral cavities,
pharynx and oesophagus
and also leads to coronary art­
ery diseases. The committee also
says it has data to prove that con'.
|^h>tion of chewing tobacco has
mffeased the incidence of oral cancer
in the country. According to official sta­
tistics, consumption has increased tremen­
dously over the last decade or so. The indus­
try has grown six-fold in five years to reach
around Rs 1,200 crore in turnover in 1997.
Among the studies referred to by the com­
mittee is one by the National Institute of
Nutrition, Hyderabad, which states that
pan masala with chewing tobacco, if consu­
med for five to seven years, led to oral fibro­
sis. Another study by the Regional Cancer
Centre, Thiruvananthapuram, in collabora­
tion with Johns Hopkins University of the
US, showed mutagenic activities—which
could lead to genetic deformities—amongst
users of pan masala, with or without toba­
cco. Yet another study by Chittaranjan
National Cancer Institute, Calcutta, revea­
led that 31 per cent of malignant cancer
cases were attributable to tobacco.
The prospect of this ban has left manufac­
turers of flavoured chewing tobacco fum­
ing. The domestic industry, with close to

Manufacturers find it funny
that pan masala, which has
20 per cent tobacco
content, is being banned
and not cigarettes which
have 100 per cent tobacco.
a cigarette, which has 100 per cent tobacco
content, is allowed to survive and pan masala and gutka, with 20 per cent tobacco, is
being banned," says Shree Gopalji Gupta,
MD, Gopal Industries of Gopal zarda. Says
M.M. Kothari, proprietor, Kothari Products,
makers of the popular Pan Parag pan masala
and gutka: "Cigarettes have been proven to

0 U T L 0 0 K ■

54

photo copy 1b bslna supplied

April 20,1998

be harmful. When doctors and researchers
in the US and Europe are asking people to
switch to chewing tobacco, in India, the
government is going the other way round."
Manufacturers argue that studies show
chewing tobacco is 98 per cent safer than
cigarette smoking. A study by the Central
Tobacco Research Institute, a government
agency, said "chewing of tobacco or its pre­
sence in gutka and pan masala is far less
harmful, if at all, in comparison to direct
smoking of tobacco, cigarettes and cigars."
The manufacturers also point out that the
committee in its report has admitted that
epidemiological studies linking oral cancer
to the use of pan masala and other forms of
chewing tobacco, were unavailable and the
government had based its report on unsub­
stantiated theories. "The government has
no concrete evidence to prove this sector
is directly responsible for
the incidence of oral
cancer. Its decision is

arbitrary,"
says
Ashok Agarwal of
Dharampal
Satyapal
Group, makers of Rajnigandha
pan masala and Tulsi zarda.
But dghs officials say that since
pan masala in India is of recent ori­
gin and oral cancer has a long incuba­
tion period of 15 to 20 years, any epi­
demiological study now would be useless.
Their theory: "Sufficient information is ava­
ilable on the carcinogenicity or cancerous
nature of two mixtures similar in composi­
tion with pan masala containing tobacco—
Mainpuri tobacco and mawa, a tobacco
mix. If these can have a harmful effect on
human beings...pan masala containing tob­
acco would have the same harmful effects."
The other aspect is that the industry emp­
loys over 50 million people in its manufac­
ture and raw material supply and many
more in its distribution networks. That
could be too large a number for a bare-majority Union government to offend. If it fol­
lows the committee's recommendations,
there could be serious political repercus­
sions. The question now is of priorities. ■
Arindam Mukherjee

BUSINESS STAISoARD
1

Ar-cui-raj

T)

J 2 SEP 1W

Prodtacti®m=linked
excise levy for pan
masala units soon
Our Economic Bureau
NEW DELHI

JD7S
g_S

,

fter mini-steel rolling mills, the revenue department is propos­
ing to target pan masala manufacturers to check excise eva­
sion by bringing them under the purview of production linked
method of excise assessment.
Targeting sectors where units are suspected to be evading
excise duty payment, through suppression of their production by
under invoicing, is part of the revenue department’s game plan to
mop up additional revenue for the current financial year.
Production linked assessment of excise is based on the
premise that the excise paid by the manufacturer at the gate
should broadly match the installed capacity of the unit multiplied
by the value of the product
If the company has either under invoiced or suppressed pro­
duction, the revenue department believes that it would be reflect­
ed when excise inspectors resort to this rough calculation.
The pan masala is an unorganised industry and only a few reli­
able estimates are available about its size, production or turnover.
Even Pan Parag, the best known pan masala brand in not listed.
However, the pan masala business is roughly estimated to be a
Rs 500 crore industry, localised to the Uttar Pradesh belt, with a
large number of units operating in this sector estimated to be
evading tax payments.
Mini-steel mill and ingot manufacturing units were the first sec­
tor to be brought under the purview of production linked mode of
value assessment of excise duty payment
The industry is also localised and is concentrated around the
Delhi belt Here too, the revenue department suspects that the
manufacturers have been suppressing production by under invoic­
ing to evade excise duty payment.
The revenue department is looking at various alternatives to
raise duty collections primarily on account of the across the board
rate cuts effected by the 1997-98 budget, combined with an indus­
trial deceleration which is not expected to clear- before the second
quarter of the current financial year.
“We are now looking microscopically at excise evasion,” rev­
enue department sources said.
The MRP is the other mode of assessment being implemented
by the revenue department to check excise evasion.
The revenue department has notified a number of- sectors,
including cosmetics and toiletries, footwear, aerated “water and
television manufacture under MRP.
w
>

A

'

m 1

'Of li-f&Lt

I

11

C 3 MAY

Should gutka be banned? Yes, says a majority
Chewing tobacco and pan masala have been linked with OSF, a mouth disease that could lead to oral cancer. Till recently the condition was restricted to the elderly. Today,
eight out of 10 new cases involve people under 35, many of them still teenagers. An expert committee has called for a ban; the government is reportedly working on
a notification. Clearly, the dangers cannot be ignored.

Beginning a series of surveys on issues of compelling national interest, the Sunday Times initiated a wide-ranging, scientific opinion poll to gauge public feelings on whether
the ban is necessary, fair or even feasible. Adding the full health picture to the findings, we present a comprehensive Special Report on a serious matter to chew on
By K. Balakrishnan and
G. V. L Narasimha Rao
HE consumption of pan
masala and gutka (flavoured
mixtures of supari. lime,
chewing tobacco and spices) has
increased phenomenally in the

T
I

I

Between pan masala and
bidi/ cigarette, which
do you consider
more harmful ?

evidence that these products are
highly carcinogenic, and are
responsible for the increasing inci­
dence of oral submucous fibrosis
(OSF) and oral cancer.
Pan masala by itself (without
chewing tobacco) has been shown
to have 'high mutageneity', and

e oth

s5%/^

Pan
Cigarette/
masala/
bidi
nirtka
16%
’7*
00

Are you tn favour of similar
ban on cigarette I bldi?
8

Treat them
the same
way

Neither
6%

Don't
Know
6%

J! "ot a ban'
T°u in,fav0“r °f
discouraging consumption o pan
m itkg through high taxes
on advertising ?

YES
NO
CANT SAY

So much so that an expert com­
mittee appointed by the central
government (headed by Dr S P
Agarwal, Director General of
Health Services) has recommend­
ed a comprehensive ban on the
manufacture and sale of these
products and. reportedly, the gov­
ernment has readied a notification.
The imminence of a ban has had
manufacturers of pan masala and
gutka crying foul.They cite the dis­
tress that will be caused to the mil­
lions of farmers and workers
dependent on this industry for
their livelihood and they also see
the hand of the powerful MNCdominated cigarette industry
behind this move since the growth
of the “smokeless’’ chewing tobac­
co products has cut into the mar­
ketshare of cigarettes.
What do the consumers and the
public at large feel about this

TIMES
ADITYA BIRLA GROUP

OPINION POLL

The Times Adrtya Blria Group Opinion PoH was ducted by Development & Research Services (DRS)
among a sample of 2062 aoufis n e gn metropottan afes on April 25 and 26.

TQI Gratz c SWJpn
country over the last decade or so
— particularly after these prod­
ucts were made available in small
5ml pouches. And. concomitantly.
there has been growing concern
over the accumulating scientific

gutka (pan masala with tobacco)
even more so. And clinical studies
suggest that use of these products
leads more readily to OSF and oral
cancer than the traditional betel
quid with tobacco.

issue? An opinion poll conducted
for The Times of India in eight
metropolitan cities across the
country brings up some very inter-

esting results.
The survey shows that 36 per
cent of the respondents (48 per
cent of the men and 18 per cent of
the women) have at some time

consumed pan masala or gutka.
More significantly, in 46 per cent
of the households someone is a
regular consumer of these prod­
ucts. This proportion, of captive

consumer households, is highest in per cent of those polled would
Ahmedabad (at 85 per cent), is 65 favour discouraging consumption
per cent in Patna, 62 per cent in of pan masala/gutka through
Lucknow and is the lowest in mandating prominent statutory
Delhi where it is 31 per cent.
The poll clearly brings out the warnings, ban on advertising and
high level of awareness and con­ heavy taxes — just as in the case
cern among the metro population of cigarettes.
of the health hazard posed by
these products. A large majority
Help them shift to
(69 per cent) of the respondents
favour a complete ban on them.
other occupations
The sentiment favouring a ban
Even though millions of farmers
is highest in Bangalore (86 per
and workers might be affected.
cent) where the consumption
most favour a ban...
level is relatively low but. signifi­
cantly, even in high-consumption
cities a large majority are in
favour of a ban: 82 per cent in
Lucknow. 78 per cent in Patna
and 69 per cent in Ahmedabad. In
Calcutta, only 51 per cent favour
a ban while 36 per cent are
against it.
The adverse impact a ban is
likely to have on the livelihood of
lakhs of people (tobacco and arecanut farmers, workers in manu­
phased ban
facturing units, distributors and
panwalas) was brought to the
..but they are in favour of
attention of the respondents.
incentives
to
affected
groups to
Despite this, 52 per cent of the
shift occupations:
respondents are firm in their
opinion that an immediate ban is
49%
favour
incentives
to
desirable, while 19 per cent feel
manufactivers to shift to
the ban can be phased out over a
other businesses;
j
period of two to three years to
enable farmers to switch to other
66% favour incentives to
crops and for manufacturers and
farmers to sfaft to
workers to shift to other occupa­
other crops; and
tions. There is a great measure of
support for incentive schemes for
72% favour incentives to
farmers, manufacturers and
workers to shift jobs.
workers to enable them to switch
to other crops and occupations
smoothly.
TOt Graprx. seexn
In case a ban is not imposed. 55

Are pan masala and gutka
more harmful than cigarettes and
bidis. and is a.differential treat­
ment between them justified? A
clear majority feel they are equal­
ly harmful and that a ban. if
imposed, should extend to
cigarettes and bidis too.
A significant finding of the
study: Women are much stronger
votaries of a ban on pan
masala/gutk#
along
with
cigarettes and bidis — about 75
per cent of the women favour a
comprehensive ban compared to
55 per cent of the men.
The survey was carried out for
The Times of India by
Development
&
Research
Services, the Delhi-based public
opinion polling agency, in the
eight metropolitan cities of Delhi.
.Mumbai, Calcutta, Chennai.
Bangalore.
Ahmedabad.
Lucknow and Patna. In each city,
200 to 300 adult respondents
were interviewed following a
stratified random sampling pro­
cedure. In all. 2,062 respondents
were interviewed in households
with the help of a structured
questionnaire on April 25 and 26.
The findings are subject to an
error margin of plus or minus 3
per cent.

iThis is thefirst ofa series of opin­
ion polls that have been planned
on important national issues. The
opinions expressed in this survey^
are entirely those of the respon-'X
dents in metro cities who were'T
carefully selected according to a ’
scientific sampling procedure.*
They are not to be attributed to'
this newspaper or to the sponsor) '

THEY,,.... ... MDIA

.r140C7

yiaie asnea io
clarify stand ( ,,,
on ‘gutka ’ trade
'

By A Staff Reporter"^^

MUMBAI: The Mumbai Bidi Tambakhu Vyapari Sangh has demanded
that lite state government clarify its
position on the proposal to ban the
sale of gutka in Maharashtra.
Although state health minister
Daulatrao Aher has made several announcements about the proposed
ban, no legislation has been introduced so far. As a result, retail traders
were often harassed for selling the
item, the Sangh said.

i

I
t
I
:

"We do not oppose the ban. But
we have continued to sell gutka
because the state government’s posi­
tion is unclear. However, several
people have demanded money from
, I retail traders by threatening to report
J them for continuing to sell gutka,"
said Sangh president Sharad Rao. He
i said the state had banned only three
gutka brands so farbut the public be: —
lieved there was a blanket ban on
gutka.
The Sangh will hold a demonstra­
tion in the city on Thursday to press
i- its demand. A delegation will meet
deputy chief minister Gopinath
Munde. If their demands are not at­
tended to, around 20,000 retail tra­
ders in the city start boycotting Goa :
gutka, Mr Rao said. There are around i
35,000 gutka outlets in the city, he ;
said.

Mr Rao also demanded that gutka
manufacturers provide bills to the re­
tailers. He claimed that when adul­
terated gutka packets were detected,
the government lodged proceedings
against retailers. "Since they have no
bills to pin the blame on manufactur­
ers, the retailers are made scape­
goats,” said Mr Rao.
When asked how many cases had
been lodged against retailers so far,
Mr Rao said that only around eight
cases had been lodged so far and that
too by the weights and measures de­
partment.

Mr Rao also said that workers from
the Brihanmumbai Electric Supply
and Transport Undertaking (BEST)
would hold a dharna on Wednesday ’
to press for Diwali bonus.

Contro’ of Tobacco-related Cancers and Other Diseases
International Symposium, 1990. Prakash C. Gupta, James E. Hamner, III
1992.

and P.t. Murti, eds. Oxford University Press, Bombay,

VitariusJ, Hecht
r compounds on
.rosopyrrolidinc and
rat target tissues.
•8.

Hecht SS. Effects
isothiocyanates on
md 4-(mcthylnitrotanone
oc-hydro‘lation in rat liver.
-43.
Stoner GD, el al.
’Initrosatnino)-1 -(3:cd DNA adduct
:ity in the lung of
:hyl isothiocyanate.
Iecht SS, Chung
hiocyanales on tuline formation and
pcciftc nitrosaminc
l-pyridyl)-l-butaCancer Res 1989;

Kmin SG, Hecht
tyl chain length on
:cd lung neoplasia
; isothiocyanates.
1-9.
A, Miller EC.
aironidation and
roxyarylamines in
r carcinogenesis.
annenbaum SR,

ducts of 4-aminosmokers. Cancer
. Formation of
tatment of F344
ic nitrosamines
>yridyl)-l-butaae. Cancer Res

Carcinogenic potential of some Indian tobacco
products
SUMATI V. BHIDE
Cancer Research Institute, Tata Memorial Centre, Bombay, India

Although there is epidemiological evidence to link tobacco use with oral cancer in India, the
carcinogenic potential of tobacco products has not yet been established in long-term bioassays. In
a study conducted in animal systems with tobacco products commonly used in India, we conclude
that (i) certain tobacco products used in India arc carcinogenic to animal systems; (it; the carci­
nogenicity is enhanced by a commonly used herbicide ’nd by chillie extract; (iii) betel quid con­
taining tobacco extract is less harmful than an extract of tobacco alone; and (iv) bidi smoke con­
densate is also carcinogenic. Il is suggested that various modulatory factors mayj^e involved in
oral < arcinogcncsis, and the identification of such factors constitutes an important means of reduc­
ing die risk from tobacco.

INTRODUCTION
Tobacco habits arc prevalent in all sections of
Indian society, and most consumers begin use
at an early age and continue for several dec­
ades. 'flic dynamics of tobacco use in the pop­
ulation is described in an earlier paper (sec
Bhorslc id al., this volume). Tobacco habits in

Indir include smoking of cigarettes, bidis, chutlas, c'silum and hookli. Tobacco is also chewed,
gene 'ally with slaked lime or in a betel quid. In
rural areas, tobacco is also used as a toothpaste
in the form of gudhaku and mishri. The latter is
a py -olysed product used initially for cleaning

teeth but which becomes a habit, especially
amotg v.omen in Maharashtra (1). Several

tobacco-containing toothpastes (creamy snull)
have become available commercially and are
becoming increasingly popular. Tobacco is
also used or inhalation as snuff by a small

such tobacco products has not yet been estab­
lished in long-term bioassays. We report here

on the carcinogenic potent1".! of some Indian
tobacco products in mice, rats and hamsters.

MATERIAL AND METHODS
Experimental animals: Ei8ui-week-old male
Swiss mice, 8-week-old male Wistar rats and

8-week-old, male Syrian golden hamsters were
treated with various extracts, as described
below. Animals were maintained at 20 ± 1°C
and fed standard laboratory diet (4). They
were treated with the preparations described
below.

Preparation of products and extracts
Tobacco extract: Pandharpuri brand of chew­
ing tobacco (Nicotiana rustica) was purchased

from a local market and an ethanol extract was
prepared by the method of Shah et al. (4).

minority of older people.

quit) and oral cancer was suspected as early
as 1 .402 (2), and this was subsequently confirm­

Betel quid with tobacco: A water extract
of a quid containing two Piper belle leaves, 1 g
areca nut, a pinch of catechu, slaked lime and
4 g tobacco was prepared by the method of

ed (3); however, the carcinogenic potential of

Shirname et al. (5).

A link between tobacco chewing (in betel

Biiidk

218

Carcinogenicity of Indian tobacco products

219

normal diet only, (iii) A further group of 40
Swiss mice received the diet containing to-

processed by routine histological techniques

carcinomas in 10/20 and 8/18 treated animals,

and embedded in paraffin. Paraffin sections, 6

tobacco

bacco/saliva extract and benzene hexachlo­
ride ad libitum to the age of 18 months. At the

pm thick, were cut and stained with haematox­
ylin and eosin for microscopic examination.

respectively (Table 1). Only one mouse in the
control group developed a lung tumour. The
extract of betel quid with tobacco was less

habit. The mixture was diluted in distilled
water and Hash-evaporated to obtain a viscous

end of treatment, they were returned to a nor­
mal diet and observed for life. Groups of 40

RESULTS

fluid, which was mixed with mouse diet and
with 0.625 g benzene hexachloride, a common
herbicide, to a final concentration of 125 ppm.

mice receiving only 125 ppm benzene hexa­
chloride or only the tobacco/saliva extract or

Tobacco extract administered to Swiss mice by
gavage or in the diet induced lung and liver

Tobacco plus benzene hexachloride: In order to
simulate the human situation, 50 g tobacco
were mixed with 100 ml saliva obtained from
normal, healthy subjects with

nd

Chillie extract: Chillies, (Capsicum annum and

C. Jrutescence), often used in the Indian diet,
were extracted by the method of Nagabhushan

and Bhide (6).
Mishri: Mishri was prepared as described
previously (see paper by Bhonsle et al., this vol­
ume). An extract was prepared by the method

of Kulkarni ct al. (7) and evaporated to dry­
ness. The residue was dissolved in acetone

to give a total of 1 or 2.5 g mishri in 20 pl of
acetone.

Bidi smoke condensate: A solution of bidi
smoke condensate in dimethyl sulfoxide was

prepared as described by Shirname et al. (8).
Snuff. One popular brand of crude nasal
snuff and one of scented nasal snuff were

suspended in liquid paraffin for topical ap­
plication.

normal diet were used as controls, (iv) A group

of 25 BALB/c mice received tobacco extract in
the diet and chillie extract in drinking-water (1
mg capsaicin/ml) ad libitum until the age of 18

months, after which time they were observed

until death. Control groups of 25 mice received
only tobacco extract or only chillie extract, (v)
Groups of Swiss mice, Wistar rats and Syrian
hamsters consisting of 30 animals in each
group were fed diets containing 10% mishri

for 20 months, after which time they were
returned to a normal diet and observed until
death, (vi) Groups of 30 Swiss mice and Swiss

nude mice, a mutant strain that is highly sensi­
tive to skin carcinogenesis (9), were painted on
the back skin with 2.5 mg mishri extract once a
day for five days per week until they were 20
months old and were observed until death.
Mice receiving acetone or no treatment served

as controls, (vii) 20 Swiss mice were given 1

mg bidi smoke condensate by gavage once a
day on five days per week for 35 weeks, then

Treatments: Eight independent experiments

observed until death. Controls received either

were carried out using the products described

0.1 ml dimethyl sulfoxide or no treatment.
(viii) Groups of 20 hamsters were treated top­

above.

with tobacco by gavage, five days per week for

16 months. At the end of this period, animals

received only a normal diet and were observed
until death. Controls received distilled water
by gavage and a normal diet, (ii) In the second

mg crude or scented snuff on five days per
week for a period of 21 weeks, at which
time they were sacrificed. A positive control
group of 20 hamsters received 7,12-di-me-

Tumour incidence in Swiss and BAI.Bic male mice treated with betel quid and tobacco (BQT), tobacco IT) alone or in
combination with benzyl hexachloride (BHC) or with chillie
Group

Swiss
Untreated
BQT
T
T
T+BHC
BHC

'rumour incidence (months)

Effective
no. of
mice

Route

20
18
20
18
40
35

Gavage
Gavage
Diet
Diet
Diet

9-14

21-25

Total
tumour
incidence

0/6
1/10
8/15

1/20 (5%)
4/18 (22%)
10/20 (50%)
8/18 (44%)
34/40 (85%)
21/35 (60%)

14/20
0/10

20/20
7/9

1/14
3/8
2/5
8/18
—
14/16

T
T+chillie

15
15

Untreated
Chillie

20
23

Diet
Diet
Drinkingwater
—
Drinkingwater

0/6
0/3

2/9
4/12

—
—

2/15 (13%)
4/15 (27%)

0/6
2/14

1/10
0/9

—
—

1/20
2/23

(5%)
(9%)

“Number of mice that surviv•ed beyond cright months

Table 2

Lung and stomach papilloma incidences in mice, rats and hamsters kept on 10°/o mishri diet

Species

.Age group (months)

Treatment

12-18

thylbcnz[a]anthracene (DMBzk), a standard

carcinogen, and a further control group re­

15-20

BALB/c

Mice

ceived no treatment.

19-25

1 lung
2 stomach
2 lung
12 stomach

Untreated

Mishri

experiment, 20 Swiss mice received a diet con­

taining 50 g tobacco per kg diet until they were

animals treated with tobacco extract + BHG,

Table 1

ically on the cheek pouch epithelium with 20

(i) In the first experiment, 20 male Swiss
mice were fed extracts of tobacco or betel quid

tumorigenic; however, simultaneous treatment
with benzene hexachloride or with chillie en­
hanced the tumorigenic effect of tobacco. In

Histological methods: All the control and

Total
tumour
incidence

3/27 (11%)

14/26 (54%)

20 months old. Both the diet and drinkingwater were given ad libitum. At the end of treat­

treated animals from different groups were
killed by cervical dislocation and dissected

Rats

Untreated
Mishri

0/6
2/6

0/19
8/21 stomach

0/25
10/27 (37%)

ment, they were returned to a normal diet
and obscived until death. Controls received a

carefully. Lung, liver, kidney and other grossly

Hamsters

Untreated
Mishri

0/6
3/10

2/20 stomach
9/18 stomach

2/23 (9%)
12/28 (43%)

abnormal tissues were fixed in 10% formalin.

220

Bhide

Table 3
lesions induced by daily painting 0/ mishri extract on the hack skin of Swiss and Swiss nude mice

strain

Swiss

Swiss nude

Treatment

Acetone (20 Ail)
Mishri (2.5
mg/day)
Acetone (20 /xl)
Mishri (1 mg/day)
Mishri (2.5
mg/day)

Incidr nee of lesions
Hyperplasia

Pi ipilloma

Carcinoma

8/30 (27%)
14/30 (47%)

0
0

0
0

Total
tumour
incidence

0
0

Untreated
DMBA
Crude snulf
.Scented snuff

>
20
20
20

Tobacco used for chewing, in the crude or
in processed form, contains considerable
quantities of TSNA (19,20). two of which,
N-nitrosonornicotine
and
4-(methyl-nitrosamino)-l-(3-pyridyl)-l-butanonc (NNK), are

found hamster cheek-pouch mucosa to be more
resistant than forcstomach mucosa. Bidi smoke
condensate induced two carcinomas, one of

which was in the oesophagus. These data indi­

19/23 (83%)
13/21 (61%)
9/17 (53%)

0
1
0

o
6
6

0
7/21 (33%)
6/17 (35%)

products used by the Indian people.

The carcinogenicity of cigarette smoke,
which contains two major classes of car­

cinogens, namely polycyclic aromatic hydro­

Table 4

No.

moter types of compounds, respectively (16,17).

weak carcinogen, since it induced only benign
tumours in the skin of mice and in the forcstomach of r.ticc, rats and hamsters. We further

cate the carcinogenicity of many of the tobacco

carbons and tobacco-specific N-nitrosamincs
(TSNA), has been adequately proven (13-15);

Tumour incidence m .Syrian golden hamsters treated with snuff inhalation

Group of
animals

cinogenic as well (12); Mishri appears to be a

1 ’apilloma

we report here on the carcinogenicity of bidi

Papillomas per hamster

smoke condensate. Bidi smoke is reported to

Check pouc h

Stomach

0.5-1.0 mm

1-1.5 mm

2-4 mm

Total

10/15 (66% )
0/20
0/20

15/15 (100%)
17/20 (85%)
15/20 (75%)

contain both polycyclic aromatic compounds
as well as TSNA (16,17). The carcinogenicity
in experimental animals of smokeless tobacco

9.9
12.7
6.7

6.8
1.0
1.5

—

16.7

1.0

9.2

products used in the USA and Europe has also
been reported in recent years (13,18), and we
reported earlier on the carcinogenicity of chew­

hepatocarcinomas were observed, and the
increase in tumour incidence was significant
(p<0.05). In die tobacco + chillic group, an
increased incidence of lung adenocarcinomas

stomach and one of the oesophagus). The
other tumours were four liver haemangiomas
and a papilloma of the stomach. No tumour

potent carcinogens in mice, rats and hamsters

(18,21). These two compounds induce tu­
mours in lung, liver and stomach; however,
relatively few tumours are observ.d in the oral
mucosa. Recently, we succeeded in inducing
cheek-pouch tumours in hamsters by adding
hydrogen peroxide simultaneously with NNK;

in vitro, peroxide radicals appear to be formed
transiently in the oral cavity during the chew­

ing of tobacco (22).
Although the oral mucosa of tobacco
chewcrs is bathed in saliva containing TSNA
(74-440 /xg/day), other modulatory factors,

such as spices, nutritional status and concur­
rent exposure to other carcinogens (through
air, water and occupation) may influence

of polycyclic

ing tobacco in mice (4) and the presence
aromatic hydrocarbons and

transformation of the normal oral mucosa to
malignant tissue. The identification of such
modulators is an important aspect of reducing

TSNA in snuff, which arc initiator and pro­

the cancer risk of tobacco users.

was seen in controls.

was observed (p<0.1).
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Eceding of 10% mishri in the diet to mice,
rats and hamsters increased the incidence of
papillomas in the lung and stomach in all the

three species over those in controls (Table 2).
Mishri extract induced skin papillomas in
Swiss nude mice but not in Swiss mice, al­
though hyperplasia was seen in 14/30 animals
(Table 3).

Neither type of snuff induced cheek-pouch
papillomas in treated hamsters, but foresto­

mach papillomas were observed in 17/20 and
15/20 animals (Tabic 4).
Among BALB/c mice treated with bidi
smoke condensate, 7/15 developed tumours,

two of which were carcinomas (one of the

DISCUSSION
We have demonstrated the carcinogenicity to

experimental animals of an extract of the
tobacco commonly used for chewing in India,

and have shown that the carcinogenicity is
enhanced by a commonly used herbicide (ben­
zene hexachloride) and by chillic (a common
component of the Indian diet). The finding
that the extract of betel quid containing to­
bacco was less’ carcinogenic to mice after

gavage than tobacco extract may be attributed

to a chemopreventive effect of betel leaf and
catechu, two important constituents of betel
quid, which are proven antimutagens (10,11).
Betel leaf has been shown to be anticar-

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PH^.

222

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AV, Bhide SV. Nonmutagenicity of betel-leaf
and its antimutagcnic action against environ­
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el al. Catechin as an antimutagen. Its mode
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114:177-82.
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Bhide SV. Anticarcinogenic effect of betel leaf
extract against tobacco carcinogens. Cancer
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nitrosamincs: an important group of carcino­
gens in tobacco and tobacco smoke. Carcino­
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Lavoie EJ, Hecht SS. Skin bioassays in
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aromatic hydrocarbon profiles of pyrolysed

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19. Bhide SV, Pratap Al, Shivapurkar NM,
Sipahimalani AT, Chadha MS. Detection of
nitrosamincs in a commonly used chewing
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of iV-nitroso compounds in Kiwam tobacco.
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21. Padma PR, Lalitha VS, Amonkar AJ,
Bhide SV. Carcinogenicity studies on the two
tobacco-specific nitrosamincs, W-nitrosiinomicc,tine and 4-methylnilrosainino-l-(3-p>ridyl)-lbutanonc (NNK). Carcinogenesis I989;l(l;
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The Public Health Importance of Tobacco Control
The Case of Chewed Tobacco (Gutklia, Pan Masala, Zarda etc.)

A Review of events in India *

Health Impact:
Regular habitual tobacco chewing of 4-5 packets per day, over several years,
results in gingivitis, leukoplakia, erythroplakia, and oral submucuous fibrosis
(OSMF). These effects occur even within 3-5 years with later progression in 58% of cases to oral and throat cancer.

These cause-effect relationships have been extensively studied and substantiated
by credible institutions, such as the Mumbai Preventive Oncology Dept, of the
Tata Memorial Hospital; the Tata Institute of Fundamental Research, Mumbai
which studied over 300,000 oral cancer patients country wide, over a 30 year
period; Nanavati Hospital, Mumbai; Regional Cancer Institute, Trivandrum;
Chittaranjan National Cancer Institute, Calcutta; Cancer Research Hospital,
Kancheepuram; Chennai Government Dental College; among others.

Public Health Dimensions:
The production, sale and use of chewed tobacco in India has increased,
particularly during the past two to three decades. There is no stigma, but in fact
positive social sanction, for the use of chewed tobacco. It is popular among
women and men, and even used by children.
Epidemiological studies reveal a shift in the age group affected by oral
submucous fibrosis over two decades, from those above 40 years progressively to
younger persons between 25-35 years. This disabling disease, that is incurable,
results from a thickening of the inner lining of the mouth. A ten-fold increase in
incidence is noted, over the past 30 years, and is described as an epidemic
growing in front of our eyes.

Oral cancers account for 18-20% of cancers in India and are mainly tobacco
induced. India has the second highest incidence of oral cancer.

by Dr. Thelma Narayan, Community Health Cell, Bangalore.
Sources of information include newspaper reports during the concerned periods.

EQ.

Legal Action :

1.

Following public debate and representations from consumer and citizen’s groups
etc., a statutory Central Committee for Food Standards (CCFS) was constituted in
1994, under the Prevention of Food Adulteration Act (1954)
,
*
during the Prime
Ministership of Sri P. V. Narasimha Rao, to go into “the use of chewing tobacco in
pan masala and gutka and its effects on public health”. At its fourth meeting on
November 26-27, 1997, based on a comprehensive review paper prepared by the
Indian Council.of Medical Research (ICMR), and on scientific evidence from
other research institutions, the Committee recommended a ban on the
manufacture, sale, distribution and storage of chewed tobacco (gutka, pan parag
etc.).

2.

The Director General of Health Services, who had chaired the expert committee,
sent a communication to the State and Union Territories for a massive educational
and public awareness campaign. There is not much evidence that this has trickled
down to the field.

3.

Based on the CCFS Report, the Government of India initiated work towards
amending the PFA Act 1954. This was not taken to “fruition”, as there was a
change in the government.

4.

It is useful to remember that the earlier ban on tobacco toothpaste was legally
challenged. Despite the Supreme Court upholding the ban in 1997, tobacco
toothpaste was reportedly still available in December 1997.

5.

Rulings by the Rajasthan High Court (in early 1997), and by the Aurangabad
Court in May 1997 (following a PIL by a consumer activist), have also asked for a
total ban on gutka.

6.

Kerala State had a different process. Following a campaign and social ban called
for by NGOs, a particular Gram Panchayat of Pallipuram exercised its power and
banned the sale of gutka, pan parag, etc. on 4.2.1997. North Paravoor
Municipality in Emakulam District also banned the sale of chewed tobacco
products. This, was followed by Kalamasseri Municipality in Emakulam district.
The above 3 instances were preceded 2 years earlier (1995) by Koolimad Village
Panchayat of Kozhikode which banned sale of all tobacco based products.
Later in 1997 the larger Kochi Municipal Corporation banned the sale of pan
masala and gutka, followed by the checking of shops/ kiosks/ outlets by health
inspectors and food inspectors. Under the ban, cancellation of trade licences and
seizure of goods are to be undertaken.

*

Under the prevention of Food Adulteration (PFA) Aet; 1954, the government is empowered to ban the

sale of substances injurious to health, when used as food or as an ingredient of food.

-2-

In Kerala, the apex body of the merchant community, the Kerala Vyapari
Vyavasai Ekopana Samiti was reportedly supportive of the move even at the cost
of a loss of profit, because of a sense of “social responsibility”.

This public debate, public action and action by local bodies, concerning tobacco
use, has been taking place for more than five years, setting the societal context for
the Kerala High Court Judgement of 1999 banning smoking in public places,
which is to be implemented on a State wide level.
•'
7.

The chewed tobacco industry has challenged and opposed the proposed measures
for control, through the All India Pan Masala and Tobacco Manufacturer’s
Association, the Zafrani Zarda Manufacturer’s Association and by farmers’
lobbies. They ask for further evidence or proof of direct link between use of the
product with cancer through a countrywide survey.
Issues concerning
employment, revenue and appeals to swadeshi sentiments are raised. Proposed
actions against chewed tobacco are attributed to be instigated by the smoked
tobacco'lobby as an internal competition, and also by MNCs in an attempt to
“snuff out” domestic industry.

In mid 1998, the organised and unorganized sector of the Gutka Trade reportedly
accounted for an annual turnover of Rs 2000 and Rs 3000 crores respectively.
Imposition of a country wide ban would potentially effect 400 manufacturers of
branded gutka and pan masala, who are estimated to control 65% of the market,
and to employ 10,000 persons in India. Instances of different companies cited in
Maharashtra show that the revenue generated to government is low, with most of
the income being undeclared. The number rendered jobless was also small, who
could be accommodated elsewhere, e.g.

Rahul Fine Products,
Johnny Walker Tobacco,
Sanket Food Products,

Rs 2 lakhs revenue, 74 employees
Rs 20 lakhs “
65
Rs 7 lakhs “
46
(Source-Indian Express 12/10/97)

The Maharashtra FDA Commissioner had recommended a ban on gutka and the
Govt, of Maharashtra had written to the Central Govt, in July 1997 recommending
a ban on gutka.
Conclusion
A cost benefit analysis is often used in decision making. While the costs to the
industry are often mentioned in news items, the direct and indirect costs of illness
to persons, households and health institutions need to be considered. Intangible
costs of suffering are important components that we as informed citizens and
concerned policy makers also need to consider. Would we like to subject our
loved ones to these risks?

-3-

CHAUDHRY : IS PAN MASALA-CONTAINING TOBACCO CARCINOGENIC?

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68

THE NATIONAL MEDICAL JOURNAL OF INDIA

VOL. 12, NO. 1, 1999

21

Review Article
Is pan masala-CQntairiuig tobacco carcinogenic?
KISHORE CHAUDHRY

ABSTRACT
Background. Pan masala-containing tobacco (PM-T) was
introduced in the Indian market during the 1970s. It is a mixture
of areca nut, tobacco, lime, catechu and spices. Despite mounting
evidence of health hazards of tobacco, tobacco manufacturers as
well as policy-makers often seek evidence regarding the carcino­
genicity of newer tobacco mixtures such as PM-T.

A. Methods. All the studies on pan masala (with or without
^^obacco) listed on MEDLARS, and the studies known to the
expert committee on the subject constituted by the Directorate
General of Health Services, were reviewed. The studies on
individual components and PM-T like substances were also
reviewed. The interpretation of carcinogenicity of PM-T has been
' made, based on studies on (i) PM-T; (ii) PM-T like mixtures; and
(Hi) the effect of individual ingredients of PM-T and the likely

effect of their combination.
Results. Studies on Chinese hamster ovary cells and Ames test
indicate that PM-T is mutagenic. There is limited evidence that it
may be carcinogenic to animals. The proportion of areca nut and
tobacco in PM-T is in between the proportion of these substances
in two known tobacco-areca nut mixtures of India (Mainpuri
tobacco and mawa). Studies on Mainpuri tobacco indicate that it
is carcinogenic, while literature suggests an association between
mawa use and oral submucous fibrosis.
Conclusion. Human studies on PM-T like mixtures and the
limited studies on PM-T suggest that PM-T is likely to be carcino­

genic.
Viatl Med ] India 1999;12:21-7
INTRODUCTION
Betel quid chewing is an ancient, socially acceptable habit in
India. This has helped in popularizing tobacco chewing practices.
The introduction of pan masala in 1975 offered an easy way to
carry the mixture which removed the inconvenience of its prepa­
ration. The increasing popularity of pan masala helped in intro­
ducing pan marda-conlaining tobacco (PM-T). In 1994, in Agra
and Mainpuri regions, 52 brands of pan masala and 47 brands of
PM-T were available. Thirty-five brands of pan masala were
found to be popular among children. Twelve companies sold pan
masala without a brand name. Pan masala (with or without
tobacco) is available in tins as well as in small sachets. The sachets
generally contain 3-5 g of the mixture. However, some brands
have 2 g and 10 g packs as well. The price of these sachets varied

Indian Council of Medical Research, Ansari Nagar, New Delhi 110029,
India
© The National Medical Journal of India 1999

from Re 0.25 to Rs 2.25 in Agra in 1994 (Lahiri VL, unpublished
data, 1994).
Despite mounting evidence of the health hazards of smokeless
tobacco, evidence is sought (especially by tobacco manufacturers
and policy-makers) regarding the carcinogenicity of nev/er mix­
tures of tobacco. Human studies arc the most important evidence
for deciding the carcinogenicity of any substance, which means
that to prove such an association one would have to follow up the
users for a long time after introduction of these substances, or wait
for 15-20 years to initiate case-control studies. Such an approach
is against the principles of prevention. Therefore, it is important
that the existing data are analysed for the possible health hazards
of newer formulations of tobacco.

METHODS
This paper was prepared to help an expert committee of the
Directorate General of Health Services, New Delhi, to decide on
the health hazards of PM-T. All the studies on pan masala (with
or without tobacco) listed on MEDLARS, and the studies known
to the members of the expert committee were reviewed. The
studies on individual components of PM-T and PM-T like sub­
stances were also reviewed.

CONTENTS OF PAN MASALA

The contents ofpan masala vary from brand to brand and the exact
details about their contents are closely guarded secrets. Three
types ofpan masala are available in the Indian market—plain pan
masala; sweet pan masala; and PM-T. The constituents listed on
the packets of various pan masalas include areca nut, catechu,
lime, sandal oil, menthol, cardamom, flavours, spices, aniseed,
sugar, waxes, oil seeds, colours, etc. Thus, pan masala has all the
ingredients of betel quid except the betel leaf and some additives
which are occasionally used in betel quid. Dry dates replace most
of the areca nut in sweet pan masala. PM-T contains tobacco in
addition to varying proportions of substances found in pan
masala. On washing, pan masala has been found to have soft
wooden particles other than areca nut (Lahiri VL, unpublished
data, 1994). Areca nut forms about 80% of pan masala; catechu
about 10%; lime about 1% of weight; and the remaining 9%
includes various spices.1 Areca nut also accounts for about 70%80% of the weight of PM-T.2
The long shelf-life of pan masala is achieved by keeping the
mixture free of moisture. The manufacturing process of pan
masala involves cutting the areca nut into small pieces and drying
it in ovens, till all the moisture evaporates. All the ingredients are
then mixed manually or with the help of mixers. The mixture is
immediately packed and sealed.
Other mixtures of tobacco, areca nut and slaked lime
Although PM-T was introduced in the 1980s, mixtures of areca

22

THE NATIONAL MEDICAL JOURNAL .OF INDIA

nut, lime and tobacco (with or without additives) have been
popular for a long time in different parts of India. Mainpuri
tobacco is a mixture of mainly tobacco with finely cut areca nut,
slaked lime, camphor and cloves? However, the shelf-life of this
mixture is about 10-15 days, after which it is not used, due to a
change in colour, even though the manufacturers believe that it
has the same effect. For this reason, the consumption of Mainpuri
tobacco is limited to the Mainpuri district of Uttar Pradesh and
areas around it
Mawa is a mixture of 5-6 g of areca nut shavings, 0.3 g of
tobacco and a few drops of watery slaked lime. The mixture is
placed on cellophane and tied with a thread into a ball. Just prior
to. its use, the packet is rubbed vigorously to homogenize the
contents, and a portion is rubbed on the palm and then chewed?
The use of mawa is popular in Gujarat, but it is also prevalent in
other regions of India.
Chemical analysis of pan masala
Chemical analysis of five common popular brands of pan masala
showed the presence of polyaromatic hydrocarbons, nitrosamines,
and toxic metals such as lead, cadmium and nickel? Another
analysis of four brands of pan masala and three brands of PM-T
showed the presence of polyaromatic hydrocarbons and residual
pesticides, with wide variation between different brands. In this
limited experiment, the variations did not seem to be due to the
presence or absence of tobacco (National Institute of Occupa­
tional Health, Indian Council of Medical Research, Ahmedabad,
unpublished data, 1989).

HEALTH HAZARDS OF PAN MASALA WITH TOBACCO
Human observations of the health hazards of pan masala (with or
without tobacco) are not available. Some studies on its in vitro
mutagenic and genotoxiepotential, and a few animal studies have
been reported. PM-T contains a known carcinogen—tobacco.
Areca nut, the major ingredient, is suspected to be associated with
oral cancer and submucous fibrosis (a pre-cancerous condition).
Information on the use of PM-T in the community is not
available. As the consumption of PM-T increased during the late
1980s, it is possible that the proportion of persons currently using
PM-T alone, for a period longer than the incubation period of oral
cancer, may be small. Due to the long incubation period of oral
cancer, epidemiological studies may not show any association
between PM-T and oral cancer (even if it exists), unless the
incubation period of the mixture is shorter than betel quid contain­
ing tobacco.
The main ingredients of pan masala, mawa and Mainpuri
tobacco are areca nut and tobacco, though their relative propor­
tions may vary in these mixtures. The proportion of areca nut and
tobacco in PM-T is somewhere between that of mawa and Mainpuri
tobacco. Lime is added to all the three mixtures. Presence of
catechu in PM-T is a variation. Catechu is known to liberate
tannins and polyphenols? Since PM-T is likely to encompass the
health hazards which are present in both mawa and Mainpuri
tobacco, a comparative study of all these substances would be in
order to determine the health hazards of PM-T. Thus, the likely
health hazards of PM-T to human beings in this review have been
based upon studies on (i) PM-T; (ii) PM-T like mixtures; and (iii)
the effects of individual constituents of PM-T and the likely effect
of their combination.

ANIMAL STUDIES

Very few studies’-8 have been reported on the effects of pan

VOL. 12, NO. 1, 1999

masala (with or without tobacco) in animals, and there is onlyone
study on PM-T and carcinogenesis.
Sinha’ applied 0.5 g of PM-T in paste form on alternate days
for six months on the entire buccal mucosa of 21 albino rats
weighing 150-200 g, excluding two periods of two weeks each
following the biopsy. Biopsies of the buccal mucosa were taken
from both cheeks (by microlaryngeal biopsy forceps on one side
and punch biopsy forceps on the other side) at the beginning of the
study and every 2 months thereafter. The histological findings
were compared with a control group of 14 albino rats. Fibronectin
levels in serum and biopsied tissue (by combining 3 samples due
to small amount) were also measured in both the groups. The
proportion of animals with hyperkeratosis, oedema and increased
vascularity in both the groups was not significantly different at
any time during the study. Papillomatous changes were observed
in 4 rats in the experimental group after 2 months, and in only 1
rat after 6 months. Such changes were not observed in the control
group. Dysplasia was seen in 7 (3 moderate and 4 mild) of the 18
slides examined after 2 months. The number of animals with dys­
plasia gradually increased, and by the end of the study, 20 out of
21 animals showed dysplasia (6 severe, 9 moderate, and 5 mild).
In contrast, 2 out of 14 controls showed mild dysplasia. Compared
to controls, there was a significant decrease in the tissue levels and
increase in serum levels of fibronectin in the experimental group.
A previous study8 had shown that the development of carcinoma
in the hamster buccal mucosa pouch model was preceded by
hyperkeratotic, dysplastic lesions which were similar to the dysplastic leukoplakia of humans.
Painting 1 g of pan masala in the oral cavity of albino rats on
alternate days for 6 months also resulted in a mild-to-moderate
loss of nuclear polarity, and increase in keratoses, parakeratoses,
inflammatory cell infiltration and vascularity, as compared to
controls? The increase in mitotic figures was statistically not
significant and no definite changes in the pigmentation of atypical
cells were seen. Submucosal collagen increased steeply and
steadily throughout the study period and at the end of 6 months, t
88% of biopsies showed thickened and condensed submucosal
collagen, suggesting submucous fibrosis. Although the compari­
son at the end of six months of intervention was statistically signi­
ficant, the trend of increasing percentage positivity with time was
observed only for submucosal collagen and vascularity. In this
study, the effect of local injury as a confounder on these two
parameters cannot be ruled out, as the biopsy quantum was more
and the duration between the biopsies was less than that in the
experimental group.
Earlier studies have suggested that the combined effect of an
extract of tobacco and areca nut mixture on hamster cheek pouch
is likely to be more than their individual effects. Suri et al.'°
showed that the development of leukoplakia and tumours in the
buccal pouch mucosa of male golden Syrian hamsters was faster
after the application of a dimethyl sulphoxide (DMSO) extract of
a 2:1 mixture of tobacco and areca nut, compared to the extract of
the individual substances. The extent of growth of tumours was
also greater after application of the extract of mixture. Ranadive
et al.1' reported cheek pouch malignancy in male Syrian hamsters
after application of DMSO extract of tobacco and areca nut, but
not after application of extracts of the individual components. In
another experiment, the proportion of Syrian hamsters developing
buccal pouch malignancy was more with an aqueous extract of
tobacco and areca nut (with and without lime) compared to an
extract of areca nut, while an aqueous extract of tobacco or betel
quid (with or without tobacco) did not result in malignancy.12

CHAUDHRY : IS PAN MASALA-CONTAINING TOBACCO CARCINOGENIC?

Chronic gavage feeding of pan masala in rats has been
reported to result in impaired liver function (indicated by elevated
serum glutamic oxaloacetic transaminase, glutamic pyruvate tran­
saminase, and alkaline phosphatase), decrease in relative weights
of the gonads and brain,13 increase in sperm head abnormalities,
and increase in the frequency of X-Y univalents and breaks.14 A
dose-dependent increase in sperm head abnormalities, sister chro­
matid exchange and cell cycle delay has been reported by intra­
peritoneal injection of pan masala in mice.15 The same study
reported a dose-dependent increase in chromosomal aberrations
in the bone marrow after one month of feeding mice pan masala
or PM-T. A significant dose-dependent increase in sperm head
abnormalities was noted, but no significant changes in the weight
of testes and total sperm count was seen.

MUTAGENICITY
Mutations in Salmonella typhimurium (Ames test)

Two reports on the mutagenicity ofpan masala using Salmonella
typhimurium are available.1617 Both the studies did not specify if
the pan masala used in the experiment contained tobacco. Using
fcpe tester strain TA98 and TA100, Polasa et al.16 tested aqueous
Extracts of 8 varieties ofpan masala, 6 varieties of scented supari

and areca nut. Three tested concentrations of dry extracted mate­
rial (100, 200 and 300 pg/plate) showed statistically significant
higher frequency of revertants, as compared to controls, except
for one variety at 100 pg extract/plate with TA98. An enhance­
ment of the effect was seen by activation with S9 mix. A dose­
response relationship was also observed. All the 6 samples of
scented supari (200 pg of extract) showed significantly higher
revertants inbothTA98 and TA 100. Metabolic activation gener­
ally enhanced the effect. The effect was the same after addition of
500 ppm of saccharin to 2 samples of scented supari. The TA 100
strain showed statistically significant results more often than
TA98, and after S9 activation all the values with scented supari
in TA100 were significantly higher than those in controls. The
mutagenic effects ofpan masala and scented supari extracts were
similar to those produced by areca nut extract.
Bagwe et al. ” tested polar and non-polar extracts of a popular
brand of pan masala on Ames test using TA98 and TA 100 tester
strains of Salmonella typhimurium. No mutagenic response was
^een in aqueous extracts, aqueoustethanolic extracts and chloroJbrm extracts. Pre-treatment with 300 pg of sodium nitrite at an
acidic pH or metabolic activation did not change the results. How­
ever, the ethanolic extracts elicited a weak mutagenic response in
strain TA98 without metabolic activation, suggesting the pres­
ence of direct-acting frameshift mutagens in pan masala. A dose­
dependent increase in the number of revertants was seen up to a
dose of 25 mg, after which there was a negation of the mutagenic
response. The reason for the difference in these two studies is not
clear.
Bhide et al.'3 found that only ethanolic extract of Nicotiana
tobaccum induced mutations in Salmonella typhimurium TA98
but not in TA100, TA1535 and TA1538. However, Shimame et
al.'9 reported a dose-dependent increase in revertants in Salmo­
nella typhimurium TA1535 and TA100 (but not in TA98 and
TA1538) by aqueous extracts of betel quid (with or without
tobacco) and areca nut. An aqueous extract of betel leaf was not
mutagenic in all the four strains, and in fact reduced the mutage­
nicity of areca nut in TA 100 strain in the presence of S9 mix.
Arecoline induced mutagenicity of areca nut in all the four
systems in the absence as well as presence of S9, while arecaidine
required S9 for inducing mutations in all these systems.

23

The addition of S9'mix in different studies has shown variable
effect—no effect to potentiation of mutagenicity. The reasons for
these variations need to be studied. Some probable factors are a
batch-to-batch variation in the raw product, processing of the raw
product, proportions of various ingredients in the mixture, storage
conditions and ageing of the raw product or the mixture. Also.
procedural differences in the conditions under which these experi­
ments were conducted may have been different.
Even though there is no study on the mutagenicity of PM-T on
Ames test, the existing literature suggests that PM-T is likely to be
mutagenic on Ames test, at least on one of the four strains used
(two studies reporting the mutagenesis of pan masala on Ames
test did not specify the presence or absence of tobacco in the
samples). This impression is based on the fact that studies have
found aqueous extracts of betel quid (with as well as without
tobacco), areca nut and areca nut alkaloids to be mutagenic.
Ethanolic extracts of tobacco have also been found to be muta­
genic. However, aqueous extracts of betel leaf have been found to
protect against the effect of areca nut in the TA 100 system. Neu­
tralization of the mutagenic effect in a PM-T mixture is unlikely
as all the ingredients have individually been found to be muta­
genic.

Studies using Chinese hamster ovary (CHO) cells
The mutagenicity ofpan masala and PM-T on CHO cells has been
studied using their aqueous, ethanolic and DMSO extracts. Simi­
lar studies have also been carried out on betel quid (with and with­
out tobacco), as well as on individual ingredients of betel quid and
pan masala. Application of aqueous extracts of pan masala to
CHO cells for 3 hours followed by recovery for 17 hours, resulted
in a dose-dependent and statistically significant elevation in sister
chromatid exchange (SCE).20 A dose-dependent increase was also
seen in the M1 fraction (with a corresponding decrease in the M3
fraction), average generation time, number of chromosomal aber­
rations (CA) per cell, and the proportion of aberrant metaphases.
However, the increase was statistically significant only for aber­
rations per cell for cultures treated with the highest dose of the
extract.
Another similar study showed significant elevation of CA,
SCE, and micronucleated cells (MNC) in a dose-dependent man­
ner in cultures without metabolic activation.21 Addition of the S9
activation system generally resulted in suppression of chromo­
somal damage, suggesting that pan masala and PM-T contain
water-soluble direct-acting mutagens. A DMSO extract of pan
masala or PM-T was also found to significantly increase the
frequency of CA, SCE and MNC in CHO cells, with the S9 mix
resulting in suppression of CAs and MNC formation. However.
there was no significant change in SCE counts.22 The cytogenetic
damage was greater with the DMSO extract than the aqueous
extract.
A study of the combined effect of aqueous extracts of 1.11 mg
of pan masala or PM-T and alcohol (in varying strengths) for 3
hours on CHO cells showed that alcohol alone, pan masala! PMT alone, as well as their combinations (irrespective of the sequ­
ence of exposure) increased CAs in a dose-dependent manner.23
Simultaneous exposure to alcohol and pan masala! PM-T showed
a higher increase than sequential exposure. Exposure to 4%
alcohol with pan masalaiPM-T resulted in necrotic cells. A 20hour treatment of CHO cells with alcohol (0.25% and 0.5%) and
combinations of 0.22 and 0.55 mg of pan masala/PM-T also
showed a similar increase in CAs. However, significant changes
were not noticed by the application of individual substances. The

24:

THE NATIONAL MEDICAL JOURNAL OF INDIA

proportion of chromatid type aberrations was higher with PM-T
extract, while it was about the same with pan masala extract (with
or without alcohol). Ethanol alone as well as a combination of
ethanol with PM-T extract resulted in a sharper increase in
chromosomal type of aberrations.
Similar studies conducted on CHO cells showed significant
increase in CAs and SCEs, using aqueous extract of Nicotiana
tobaccum,24 aqueous extract of areca nut,25-26 nicotine,27-28 areco­
line,25-29 and combinations of nicotine and arecoline.30 A dose­
response increase in CAs and SCEs was seen in all these experi­
ments. A combination of nicotine and arecoline produced
significantly higher cytogenetic damage than the corresponding
concentration of either substance alone.30 Betel leaf extract was
not mutagenic, and resulted in decrease in CA and SCE frequen ­
cies due to pan masala/PM-T'.31

Chinese hamster V79 cells
Shimame et al22 noticed that only ethanol extract of tobacco
produced mutations in Chinese hamster V79 cells with S9 mix
enhancing the effect. This extract also induced micronuclei in
bone marrow cells of Swiss mice.

EFFECT ON HUMAN LYMPHOCYTES AND BUCCAL
MUCOSA
Dave et al.2 measured the CA and SCE frequency in peripheral
lymphocytes and frequency of MNCs in the buccal mucosa in 30
healthy vegetarian teetotallers, with no history of viral infection
or antibiotic therapy during the last six months, and who were not
engaged in any hazardous occupation. The 10 pan masala and 5
PM-T chewers used the same brand as studied by the team for its
effect on CHO cells,22 and had no other concomitant tobacco,
areca nut or betel quid habit for at least one year. Fifteen controls
did not take tobacco, pan masala or areca nut. The habitues had
no clinically detectable changes in the oral mucosa, but showed
significantly higher frequency of MNC in buccal mucosal cells,
and CA and SCE in peripheral blood lymphocytes. The mean
values of SCE, CA and MNC did not differ among pan masala and
PM-T chewers.
The effect of mawa chewing on human peripheral lympho­
cytes and buccal mucosal cells has been found to be similar to that
ofpan masala and PM-T. A study on three groups of non-smoking
teetotaller mawa chewers (with oral cancer, oral submucous
fibrosis and without oral lesions) found statistically significant
elevation of per cell values of SCE and CA in peripheral blood
lymphocytes, as compared to controls.33 The number of CA and
SCEs per metaphase showed a gradual increase from controls to
healthy chewers to submucous fibrosis to oral cancer patients.
Chromatid aberrations (majority being gaps) were more frequent
than chromosome type aberrations. The MNC frequency in buccal
mucosal cells was significantly higher among healthy mawa
chewers and patients with oral submucous fibrosis (OSMF)
compared to controls.
The CA and SCE frequencies in CHO cells were found to be
significantly elevated following treatment with urine concen­
trates of tobacco with areca nut chewers (type not specified)
compared to the urine concentrates of non-chewers.34 Urine
creatinine levels were comparable between controls and T/AN
chewers. The saliva of pan masala chewers has also been found
to be clastogenic to CHO cells.35
Kayal et al.26 studied the frequency of MNCs in the exfoliated
buccal mucosa of normal healthy individuals from different parts
of India who were regularly using either areca nut alone, mawa,

VOL. 12, NO. 1, 1999

tamol, tobacco with lime, dry snuff, or masheri. The analyses
were also carried out among OSMF patients who chewed either
mawa or areca nut. Compared with healthy individuals with no
habit, all the chewer groups irrespective of their type of habit, had
significantly higher frequency of MNCs. However, no difference
in frequency of MNCs was observed according to type of chewing
habit, presence or absence of tobacco, type of areca nut used for
chewing, and the presence or absence of OSMF.
Chromosomal aberrations were found in 6 out of 9 chewers of
betel quid with tobacco, and masheri users, gaps and chromatid
breaks being the commonest aberrations.37 SCE frequency was
also significantly higher in tobacco chewers than that in controls.
Tobacco chewers and oral cancer patients exhibited significantly
higher frequency of MNCs than the controls. Urine samples from
female habitues exhibited higher levels of cotinine, and direct
mutagenicity to TA100, while control samples were non-mutagenic. Treatment with 0-glucuronidase decreased the mutagenic
potency of urine of tobacco habitues, but increased the potency of
urine of controls. Nitrosation of samples increased the mutagenic­
ity to TA 100, but the increase was higher in controls.
Higher values of CAs and SCEs per cell have also been detec­
ted among vegetarian and teetotaller areca nut chewers with or
without oral cancer or oral submucous fibrosis,38 dry snuff users,39
and chewers of tobacco with lime.39
STUDY OF PRECANCEROUS LESIONS IN HUMANS

Oral leukoplakia
There have been no studies on the association of PM-T and oral
leukoplakia. However, chewing of Mainpuri tobacco has been
shown to be associated with a higher prevalence of oral leuko­
plakia as compared to no chewing.40 Association of leukoplakia
and tobacco chewing (generally as a component of betel quid) has
been demonstrated in prospective studies,41"43 as well as in case­
control studies.44-45 These prospective studies have also shown
malignant transformation of oral leukoplakia to oral cancer.

Oral submucous fibrosis (OSMF)
Oral submucous fibrosis (OSMF) has long been suspected to be
associated with areca nut chewing.The precancerous nature of
submucous fibrosis was first mentioned by Paymaster in 1956,46
who observed the development of a slow-growing, squamous cell
carcinoma in one-third of patients with submucous fibrosis. On
examination of220 biopsies of OSMF, Pindborg47 found atypia in
13.2% of biopsies, suggesting that it is a precancerous condition.
Histopathological studies of the silver-staining nucleolar orga­
nizer region in mucosal biopsy samples of normal, leukoplakic,
neoplastic and submucous fibrosis tissues showed the highest
count in carcinoma followed by submucous fibrosis tissues.48
Prospective studies on malignant transformation of oral submu­
cous fibrosis proved that it is a precancerous condition.43-48"50
In a study of 36 patients with OSMF—12 each in grade I to
III—and 12 healthy volunteers, attending two dental colleges in
Chennai (Madras), it was noted that all patients had the habit of
chewing betel nut, pan masala or the traditional betel quid.51
Eighteen patients (9 with grade 1,7 with grade II, and 2 with grade
III OSMF) consumed pan masala, 6 (3 each with grade I and II
OSMF) chewed betel nut alone, and 12 (2 with grade II and 10
with grade HI OSMF) chewed a mixture containing betel nut, betel
leaf and lime. Ten of the 12 patients with grade m OSMF chewed
tobacco along with the mixture. Patients who chewed pan masala
were below 30 years of age and they had started the chewing habit
2-3 years prior to the diagnosis; whereas the patients chewing

CHAUDHRY i IS PAN AMil/A-CONTAINING TOBACCO CARCINOGENIC?
traditional mixtures developed OSMF 20-25 years after starting
the habit. Thirteen patients (5 with grade 1,7 with grade II, and 1
with grade IH OSMF) were smokers. The much shorter history of
chewing habit among pan masala users (addition of tobacco or
smoking unknown) is alarming.
Another comparison of the chewing habits of 50 OSMF
patients attending a dental department showed that chewers of
pan maso/o/PM-T were younger in age and had a shorter history
of the habit of chewing compared to betel quid chewers (2.7 years
v. 8.6 years, respectively).52 Patients who were smokers were not
included in the study. Even though the duration of presence of
OSMF was not indicated, the similar interincisal distance be­
tween these categories suggests a shorter incubation period of the
disease among users of pan masala.
A study on 60 OSMF patients and age, sex, religion and socio­
economic status-matched healthy controls showed that 98% of
patients chewed areca nut regularly in one form or the other,
whereas among controls 35% chewed areca nut, giving an overall
relative risk of 109.6.53 Areca nut chewing was practised most
«mmonly in the form of mawa. Mawa chewers and those who
^Bewed mawa along with other substances showed very high

relative risk. The relative risk increased with increase in frequency
as well as duration of the chewing habit. In a bivariate analysis, the
effect of frequency and duration of chewing appeared to be
multiplicative.
Bhargava et al.a in a two-year follow-up study of 43 654
industrial workers in Gujarat reported the incidence of new cases
of OSMF to be 7/2105 (0.3%) among persons chewing betel quid
with areca nut; 6/9506 (0.1%) among chewers and smokers;
3/1161 (0.3%) among tobacco chewers alone; and 10/7065(0.1%)
among those with no such habit. In the 10-year follow-up survey,43
all 11 new cases (out of 39 828 villagers) of OSMF in Emakulum
occurred among chewers of tobacco or betel quid or those with a
mixed habit (including smoking); in Bhavnagar, of the 4 new
cases seen among 38 818 persons, 2 had no tobacco habit, while
1 chewed tobacco and 1 smoked it. Some well conducted case­
control studies have demonstrated an association between chew­
ing of areca nut and development of OSMF.43'45-54
EPIDEMIOLOGICAL STUDIES

epidemiological studies have been reported on the association
of consumption ofpan masala (with or without tobacco) and oral
cancer. However, a high risk of developing oral cancer due to the
use of a mixture of tobacco, areca nut and lime has been reported
in a large, community-based, prospective study. This mixture
(Mainpuri tobacco) amounts to PM-T without catechu (although
the proportion of areca nut is much lower than pan masala'). After
analysing the cancer occurrence data for 31 months in a popula­
tion of over 1 million, Wahi3 reported that chewing of Mainpuri
tobacco was the most important factor identified in the causation
of oral cancer, the prevalence rate being 4.51 per 1000, as com­
pared to 0.8 among those using other kinds of tobacco, and 0.18
per 1000 among those with no habit of smoking or chewing.
Smoking and drinking alcohol showed an additive effect with
Mainpuri tobacco, although smoking and drinking also increased
the risk of chewing other tobacco mixtures (as also among persons
with no chewing habit). The prevalence of oral cancer was cross­
tabulated according to various combinations of tobacco usage
habits and other factors such as sex, age, education, residence,
religion, food, smoking, drinking, income and occupation. A con­
sistently higher rate was observed among those who chewed
Mainpuri tobacco than among those who chewed other kinds of

25

tobacco, which in turn was higher than that for persons without the
habit.
Some case-control studies have concluded that chewing of
betel quid with tobacco has an association with cancers of the oral
cavity and/or pharynx. 35-41 Cross-sectional surveys and prospec­
tive studies also showed an association between chewing of betel
quid with tobacco or tobacco chewing (with or without smoking)
and development of oral cancer.41-44-62 Many case-control studies
have reported an increased relative risk of developing cancers of
the oral cavity and/or pharynx and oesophagus due to use of betel
quid with or without tobacco.63-69 Khaini (a mixture of tobacco
and lime) use has also been implicated in the aetiology of oral
cancer.70
DISCUSSION
In 1985, an IARC (International Agency for Research on Cancer)
expert group6 concluded that chewing of betel quid with tobacco
is carcinogenic to humans. However, there was inadequate evi­
dence to implicate chewing of betel quid without tobacco. The
study on chewing of Mainpuri tobacco was considered as evi­
dence for association of oral cancer with chewing of betel quid
containing tobacco. This probably was due to the fact that the
habit of chewing PM-T had not gained popularity till then. How­
ever, it would be more appropriate to group this study separately,
as the habit ofchewing Mainpuri tobacco (as well as mawa) would
be equivalent to chewing PM-T without catechu. The relative
proportions of areca nut and tobacco in pan masala is between
their relative proportions in Mainpuri tobacco and mawa. Thus, if
Mainpuri tobacco and mawa chewing are found to have the same
harmful effects on humans, it can be safely concluded that PM-T
would also have these. It would be’ necessary, however, to exam­
ine the effect of adding catechu to mixtures such as Mainpuri
tobacco and mawa.
Epidemiological studies from India suggest that chewing of
tobacco and lime has a higher risk for cancer than chewing of betel
quid with tobacco.71-72 The addition of tobacco leaf extract in the
drinking water of Swiss male mice has been observed to reduce
the occurrence of tumours by two tobacco-specific nitrosamines,
N-nitrosonomicotineand4-(methylnitrosoamino)-l-(3-pyridyl)1-butanone.73 The individual anti-carcinogenic components of
betel leaf extract (eugenol and hydroxychavicol) and catechu­
catechin, have been observed to inhibit the interaction of
3(H)benzo(a)pyrene with DNA, in the presence of both rat and
mouse liver S9 fraction.74 Of the other two studied components of
betel leaf extract, 0-carotene was effective'in the presence of
mouse S9 mix only, but a-tocopherol was not effective at all.
Another study showed that hydroxychavicol, catechu-catechin,
P-carotene and a-tocopherol (but not eugenol) inhibited the
interaction between-7,12 dimethylbenzanthracene and DNA in
the presence of mouse skin S9.75 Aqueous extract of betel leaf
reduced the mutagenicity of an aqueous extract of areca nut in
Salmonella typhimurium TA 100 in the presence of S9 mix.19 A
three-hour application of aqueous extract of betel leaf along with
pan masala or PM-T resulted in a smaller increase of CAs and
SCEs in CHO cells, as compared to the action ofpan masala alone
or PM-T alone, respectively.31
v
Thus, the existing literature suggests that betel leaf may pro­
vide partial protection against the carcinogenic effect of tobacco,
areca nut and lime mixture. There is also a suggestion that catechu
may be anti-carcinogenic. However, the presence of both these
substances in betel quid-containing tobacco is not enough to
negate the carcinogenic effect of areca nut, tobacco and lime. If

26

THE NATIONAL MEDICAL JOURNAL OF INDIA

the betel leaf is removed from betel quid-containing tobacco (PMT has such a composition), catechu alone is not enough to negate
the carcinogenic effect of the areca nut, tobacco and lime mixture.
On the other hand, a recent study observed that of the various betel
quid components, catechu in the presence of lime at alkaline pH
is the most active producer of reactive oxygen species.76 Reactive
oxygen species are considered to be important in the process of
mutagenesis.
The pH of saliva of 20 children and 25 adult users of pan
masala at Agra was measured, ten minutes after its consumption.
The pH varied between 7.5 and 8.5 (Lahiri VL, unpublished data,
1995). This finding suggests that the environment of the oral
cavity after consumption of PM-T is suitable for generation of
reactive oxygen species as well as nitrosamines specific for
tobacco and/or areca nut.
Recent studies suggest that processing of areca nut prior to use
may be important in determining its carcinogenicity. Measure­
ment of active components of areca nut, arecoline and polyphe­
nols showed their presence to be the maximum in the unprocessed
nut, followed by sun-dried or roasted nut, and the minimum levels
were detected in nuts processed by soaking and boiling.77 Weak
carcinogenicity in mice fed areca nut alone was noticed only with
unprocessed areca nut.78 The findings point towards a higher
carcinogenic potential of PM-T (which contains roasted areca
nut) than betel quid mixtures using soaked or boiled areca nut.
The existing literature does suggest that if betel leaf is removed
from the traditional betel quid-containing tobacco (PM-T), the
carcinogenicity of the mixture would still remain. The finding that
pH of the saliva is alkaline after chewing PM-T would hasten the
process of carcinogenesis, especially for a mixture of areca nut,
tobacco and lime. Experimental studies indicate that a mixture of
tobacco and areca nut results in a higher degree of clastogenicity,
as compared to the independent action of the same dose of indivi­
dual components. Animal studies also suggest that a combination
of areca nut and tobacco results in a shorter incubation period of
cancer.
Experimental studies have shown that pan masala (addition of
tobacco not known) is mutagenic in the Salmonella typhimurium
test system; PM-T as well as pan masala induces cytogenetic.'
damage in Chinese hamster ovary cells; intraperitoneal injection’
of pan masala results in increased SCE and delays in cell cycle1;
pan masala as well as PM-T induces significant increase in CAs
and SCEs in peripheral blood lymphocytes and increase in MNCs
in buccal mucosa in humans. Thus, there is enough evidence to
label PM-T as mutagenic.
Animal experiments provide only a suggestion that PM-T may
be carcinogenic. Based on the then available information, an
1ARC expert group in 19856 concluded that there was limited
evidence that areca nut with tobacco (and without tobacco) is
carcinogenic to experimental animals. One of the experiments
considered by them included application of areca nut, tobacco and
lime to the buccal pouch of hamster.17 Considering that the effect
of PM-T is likely to be similar to that of areca nut, tobacco and
lime mixture, the same conclusion can be made about PM-T, i.e.
there is limited evidence that PM-T is carcinogenic to animals.
There is no study reported on carcinogenicity of PM-T. For the
reasons mentioned earlier, conducting such a study at this time
may show an association only if PM-T shortens the incubation
period of oral cancer. Recent studies point towards this possibil­
ity, by showing that 50% of OSMF cases had a two- to three-yearold habit of chewing pan masala (addition of tobacco not speci­
fied for individual groups). Combined with the earlier knowledge

VOL. 12, NO. 1, 1999

of a shortened incubation period with a mixture of areca nut and
tobacco, this may be an important area for investigation. Mainpuri
tobacco, which is a PM-T-like mixture, has been shown to be
carcinogenic to human beings in a prospective study.3 Although
no study on carcinogenicity of mawa has been carried out, the fact
that 15 patients of histologically confirmed oral cancer habituated
to mawa chewing (with no other habit of chewing, vegetarians,
teetotallers, and not engaged in any hazardous occupation) could
be enrolled in a study33 suggests a strong association of mawa
chewing with oral cancer. Association of Mainpuri tobacco3 as
well as mawa chewing53 with OSMF has been demonstrated. As
pointed out earlier, if a mixture of areca nut (95%) with tobacco
and lime (mawa), and a mixture of areca nut with tobacco (major
constituent) and lime (Mainpuri tobacco), are found to be carci­
nogenic in human beings, it is only logical that a mixture of areca
nut (70%-80% by weight) with tobacco and lime (PM-T), would
be carcinogenic to human beings. Thus, there is sufficient evi­
dence to suspect that PM-T is carcinogenic to human beings.
REFERENCES
1
Shenolikar IS. Pan masala'. Present status. Nutrition News 1989; 10:1-3.
2
Dave BJ, Trivedi AH, Adhvaryu SG. Cytogenetic studies reveal increased genomic
damage among pan masala consumers. Mutagenesis 1991;6:159-63.
3
Wahi PN. The epidemiology oforal and oropharyngeal cancer: A report of the study
in Mainpuri district, Uttar Pradesh, India. Bull World Health Organ 1968;38:
495-521.
4
Bhonsle RB, Murti PR, Gupta PC. Tobacco habits in India. In: Gupta PC, Hamner
JE III, Murti PR (eds). Control of tobacco related cancers and other diseases.
International symposium, 1990. Bombay:Oxford University Press, 1992:25-46.
5
Toxicological evaluation of pan masala. Annual Report of National Institute of
Occupational Health (ICMR). Ahmedabad, 1989-90. 1990:60-6.
6
International Agency for Research on Cancer. Tobacco habits other than smoking:
Betel quid andareca nut chewing; and some related nitrosamines, 1ARC Monographs
on the Evaluation of Carcinogenic Risk of Chemicals to Humans, Vol. 37. Lyon:
International Agency for Research on Cancer, 1985:141-202.
7
Sinha BK. Fibronectin levels and their correlation with histopathological changes
following application of instant pan masala with tobacco on buccal mucosa ofalbino
rats. Chandigarh:Post Graduate Institute of Medical Education and Research,
Chandigarh, 1991. (Dissertation].
8
Fujita K, Kaku T, Sasaki M, Onoc T. Experimental production oflingual carcinomas
in hamsters by local application of 9,10-dimethyl-l,2-benzanthraccne. J Dent Res
\973,S2:32T-32.
9
Khrime RD, Mehra YN, Mann SBS, Mehta SK, Chakraborti RN. Effect of instant
preparation of betel nut (pan masala) on the oral mucosa of albino rats. Indian J Med
Res 1991;94:119-24.
10
Suri K, Goldman HM, Wells H. Carcinogenic effect ofa dimethyl sulphoxide extract
of betel nut on the mucosa of the hamster buccal pouch. Nature 1971 ;210:383-4.
11
Ranadive KJ, Gothoskar SV, Rao AR, Tezabwalla BU, Ambaye RY. Experimental
studies on betel nut and tobacco carcinogenicity. Int J Cancer 1976;17:469-76.
12
Ranadive KJ, Ranadive SN, Shivapurkar NM, Gothoskar SV. Betel quid chewing
and oral cancer: Experimental studies on hamsters. Int J Cancer 1979;24:835-43.
13
Sarma AB, Chakrabarti J, Chakrabarti A, Banerjee TS, Roy D, Mukherjee D, et al.
Evaluation of pan masala for toxic effects on liver and other organs. Food Chem
Toxicol 1992;30:161-3.
14
Mukherjee A, ChakrabartU, Chakrabarti A, Banerjee T, Sarma A. Effect of pan
masala on the germ cells of male mice. Cancer Lett 1991;58:163-5.
15
Mukherjee A, Giri AK. Sister chromatid exchange induced by pan masala (a betel
quid ingredient) in male mice in vivo. Food Chem Toxicol 1991;29:401-3.
16
Polasa K, Babu S, Shenolikar IS. Dose-dependent genotoxic effect of pan masala
and areca nut in the Salmonella typhimurium assay. Food Chem Toxicol 1993;31:
439-42.
17
Bagwe AN, Ganu UK, Gokhale SV, Bhisey RA. Evaluation of mutagenicity of pan
masala, a chewing subsitute widely used in India. Mutat Res 1990;241:349-54.
18
Bhidc SV, Shah AS, NairJ, Nagarajrao D. Epidemiological and experimental studies
on tobacco-related oral cancers in India. In: O’Neill IK, von Borstel RC, Miller CT,
Long J, Bartsch H (eds). N-Nitroso compounds: Occurrence, biological effects and
relavance to human cancer (IARC Scientific Publications No. 57). Lyomlntemational
Agency for Research on Cancer, 1984:851-7.
19
Shimame LP, Menon MM, Nair J. Bhide SV. Correlation of mutagenicity and
tumorigenicity of betel quid and its ingredients. Nutr Cancer 1983;5:87-91.
20
Adhvaryu SG. Dave BJ, Trivedi AH. An in vitro assessment of the genotoxic
potential of pan masala. Indian J Med Res 1989;90:131-4.
21
Jaju RJ, Patel RK, Bakshi SR, Trivedi AH, Dave BJ, Adhvaryu SG. Chromosome
damaging effects of pan masala. Cancer Lett 1992;65:221-6.

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OPINION
Government lowers duty on pan masala
(Tuesday, July 6, 1999)
Anjan Mitra in New Delhi

In a quiet move , the government has reduced the excise duty on certain categories of
'pan masala' from 40 per cent to 16 percent which has raised the hackles of other
industries, specially the soft drinks industry.
The brands of 'pan masala' which are likely to benefit from
government move include 'Chutki', 'Pan Pasand', 'Pan Parag' and 'Rajnigandha'

this

In a notification, issued on June 8 by the finance ministry, the
government has said "all goods containg not more than 10 per cent betel nut by weight'")
and not containing tobacco in any portion" would attract an excise duty of 16 per cent — I
dowfTby a whopping 40 per cent.
=L

What's more surprising, the June 8 government notification states: "The Central
government being satisfied that it is necessary in the public interest to do so..."

Earlier on 'pan masala', the government levied an excise of 40 per cent, which included |j
24 per cent basic and 16 per cent in the form of SAD.
However, the 'pan masala' and 'gutka' industry is not very happy with this reduction.
"Not very many companies would benefiFby this reduction in excise duty as we have
been demanding for a
uniform policy," All-India Pan Masala & Tobacco
Manufacturers Association (AIPMTMA)spokesperson, Bharat Thakkar, said.
According to Thakkar, critics do say that such products cause cancer, but "the
government cannot have a stick and carrot policy policy towards us."

Thakkar said if there is a uniform excise duty on 'pan masala' and 'gutka', then standards
and quality of the products can be also raised which would reduce spurious goods
flooding the market.

The government move has been resented in many other industries. For example, the_soft
drinks industry feels instead of harmful products their industry should have got some
excise relief.

According to soft drink industry sources, soft drinks are being taxed at the highest rate of
excise duty (40 pencentX-while no other consumer goods industry is taxed~at this level?-’
Reacting to the government notification, soft drinks industry sources said the excise duty
rate is highest in India even among developing countries where soft drinks are
concerned.
While India has levied 40 per cent duty on soft drinks, in
Pakistan the corresponding figure is 25 per cent, in Thailand it is 18 per cent and in
Bangladesh it is just 10 per cent.

According
to
AIPMTMA's
Thakkar,
they
have
given
several
representation to the government earlier on the high excise duty'pan masalas' and
’gutkas', but to no avail.
(ENDS)/ 7 p.m.

Your Deadly Friend: Paan - Masala
by Dr. Anil Nirale, M.Ch. Plastic Surgeon
Do you want to make friends with Mr. DEATH ? Are you ready to die a slow, lingering
and painful death?
I think yes ! Yes, some of you are ready to die from an irreversible disease wherein
death is guaranted. So here is the easiest way. Just develop the habit of chewing
Paan Masala or Gutka regularly and you will succeed in meeting Mr. DEATH easily.
This is indeed the truth. The other side of your habit of eating "Paan Masala" is very
dark and unbelievable.

What is Paan Masala, Gutka ?
Paan Masala = Powdery mixture of betel nut, lime, arecanut (Supari) in various
proportions.

Which class of people eat paan masala? Who are the persons affected by this
habit?

Nowadays eating paan masala has become a "Status Symbol". This habit is common
in all socio-economic class. A labourer eats it to take rest from his work and to freshen
up. A high class executive eats it to show how "modem and advanced" he is ! A school­
going kid eats it as an experiment, or just to copy his parents. The house wife eat it after a
day's cooking and after food. College boys eats it to make a time-pass at "nukkad".
So in the end, everybody falls prey to this temptation of so called "freshening" his/her
mouth with this "slow poison".

Is paan masala a real "Slow poison"?

Yes, According to various studies carried out at national and international levels, it has
been proved beyond doubt that paan contains "Mutagens" which can change our
normal tissues into cancer tissues, and can causer a progressive disease called, "Sub
Mucous Fibrosis" (SMF).

What is SMF? How does it happen?
SMF means Sub Mucous Fibrosis... i.e. a permanent thickening and hardening of the
inner lining of the mouths. The various materials used in paan masala causes irritation
to our mouth, which gradually leads to thickening and hardening. Then gradually the
mouth opening decreases and a day comes when the victim will not be able to open
his mouth at all.
The tongue will lose its roughness and will becomes smooth and white. Taste
sensation wilFbe lost. You will not be able to tolerate spicy foods. All these things
happen slowly but progressively and are guarrantecfto happen.

What is more dangerous then SMF?
Oral Cancer. The person who is a habitual chewer has a 400 times greater risk of
getting oral cancer because SMF is a precursor to oral cancer. And all of you are
aware of the fatality of oral cancer.
Can we prevent SMF?
Yes, stop the chewing habit and SMF will leave you (only in its early stages).
How can "Plastic Surgery" help patients with Sub Mucous Fibrosis?

In patients with established SMF, the mouth opening is restricted and the inner lining is
permanently damaged. These problems can be treated by the various plastic
surgical techniques listed below.

a. The hardened bands can be removed surgically.
b.
The
wider area of thickened tissue can be removed and new skin can be placed
there by a plastic surgical technique called "Excision and Skin Grafting".
Whenever surgeons want to give the patient, a soft, moist, pliable cover, then a
c.
special procedure of making use of a portion of the tongue to cover the cheek
has to be done - a "tongue in cheek" or a "Tongue Flap" operation.
Similarly, the excess skin from the outside of the cheek can be placed inside
d.
the oral cavity by a operation called - '^Nasolabial Flap" surgery.
e.hijections of steroids into the hard tissues are also helpftil.
Creams and jelly for local application and massage are of a temporary nature.
f.
All these operations are to treat the complications caused by paan masala. To prevent
recurrence of SMF you have to give up this habit permanently and immediately.
VAoO-LcO

ckU?

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Dangers of chewing tobacco
Answered by Kim Loos, DDS

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1 of io

Do you have any information about
the dangers of chewing tobacco? How
do I teach my sons that chewing
tobacco is harmful when their favorite
baseball players chew?

SPONSORS

DON'T MISS

J

A. Numerous studies have shown that dipping snuff or
chewing tobacco can lead to oral cancer. Oral cancer, if left
unchecked, can be fatal. This is why oral cancer screenings
should be part of every routine dental examination. An oral
cancer screening is quick, easy, and painless.

It is estimated that about 40% of all major league baseball
players and about 30% of all minor league baseball players
chew tobacco or dip snuff. One study found that about ,59%
(83/141) of major league baseball players that use smokeless
tobacco already have lesjons-that may develop into cancer.
This is very alarming news! Dr. John Greene, a former dean at
University of California at San Francisco Dental School,
examined 141 professional baseball players during spring
training. According to the April 9, 1998 edition of the San
Francisco Chronicle newspaper, fifteen players had serious
lesions that required biopsies. It was reported that Curt
Schilling, an excellent pitcher, quit using snuff after a
dangerous lesion was detected in his mouth.
2/24/00 11:36 AM

Pregnancy: Exposure Concerns: Dangers of chewing tobacco

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dangerous lesion was detected in his mouth.
During a biopsy, a sample of the lesion is removed to
determine if the cells are cancerous. Cancerous lesions may
be treated using a combination of surgery,' chemotherapy, and
radiation. Oral cancer can spread Io the lymphatic system.
However, oral cancer can also be successfully treated if it is
detected early.

Some players claim that chew enhances.their athletic
performance. However, Robertson et al. (1995) reports that
"the use of snuff and chewing tobacco is unrelated to whether
or not a baseball player makes it to the major leagues, or how
he hits a ball, fields a hit or throws a pitch." However, they did
determine that the use of smokeless tobacco is correlated with
the presence of oral lesions.
Smokeless tobacco has been banned by all youth baseball
leaguesrthe National Collegiate Athletic Association and all of
Major League Baseball's minoFieaque clubs. The Professional
Baseball Athletic Trainers Association also discourages the '
use of~smokeless tobacco (Connolly et al. 1995).
Onfortunately, smokeless tobacco has not yet been banned
from the American or National Baseball Leagues. The leagues
do cooperate with the Rational Spit Tobacco Education
Program to discourage children from usinq.tobacco. When
people team up with tobacco, they lose.
Additional information

• Oral Cancer: Prevention and Detection
• Chewing Tobacco and Cancer
• Smokeless Tobacco and Oral Cancer
• Teenager Has White Spots In Mouth
• Detecting Oral Cancer / Extraoral Examination
• Oral Cancer Information Center
• Spit Tobacco Prevention Network
. Spit Tobacco
• Tobacco Intervention Network
• Facts About Oral Cancers
References:

2 of 10

2/24/00 11:36 AM

Pregnancy: Exposure Concerns: Dangers of chewing tobacco

fi!e:///E|/OFFICE/zebaysh/0,3105,7071,00.html

. Connolly et al., "Commentary: It's time Major League
Baseball made tobacco history" J. Am. Dent. Assoc.
(1995) pp. 1121-1124.
• Christen et al., "Smokeless tobacco addiction: a threat to
the oral and systemic health of the child and adolescent"
Pediatrician (1989) 16(3-4):170-177.

. Robertson et al., "Smokeless tobacco use: How it affects
the performance of Major League baseball players" J.
Am. Dent. Assoc. (1995) pp. 1115-1121.
• Greer et al., "Oral tissue alterations associated with the
use of smokeless tobacco by teenagers. Part I. Clinical
findings" Oral Surg. Oral Med. Oral. Pathol.(1983)
56(3):275-284.

• Connolly et al., "Snuffing tobacco out of sport" Am. J.
Public Health (1992) 82:351-353.
. Glover et al., "The smokeless tobacco problem: risk
groups in North America" Shopland DR, Stotts RC,
Schroeder KL, Burns DM, eds. Smokeless tobacco or
health, an international perspective. Bethesda, Md.:
National Institutes of Health, (1992) NIH publication no.
92-3461:3-10.
• Centers for Disease Control and Prevention. "Use of
smokeless tobacco among adults - United States, 1991"
MMWR (1993) pp. 42:263-266.

• Greene et aL, "Oral mucosal lesions: clinical findings in
relation to smokeless tobacco use among U.S. baseball
players" Shopland DR, Stotts RC, Schroeder KL, Burns
DM, eds. Smokeless tobacco or health, an international
perspective. Bethesda, Md.: National Institutes of Health
(1992) NIH publication no. 92-3461:41-50.
• Robertson et al. "Periodontal effects associated with the
use of smokeless tobacco" J. Periodontal. (1990)
61(7):438-443.

3 of 10

2/24/00 11:36 AM

VALUE OF TAKING HISTORY OF TOBACCO CONSUMPTION IN PRIVATE
PRACTICE
OP Kapoor
Hon Visiting Physician, Jaslok Hospital and Bombay Hospital, Mumbai,
Ex Hon Prof of Medicine, Grant Medical College and JJ Hospital, Mumbai

400 008.

Many G. Ps do not have any idea about the ways in which tobacco could be absorbed by
the body. One of
the methods is:
I.Smoking
smoking cigarettes
a.
smoking bidis
b.
smoking hukka (Arabic countries call it shisha)
c.
chilam
d.
The tobacco can be consumed through the mouth in the following ways:
II.
a. Applying tobacco paste couple of times a day, popularly known as kudaku.
To put raw tobacco in the mouth with or without supari which could start from a
b.
"saada
tobacco" and going upto 120-160-300 and about 600 strength. This tobacco could
also be^put
in the pan. Khainee is the commonest tobacco used in Maharashtra.
Very often Pan Parag contains tobaccoJn various forms.
c.
There is a preparation known as Gutka which-contains_a_vervJieayy dose of
d.
tobacco and
supari and many other ingredients which the Indian patients keep in the mouth and
consume
5-10 times a day..The most costly and strongest gutka is Manekchand_Gutka.
Tobacco is often used in pan as "Kemam".
e.
Tobacco
III.
could be consumed in the form of snuff as is done by Pathans and many
Maharashtrians.
Finally,
IV.
the Yemenese patients consume tobacco in the form of "qat".

All the above oral methods can lead to oesophagitis, gastritis, stomach ulcer, duodenal
ulcer, cancer of the
oral cavity, severe stomatitis and leucoplakia. Also tobacco increases hypertension and
the symptoms of
coronary, artery disease.
Finally, smoking in any form is the commonest cause of cancer of the lungs. In addition,
it causes ischaemic
heart disease,_COP.D_ and duodenal ulcer.

Every doctor practising in India should be aware of consumption of tobacco and the
history should be elicited
in detail and not by a casual question - do you smoke?

To Section TOC

V4 oAa.

10 O wa

(AAo vij-

Indian Journal of Community Medicine Vol. XXII, No.2, Apr.-Jun . 1997

17.

Americans and other adolescents in the Northwest.

II.

Correlates of adolescents use of smokeless

1586-1588.

tobacco. Health Education Quarterly, 1989; 16(1):
91-100.

Kaplan M, Carriler L, Waldron 1. Gender

differences

12.

in

tobacco

use

in

18.

Kenya.

Smokeless tobacco use in adolescent females:

310.

prevalence and psychosocial factors among racial/

ethnic groups. Journal of Behavioural Medicine,

Schaefer SD, Henderson AH, Glover ED, Christen

1990; 13(2): 207-220.

tobacco consumption in school age children. Acta

19.

Hughes JR, Hatsukami D. Signs and symptoms

Otolaryngol. 1985: 111: 639-642.

of tobacco withdrawal. Archives of General

Rinchuse DJ, Rinchuse DJ, Browdie GS et al.

Psychiatry, 1986; 43(3): 289-294.

Demographic and

20.

psychosocial characteristics

Prabhu SK. Wilson WF, Daftary DK, Johnson

of western Pennsylvania school age tobacco users.

NW (Eds.). Oral diseases in tropics. New Delhi:

ASDC Journal of Dentistry for Children, 1992;

Oxford Medical Publications, 1993.

59(6): 425-436.
14.

Riley WT, Barenie JT, Mabe PA, Myers DR.

Social Science and Medicine, 1990; 30(3): 305-

AG. Patterns of use and incidence of smokeless

13.

Colbom JW, Cummings KM, Michalek AM.

American Journal of Public Health, 1988; 78(12):

21.

Epidemiology, etiology and prevention of

Lu CT. Lan SJ. Hsieh CC et al. Prevalence and

periodontal diseases. WHO Technical Report

characteristics of areca nut chewers among junior

Series 621. Geneva: WHO 1978.
"22?) Anonymous. Oral Health.-ICMR_Bulletin,.J-9-94;

high school students in Christian Hospital.
Community Dentistry and Oral Epidemiology,

24(4): 51-55.

1993; 21(6): 370-373.

15.

Acknowledgements:

Many PJ, McDermott RJ, Williams T. Patterns

of smokeless tobacco use in a population of high

We wish to acknowledge our thanks to Dr. D.K.

school students. American Journal of Public

Srinivasa, former Director - Professor of Preventive

Health. 1986; 76(2): 190-192.

16.

and Social Medicine for his advice in the initial stages

Cohen RY. Sattler J. Felix MRJ, Brownell KD.

of the study, Dr. S. Chitra. Dental Surgeon cum tutor,

Experimentation with smokeless tobacco and

for her suggestions while conducting the study, Dr.

cigarettes by children and adolescents: Relationship

D.S. Dub.ey, Director, JIPMER for his encouragement,

to beliefs, peer use and parental use. American
Journal

of Public

Health,

1987;

the staff of JIRHC Ramanathapuram for their help

77(11):

during the study and the women who participated in

1454-1456.

the study for their cooperation.

Co ntd. from Page 53
References:
I.

Annual report: Registration of Births & Deaths
Act I960 Union Territory Chandigarh 1983.

2.

World Health Organization; International
classification of diseases - Ninth Revision,

Organisation, Geneva. 1993.
5.

6.

Survey of causes of death (Rural). Annual report

Act

Registration

of

1969.

Territory,

Union

Births

Martin Bland, An Introduction to Medical

Statistics, 1987.

1990: Series 3: No. 23.

7.

World Health Statistics Annual 1992. World Health

Chewing Habits of Women

Report.

Deaths

Chandigarh 1990.

Geneva. 1977.
3.

Annual
and

Gupta SC, Kapoor VK, Fundamentals of

Mathematical Statistics, 1980.

81

Jagadeesan et al

Indian Journal of Community Medicine Vol. XXII, No.2, Apr -Jun , 1997

CHEWING HABITS AMONG RURAL WOMEN IN PONDICHERRY
M. Jagadeesan, S.B. Rotti, M. Daiiabnlan, K.A, Narayan
DcpiU'tincnt of Preventive and Social Medicine

JIPMI-R. Pondicherry- 605006

Abstract:

Research question: I. What is the prevalence ofchewing habits among rural women?
2.

What are the factors associated with their use?

Objectives: To find out the prevalence of chewing habits and correlates of chewing habits.

Design. Cross-sectional descriptive study.
Participants: Females aged 15 years and above.
Study variables: Age. educational status, marital status, occupation, income, type of family, age of starting habitual chewing.
persons influencing chewing habits and reasons lor continuing the habit.

Outcome variable: Chewing habits.
Statistical analysis: Chi-square test. Analysis of variance. Odds ratio and Logistic regression.

Results: The prevalence of chewing betel quid was 2-1.6%. betel quid with tobacco 13.7% and betel nut 0.2%. Mean age of starting
betel quid was 22.7 years and betel quid with tobacco. 16.5 years. Friends were the most inllucncing persons for starting the
habit. The most common reasons for continuing was craving for the substances. There was direct relationship of chewing habits
with age"and inverse relationship with educational sla"is. The chewing habits were more prevalent among married women and
women engaged as agricultural labourers.

Conclusion: Chewing betel quid with or without tobacco is a common practice among rural women. It is influenced by socio­
cultural factors.

Key words: Rural women, betel quid, tobacco, chewing habits

Introduction:
India has a very long tradition in the usage of

The effects of tobacco and chewing substance

betel quid and betel quid with tobacco. It is a part

are well known. Several studies have been conducted

of Indian culture, perhaps there is no person in India

in India on tobacco use.

who has not chewed betel quid some time or the

concentrated on tobacco and its effects. Very few

other1. Different studies have given different prevalence

studies have reported about tobacco use and its

rates in tl._ country on the usage of betel quid. In

correlates. In order to reverse the rising trend of

Most of them have

1994 Mehta et al have estimated that there were about

chewing

400 million betel quid chewers all over the world2.

quantify the problem and to identify the determinants

substances

studies

are

required

to

India is third among the world's nations leading
in tobacco use’. WHO (l.988\has estimated that lliere

and their distribution. The available information is

were around 100 million tobacco users in India and

has to be area-specific because variations are

Pakistan alone4. In the world, tobacco use is increasing

known to exist between areas. Hence this study was

bv 2% per annum, in developing countries _it is

conducted to find out the prevalence of chewing

increasing by 3.4% and in developed countries it is

habits and to describe the characteristics of women

decreasing by 0.2%'.

with chewing habits.

limited to a few studies. Moreover, this information

74

Indian Journal of Community Medicine Vol. XXII, No.2, Apr-Jun . 1997

not available during three consecutive visits in a month

were excluded from the study. The data was tabulated
I'he study was conducted in the service area
of Jawaharlal Institute Rural Health Central (J1RHC),

Ramanathapuram. Pondicherry, which is the rural field

with the help of Foxbase and Epi info-6 softwares.
Chi-square test, analysis of variance (ANOVA), odds

ratio and logistic regression were used for analysis.

practice area of the Department of Preventive and Social

Medicine. Jawaharlal Institute of Postgraduate Medical

Results:

Education and Research (JIPMER), Pondicherry.
The total women in the age group of 15 years
and above were 2370 and it was decided to study

1000 women. To compensate for loss due to exclusion

The percentage of women chewing betel quid
was 26.6%, those chewing betel with tobacco was

13.4%, while the remaining 60% were non-chewers.

1100 were selected. Since the study population was

Majority in betel quid group started their habit

almost half of the total population so systematic random

when they were between 11 and 20 years of age

sampling was used taking alternate houses. In the

(45.7%). In betel quid with tobacco group majority

sampled houses all the females of age J.5_years &

of them started before the age of 11 years (41.8%).
TlieTnean age of those who started with beteTquicf

.il'oxe were included. Chewers were defined as chewing
either regularly or intermittently for at least six months.

was 22.7 years, whereas for the betel quid with tobacco

1‘he information was collected by an interview' and

it was 16.5 years. This difference was statistically

observation of substances used for chewing. Women

significant (p<0.0l) (Table-1).

i able I: Age of starting chewing habit
Age group

Beta! quid

Betel quid + tobacco

(in y<jars)

(n=243)

(n=!22)

Lpto 10 y ears

6.5

41.8

11 to 15

21.0

16.5

78

16 to 20

24.6

14.8

64
53

21 to 25
26 to 30
31 to 35

36 & above

1 otal

‘

Tut::!

71

19.3

13.9

16.9

9.8

17

6.2

1.6

15

5.5

1.6

100.0

Mean age lor starting'in Betel quid group = 22.7 years

67
100.0__________________365
All figures are percentages.

Mean age lor starting in Betel quid with tobacco group= 16.5 years

Variance between samples- 31.26.20
Residual variance= <82.52

Chewing Habits of Women

Jagadeesan et al

Indian Journal of Community Medicine Vol. XXII, No.2, Apr.-Jun., 1997

Around 50% of the chewers of both categories

other influences were from parents (only mother or

were influenced by their peers. About one-fourth of

both) and other relatives in the house. These differences

the betel quid chewcrs and a few (2.3%) of betel

in the persons influencing the onset ofchewing habits

quid with tobacco chewers started on their own. The

were statistically significant (p<0.01) (Table-ll).

Table II: Persons influencing onset of chewing habits

Betel quid

Persons

Betel quid +tobacco

_ ______________________ (n=243)_____________

(n=122)

Peer

59.5

Self

23.8

2.3

Both Parents

5.9

11.5

Mother alone

3.3

22.7

Others

7.5

Total

53.3

10.2

100,0_______________

•

________________ 100.0______________

Figures shown are percentages.

Table III shows the reasons for continuing the

the beiel quid and tobacco chewers (90.6%) and among

chewing habits. There were multiple responses. Among

27.3% in betel quid group. The other reasons quoted

betel quid chewers more than half (64.1%) used it

on special occasions, to prevent wastage or for fun.

were: to prevent sleeplessness, oral odour, tooth ache.
dullness, salivation, to suppress appetite and to relieve

Craving was a reason for continuance by most of

soreness of throat

Tabic III: Reasons for continuing the habit

Reasons

On special occasions

Betel quid

Betel quid+tobacco
(n=243)__________________ ________________ (n=l22)___________
31.6

0.0

Craving

27.3

To prevent wastage

18.5

90.6____
' 0.0

For fun

14.0

1.6

Sleeplessness

13.2

0.0

Oral odour-------------------------------------------

11.5

After meals

6.7

6xF~

Tooth ache

6.1

13.1

Dullness

4.9

Soreness of throat

4.9

Salivation

4.5

13.9

Suppression of appetite

2.4

13.1

Others

2.0

4.0

13.9

•

4.0

There were multiple responses.

Chewing Habits of Women

76

Jagadeesan et al

Indian Journal of Community Medicine Vol. XXII, No.2, Apr.-Jun., 1997

Betel quid chewers were influenced mostly by

Discussion:

their friends followed by their parents. These results

In this study it was found that there were mainly

are similar to those in the studies conducted by Rinchuse

three.types of substances which were used for

et al” and Lu et al14. Among the women who chew

chewing. They were 1) betel nut alone, 2) betel quid

betel quid with tobacco, this study has shown that

and 3) betel quid with tobacco. Since the number

majority were influenced by friends followed by parents.

of betel nut users was very small (19), they were

This was similar to the findings of Schaefer et al12,

clubbed with betel quid chewers group for further

Marty et al”, Hall et al"1, Cohen et al16, Colborn et

analysis.

al1’, Claire' and Rinchuse et al'3. Other studies have

The present study showed a prevalence of 26.6%

showed that they were influenced by negative

for betel quid chewing. Other studies have found that

prevalence of betel quid chewing was 9.5% among

perceptions15, image, low self esteem, increase in
disposable
income.
lack
of
knowledge,

Bangladeshi women6 and 42% among Aborigines in

advertisement etc.'.

China7.

The women under study mentioned some reasons

The prevalence of chewing betel quid with

for the continuation of the habit. The results indicated

tobacco was 13.4%, Various surveys conducted in

that the majority of the betel quid chewers were

India between 1960 to 1970 have revealed prevalences
among women varying from_3% in Srikakulam' to 49%

occasional chewers. In South India there is a tradition

in Pune. A surv.ey_r.eport.-af 1CMR ptLblished_in 1993

there is a ritual to offer betel quid to Gods on

showed a prevalence of 12% all over India8. George

auspicious days and festivals. Most of the women

et al have reported a prevalence of 29% in coastal

who observed / attended these festivals I special

areas of Kerala". Reports from other parts of the w orld

occasions were tempted to chew these substances.

showed the prevalence as 4% in American natives"’

The betel quid offered to god was either distributed

to offer betel quid on special occasions and similarly

and 0 to 49% in various parts of Kenya".

to some one who chewed it or they themselves

consumed it to prevent wastage. Some women used

The women studied could recall the age al which
they started chewing even though long periods of recall

it for fun. There were some women who were

were involved. The youngest age for starting chewing

dependent on betel quid. These women had a craving

was 5 years. As children, they used to take the

for it when they did not have it, they would get

substance from the bags of their mothers who were

sleeplessness, bad oral odour, tooth ache, dullness,

chewing. Such women found the habit interesting and

salivation and sore throat. Summers et al6 have listed

continued to do so. Those who started the habit at

the reasons for chewing - just as a habit, pleasant/
refreshing, good for oral cavity and relief of pain.

a later age were influenced mostly by their friends.
In the present study the mean age of starting betel

In the present study most of the tobacco users

quid was 22.7 years whereas it was 17 years among

continued because they had a craving for it when

Bangladeshi women in U.K.". The proportion of betel

they were not getting it. This might u-note addiction

quid chewers who started before the age of 10 was

to a certain extent. .In other studies it was found that

o.b% as compared to 18% as reported by Summers

the usage was due to tooth related complaints2 which

et al'. Summers et al have also reported that betel

was much less in the present study. The present study
results were similar to those reported by Huges and

quid chewers started the habit earlier than tobacco

Hatsukami” and Prabhu2”,

chewers". However, in the present study, it was the
reverse. The proportion of women who started tobacco
before the age~ of 10, Was 41.8% in this study Other

Analysing the factors associated with the
chewing habits showed the following results. Age is
a significant factor related to chewing habits but it

workers have reported higher proportions: 89% by
Schaefer et al'-" and 57% by Hall et al1".

Chewing Habits of Women

has not been studied in great details in earlier studies.

79

Jagadeesan et al

Indian Journal of Community Medicine Vol. XXII, No.2. Apr.-Jun., 1997

of rural women had chewing habits out of whom

The present study revealed that below the age of 29

years betel quid chewing was practised by only 7-

13% were chewing tobacco. It also gives information

I6% of women. Beyond 29 years of age it was in

on mean age of starting and the reason for onset and

the range of 31-47%. Similarly the proportion of women

continuing besides the influence of age. educational

status, occupation and marital status. Such information

chewing tobacco was negligible between 15 and 24
years. Thereafter it ranged between 5% in the 25-

may help the health authorities to evolve strategies

29 years age group to 44% in the age group of 60

to reduce the problem.

years and above.
References:

The influence of marital status and type of family
on chewing habits have not been reported in the other

I.

Shanta V, Krishnamurthy S. Further study in

studies reviewed. The present study has shown that

aetiology of carcinoma of the upper alimentary

married women and widows indulged more in chewing

tract. British Journal of Cancer, 1963: 17(1): 8-

compared to the unmarried. The type of family was

not a significant factor. Further studies are required

2.

to assess the role of these factors.

Mehta FS, Hammen HI, James E (eds). Tobacco
related oral mucosal lesionsand conditions in India:

The prevalence of chewing habits decreased with

A guide for dental students, dentists and

increasing level of education. As the educational level

physicians. Bombay: Basic dental research unit.

advanced, women came to know more and more about

TATA Institute of Fundamental Research. 1994.

the ill effects of tobacco and other chewing habits
e.g. the causation of cancer and other morbidities like

3.

I liramani AB. Verma SP. Social aspects in tobacco

4.

Smokeless tobacco control. WHO Technical

5.

Claire CT. Women and Tobacco Geneva: WHO.

6.

Summers RM. Williams SA. Curzon MEJ. The

use. Swasth Hind. 1994; 38(5): 101-102.

heart diseases etc. Generally there was a feeling that
chewing tobacco was a habit of older generation21.

Report Series 773. Geneva: WHO 1988.

This significant result was comparable with those
reported by George et al among fishermen community

in coastal areas of Kerala'1.

1992.

Majority of the study population were agricultural

labourers. They were using the substances while at

use of tobacco and betel quid ( pan') among

work in the fields. It helped them delay their meals,

Bangladeshi

made them feel pleasant and it gave a good odour

women

in

West

Yorkshire.

Community Dental Health 1994; II: 12-16.

from mouth. Many of them were craving for these

7.

substances. This finding was similar to that reported

Ko YC, Chiang TA. Chang SJ. Hsieh SF.
Prevalence of betel quid chewing in Taiwan and

in studies conducted by ICMRS”. The next major

related socio demographic factors. Journal of Oral

occupational group was of housewives. Ko et al have ■

Pathology and Medicine. 1992; 21(6': 261-261.

reported that chewing habits were more common among
8.

blue collar workers’.

Anonymous. Role of health personnel i;i tobacco

control. ICMR Bulletin. 1993: 23(5&6j 45-50.

In the present study the income-wise distribution

9.

of chewing habits was not statistically significant.

George A. Varghese C, Sankaranarayanan t. Nair

Studies conducted by 1CMRS22 in 1993 and 1994 and

MK. Use of tobacco and alcoholic beverages by

Ko et al’ have reported that chewing habits were more

children and teenagers in a low-income coastal

common among the lower income groups.

community in South India. Journal of ..nicer
Education. 1994: 9(2): 111-113.

Conclusions:

10.

The present study has shown that about 40%

Chewing Habits of Women

Hall RL, Dexter D. Smokeless tobacco use

attitudes towards smokeless tobacco among nat > e

80

Jagadeesan et at

Indian Journal of Community Medicine Vol. XXII. No.2, Apr.-Jun., 1997

of rural women had chewing habits out of whom

The present study revealed that below the age of 29

years betel quid chewing was practised by only 7-

13% were chewing tobacco. It also gives information

16% of women. Beyond 29 years of age it was in

on mean age of starting and the reason for onset and

the range of 31-47%. Similarly the proportion of women

continuing besides the influence of age, educational

chewing tobacco was negligible between 15 and 24

status, occupation and marital status. Such information

years. Thereafter it ranged between 5% in the 25-

may help the health authorities to evolve strategies

29 years age group to 44% in the age group of 60

to reduce the problem.

years and above.
References:

The influence of marital status and type of family

on chewing habits have not been reported in the other

I.

Shanta V. Krishnamurlhy S. Further stud}

in

studies reviewed. The present study has shown that

aetiology of carcinoma of the upper alimentarv

married women and widows indulged more in chewing

tract. British Journal of Cancer. 1963: 17( 11

compared to the unmarried. The type of family was

X-

23.

not a significant factor. Further studies arc required

' 2. J Mehta FS, llammcn HI, James E (eds). Tobacco

to assess the role of these factors.

related oral mucosal lesions and conditions in India:

The prevalence of chewing habits decreased with

A guide for dental students, dentists and

increasing level of education. As the educational level

physicians. Bombay: Basic dental research unit.

advanced, women came to know more and more about

TATA Institute of Fundamental Research. 1994.

the ill effects of tobacco and other chewing habits
e.g. the causation of cancer and other morbidities like

3.

I lirainani AB. Verma SP. Social aspects in tobacco

4.

J Smokeless—tobacco control. WHO Technical

5.

Claire CT. Women and Tobacco. Geneva: WHO.

6.

Summers RM. Williams SA. Curzon MF.J. The

use. Swasth Hind, 1994; 38(5):

heart diseases etc. Generally there was a feeling that

chewing tobacco was a habit of older generation-'.

101-102.

Report Series 773 Geneva: WHO I OSS.

This significant result was comparable with those

reported by George ct al among fishermen community
in coastal areas of Kerala''.

1992.

Majority of the study population were agricultural

labourers. They were using the substances while at

use of tobacco and betel quid ( pan’) among

work"In the fields. It helped them delay their meals.
inade them feel pleasant and it gave a good odour

Community Dental Health 1994; II: 12-10.

Bangladeshi

women

in

West

Yorkshire.

from mouth. Many of them were craving for these
7.

substances. This finding was similar to that reported

Ko YC. Chiang TA. Chang SJ, Hsieh SF.

Prevalence of betel quid chewing in Taiwan and

in studies conducted by ICMR8”. The next major

related socio demographic factors. Journal of Oral

occupational group was of housewives. Ko el al have

Pathology and Medicine. 1992; 21(61; 261-261.

reported that chewing habits were more common among

Anonymous. Role of health personnel in tobacco

blue collar workers7.

control. ICMR Bulletin. 1993; 23(5&6) 45-50.

In the present study the income-wise distribution

9.

of chewing habits was not statistically significant.

George A. Varghese C. Sankaranarayanan t. Nair

Ko et al7 have reported that chewing habits were more

MK. Use of tobacco anil alcoholic beyemecs by
children and teenagers in a low-income coastal

common among the lower income groups.

community in South India. Journal of . .nicer

Studies conducted by ICMRs:: in 1993 and 1994 and

Education, 1994; 9(2):
Conclusions:

10.

The present study has shown that about 40%

Chewing Habits of Women

111-113.

Hall RL, Dexter D. Smokeless tobacco use
attitudes towards smokeless tobacco among nut i c

80

Jagadeesan et >il

cik-

'

Lt4^sl

\) VC

16 AUG 1998

Ministries divided over
ban on pan masala
By Our Special Correspondent
CHENNAI, Aug. 1 5.
Conflicting views of the Ministries tippear to
stand in the way of the Centre imposing a ban
on pan masala/gulka etc.
The Government of India appears to be in a
dilemma with the Ministry of Food Processing
Industries as well as the Department of Small
Scale Industries and Department of Consumer
Affairs favouring the ban and the Ministries of
Labour, Agriculture and Commerce voicing
rservations over the move.
It may be recalled that the CentraEciohllnftfee"
for Food Standards (CCFS), a statutory commit­
tee constituted under- the Prevention of ;Food
Adulteration Act (PFA) recommended the' ban
following a report of an expert technical com­
mittee which held that consumption of gutka
and chewing tobacco are hazardous to health
causing oral submucous fibrosis (OSF) and oral
cancers.-'
Meanwhile, the Directorate of General Health
Services, in a communication to the States and
Union Territories, has called for a massive edu­
cation and public awareness campaign in high­
lighting the horrifying health effects caused by
gutka.
It has suggested preparation and screening of
video materials in schools tind colleges with the
help of the teaching fraternity to drive home the
message to the public through members of local
bodies and NGOs besides organising lectures, ex­
hibitions and hoardings.
An inter-departmental committee under the
n chairmanship of Dr.H.Narasimhaiah, former
I
Vice-Chancellor, BangaloreJJniversitK-cOnstituI
ted by the Karnataka government in April last
year, has among other filings, recommended a
I ban on the riiahufacture aniFsale of gutka, proI hibition of advertisements in print and electroni ic media that encourage the consumption of
tobacco products and use of services of NSS,
I NGOs and autonomous institutions to highlight
i the evil consequences of gutka consumption.

The committee was also in favour of imposing
' ■' a heavy tax on tobacco products and to make
use of the revenue therefrom to educate the gen­
eral public on the harmful effects of consump­

tion of tobacco products. The Karnataka’
Government intimated the Union Health Minis­
try that (he recommendations of the Narasimhaiah committee were under its consideration.
The State Government had also mentioned that
Dr.Narasimhaiah had not recommended substi- .
tution of ingredients which were proved inju­
rious to health by other ingredients.

The Union Ministry of Food Processing Industries as'well as the Department oTSmalTScale
Industries and Departmen t of Consumer Affairs
arc in favour of Utelbah. These Ministries’ along
with the Ministry of Education and Ministry, of •
Information and Broadcasting .havesuggested’

1
I
\
\

vigorous cainp.iigii propagating the adverse

J

-,

health cltects.oj.panmasala ;mdTnitlca~

On the other hand, the Ministries of Labour,
Agriculture and Commerce have voiced strong
reservations against the ban, citing unemploy­
ment problem of labourers engaged in the gutka
industry, adverse effect on the interest of tobac­
co growing farmers and their unwillingness to
grow alternative crops considering the high
price of tobacco and its products.
The ban suggested by the expert committee

|

comprising leading cancer experts and other sci­
entists was on the strength of a comprehensive
review paper prepared by the Indian Council of
Medical Research and other scientific evidences
produced by research institutions.

The committee, after careful deliberations at
four meetings held in October 1994. February
95,. March 96 and September 97, concluded
that consumption ofgutka and chewing tobac­
co are hazardous to health causing oral sybmucous fibroris (OSF) and oral cancers.
The recommendations of the committee were
considered by the CCFS which, at its meeting
held on November 26 and 27 last year, strongly
recommended a total ban on. use of tobacco in
pan masala/gutka by itself or tis an ingredien t in
any food item.

c
t
t .
t

c

As for the gutka trade, organised-sector, and i
unorganised sector accounted for an annual ’
turnover of RsJLiOO-and-Rs.J.OOO.irores-respec- ..
lively,-in respect of pan masala, chewing tobac­
co and gutka. according to figures made
available to the Centre.
I

3)75
T

OF

It 3 AUG 1991

Ban on gutkha ads
at Ganesh mandals
Hema Gobindram Lobo
THE Thane assistant commissioner
ojjhe FDA. R V Yadav, has. an­
nounced that the display of gutkha
and paan masala advertisements wJIL
be banned at Ganpati mandals in
Kaly.an,-Thane, Navi Mumbai,,
Bhiwandi and Ulhasnagar as well as
the talukas of Thane district such as
Palghar, Dahanu Road and Talasari.
Penalties for violating these in­
structions of the FDA will have to be
determined by the civic authorities,
said an FDA official, stating that the
FDA did not have the manpower
necessary for strict monitoring.
Meanwhile, paan shops which
have been doing roaring business,
selling gutkha— mainly to teenagers
and college students— are in for a
lean season. In the wake of the In­
come Tax raids on the 'gutkha king'
and widespread reports that plans
are afoot to ban the sale of gutkha.
several paanwallahs say that their
source of maximum profits is drying
up. Fresh paan is not their main busi­
ness anymore because it is becoming more expensiye~Ey~the"dayT
"A ban on the sale of gutkha will
mean a loss of at least Rs 100 a day,"

you lor you.- Pe^Al°«ro’.noinlndU«;idyd

said Laloo Bagher, a paan shop
owner in Vashi. But right now it's a
case of making hay when it's pos­
sible by selling Manekchand gutkha
at a premium.
‘The supply of Manekchand brand
gutkha has actually been sealedTqr
the moment,’1 a supplier said, add­
ing "this has resulted in a hike in sup­
ply pffce from Rs_lZ5-foca-box-oL50
sachets to Rs 225. Naturally, we
have to charge,our customers more,
but they don't mind paying a rupee
or so extra."
“But even at an Increased price,
there is no regular supply,"
saidanother paan-seller at CST sta­
tion, adding that, thankfully, at least
six other-brands of gutkha were eas­
ily available in the wholesale market.
Whatever the problems of supply
it is clear that as long_asJheieJs_a
strong demaoifor gutkha,.a.barton
its sale will no.Lhaye_much_e.ffect.A
ban on production is a must, insist
social activists who say that there
has to be constant vigilance to en­
sure trfat small cottage industries do
not produce the addictive masala
and counter the crackdown on the
big manufacturers.

ClVffh

W<W/ .a/o S3M1M

6^,

1

1

ri'M'7 .

1

Crutka addiction on the rise m Kerala ,
By P.K. Surendran
The Times of India News Service
THIRUVANANTHAPURAM: Pan masala or "gutka” which comes in an attractive aluminium sa­
chet is catching on with teenagers in Kerala. This
addictive-looking stuff, which comes from North
India, has become a new challenge to the state’s
grim fight against tobacco-related cancer.
The studies by the Regional Cancer Centre
(RCC) have brought out the startling fact that 10.2
per cent of the 420 students in a prominent wo­
men's college have used pan masala many times
while three per cent had been habituated to it.
The corresponding figure in the boys’ college was
12 per cent and four per cent respectively. Sample
surveys in other colleges in the state brought out
that some 12 per cent of college-going students
are becoming addicted to pan masala.
Babu Mathew, chief of the cancer centre’s com­
munity oncology'division told this newspaper on
'Wednesday that between 40 to 50 per cent of Kera­
la men suffer from tobacco-related cancer. The
smoking habit in women is far less due to social
stigma attached to it. However tobacco-related
cancer (pan and masala-chewing)-in-wotnen_syas
-fStmcTtobe 16 per cent.

The RCC plans to relaunch a "toj>acco free smoking in public offices. This has at least prehome" which it had successfully did in*1993-94 to vepted people smoking while working. The con­
relieve one laktrhomes free from tobacco. The firmed smokers would go out of the office to puff,
school-going children are first given simple fact- but it also had the risk of earning the wrath of the
based booklets or bills to be handedTiver to~par- boss who may find the person unavailable on the
ents who smoke. This would be followed by the seat when required.
visit of a group of school children who will extract
' Chief minister E.K. Nayanar, ironically a confira promise from the smoker not to smoke at least in mecTbeedi-smoker from his “revolutionary days,"
the children's presence.
has tolcfthe assemblyrnTWednesday that the gov­
This would eventually result in reducing the in­ ernment was concerned at the growing use of to­
take of smoke far less than usual, and infuse in the bacco among the youths. According to Mr Naya­
elders' a sense of guilt that will help them fight nar, 43 percent of 30 million population of Kerala
the urge for smoking. The children are then given are u~snjgtbBaccojn.one form or another. The sav­
a sticker to place on their front-door proclaiming, ing grace is that the women addicted to smoking
"This is a smoke-free home. Please co-operate."
are only 0.67 per cent.
A new difficulty, says the anti-tobacco league, is
The RCC would then contact the elders who
quit the smoking and inquire if any help was re­ that many people are found to be smoking and
quired to fight back the withdrawal symptom^ chewing pan together. This makes the battle
"Wejoun.dJajheJollaw.-up-that.82.pe£cent_who_ against tobacco a more long-drawn affair.
promised tp.the. children never_to_smoke again
The chief minister, while answering questions
stuckto.the.pledge,"Dr.Mathew.said..
in the house. said 1.86 lakh people become sick of
The centre now plans to enlarge the scheme to tobacco-relatedUls every year in the state. They
cover a larger target, the doctor said.
Tufier from oral,lung and throat cancers.
Alarmed at the widespread prevalence of srnokMr Nayanar, however, said the government had
ing among government employees jhe state gov- not yet proposed to ban pan masala. Nevertheless,
ernment had, in July 1995, issued ordgrs_to_ban. some curbs are being contemplated, he added.

BUSINESS
(CALCUTTA)

3 ’ JUL

Govt wants impact
of exposure to ™
gutka assessed
M Ahmed
NEW DELHI
he health ministry has decided to order a comprehensive study
into tire ill effects or otherwise of ‘Gutka’ Pan Masala and other
tobacco-based chewing substances. This follows demands from anti­
tobacco activists to ban Gutka sales.
The Rs 200 crore Gutka and pan additives industry has had to con­
stantly face the ire of the anti-tobacco lobby, which has come up with
various statistics to “show” that these substances are carcinogenic. .
Government sources say various representations had poured in
from the states seeking a ban on Gutka and the health ministry did not
want to take a decision on it without first making sure that Gutka
imperilled public health.
,
The job of conducting the study will be given to a public or private
agency, say sources. At present, there is no clinical research or data on
this subject, which makes it difficult for the government to accept the
anti-pan masala lobby’s contention.
While there are sufficient pointers that prolonged exposure to cig­
arette and beedis causes cancer, no such medical evidence has been
collected in tire case of Gutka.
Nevertheless, producers have to carry a notice that Gutka con­
sumption is harmftil, as in the case of cigarettes, since Gutka, too, is
tobacco-based
Sources said the study would take a few years to do a comprehen­
sive analysis of long-term exposure to Gutka.
In the meantime, no action is planned against Gutka and Pan
Masala manufacturers..
Some states like Andhra Pradesh have declared Gutka harmful
and imposed heavy excise duty and sales tax to discourage its use.
Andhra this year raised duties from 10 per cent to 50 per cent._
While the anti-Gutka lobby is are trying to discourage its use, the
industry is growing.
Most of the players are in the small sector, except the Kotharis who
have a Rs 50 crore operation in the pan masala area. The industry is
growing at over 10 per cent a yearwith an annual production of 50
tonnes, according to unofficial estimates.’ —
Government source said the heavy expenditure incurred on
advertisement by this industry indicated the high level of profits.
While the manufacturing facilities required are relatively modest, the
major outgo of funds iexpenditure is on packaging, distribution and
advertising.
Some state governments have banned certain additives in Pan
Masala. Tl^e Food and Drug Administrations (FDA) in Maharashtra.
West Bengal, Andhra Pradesh and Karnataka have initiated action
againstmanufacturers for use of certain banned additives in Gutka
and Pan Masala. _
However, analysis by the Food and Drug Administrations has not
found tlie full Gutka compound as being harmful.

T

All tvantJjpn., but fewready to give up gutka
By Sameera Khan
By Sameera Khan

Khanvilkar, general secretary of
—j-q j_ Khanvilkar, general secretary of
the Mumbai Beedi Tambaku Vya­
pari Sangh. “Almost 70 per cent of
those who us?d to cheiy.paarL(betel
quid) and other traditional forms of
tobacco have switched to gutka."

MUMBAI: The city’s paan-beedi
shops will wear a deserted look on
Friday when the BMC initiates ‘No
Gutka Day'. Following soon after
‘World No Tobacco Day', which
was observed on May 31, ‘No Gut-

ogy department of
Tata Memorial Hospital (TMH).
Now, there is a case almost every
other week. “We are especially see­
ing young adults in the age group
between 25 and 35 —many of them
began consuming.gutka_when they
were as young as 13," says Dr
Surendra Shastri, head of the pre­
ventive oncology department at
TMH.
7------Five years down the line. Dr
Shastri expects to see many more
cases of OSF. which if not treated in
time can cause cancer of the oral
cavity. Gutka also puts a person at

TIMES OF INDIA (town

to see. Till 1996, no one under the
age of 20 was seen with Oral Sub­
mucous Fibrosis (OSF) — precancerous lesions in the mouth which
are a direct result of consuming
gutka — in the t------ ----------------

- 4 JiJH

“We want to make people of this
city aware of the dangers posed by
gutka to their health." says deputy
mayor Dr Ram Barot, who has tak­
en the lead on this issue.“Increas­
ingly, we find young students falling
prey to gutka — a mixture of tobac­
co. arecanut and other additives —
and that is quite worrying for us.”
Support has been extended to
the BMC by the 10,000 members of
the Mumbai BeediTambaku Vya­
pari Sangh who will not sell gutka
on this day.
According to the Sangh, gutka
sales in the city have surpassed
even cigarettes and beedis. "It’s a
big fad among blue and white collar
workers as well as among young
people i Mumbai,” says Jagannath

risk for gingivitis (inflammation for a ban of manufacture and sal
gingivitis (inflammation for a ban of manufacture and sale
and recession of the gums) and pre- of gutka. The Maharashtra Food
cancerous lesions such as leuko­ and Drug Administration made a
plakia (white patch) and erythro- requestfolthe central governrifent _
plakia (reddish patch) on the inner fora ban on 62.bran<Js_of gutka. '
found to be contaminated with
lining of the cheek.
“Over a period of time tobacco magnesium carbonate, in July
deteriorates health in many differ­ _12S7.The request~is still'pending,
ent ways,” says Colaba-based fami­ according to Madhu Shinde, joint
ly practitioner Dr Virsen Ruparel. commissioner (vigilance), Maha­
“Tobacco users are more likely to rashtra FDA. The Indian Medical
suffer from high blood pressure, Association has "also supported
_______________ _cardiac problems, Such a ban.
"But then, India remains least reg­
caused by ham­ ulated with regard to sale and pro­
motion of tobacco products in gen­
pered blood circulation."
In such a scenario, why can't we eral. In most states — except for
simply say no to gutka every day of Delhi, Assam. Meghalaya_Sjkkim.
'Goa_ahd soon Madhya Pradesh —
the year?
“It’s not that we earnestly want Tt is legal to promote and advertise
to sell gutka, especially to school tobacco products openly (except on
children. In fact, it’s a sin to sell Doordarshan and All India Radio)
something so destructive," says Mr as well as to sell cigarettes and gut­
Khanvilkar of the Mumbai Beedi ka to people under 18.
Tambaku Vyapari Sangh. “But “A ban is not the only thing that
rather than armtwist us into not works. Sometimes self-regulation
selling it, we want the government and awareness works better," says
to ban the' manufacture of gutka it- Dr Barot. “Maybe awareness can
self.”
~~
create the social and political will
Tfiere have been other demand's;-.-that is necessary for future ation.”

u
cn

TIMES CF INDU\ (eombay4

- 6 MAY 1999

,

Lethal Masala tjjrhH

According to a study conducted by the Indian Council of Medical
• Research, paan masala and its variations like gutkha are potential
i death-traps with just two to three years of habitual consumption lead■ ing to oral cancer. Mouth and throat cancer account for 18 to 20 per
■ cent of cancer cases in India, mostly induced by tobacco-based prod' ucts. We have the world’s second highest incidence of oral cancer. Paan
masala is a deadly pot-pourri of tobacco, arecanut andsynthetjJiEarSa
. (lime), besides also containing lead, arsenic aiid^magnesium^carbon■ ate. Some leading brands have even been found to contain cadmium
- andjiickcl. Habitual and regular chewing of this aromatic and addic-,
- Uve masala corrodes the delicate inner lining of the mouth and throat, L
\veakening the protective cell layer, making it fertile ground for can­
cer. While cigarettes and bidis are traditionally the mainstay of the
male population, paan masala is popular among women, possibly be­
cause the social stigma associated with smoking tobacco is absent.
Many view it as a harmless mouth freshener and even college and
School students have acquired the habit. Most habitual chewcrs are
unaware of its harmful effects.’Flic Tata Institute of Fundamental Research screcned over 300,000 oral cancer patients throughouLthe
Country and has established beyond doubt that tobacco, betelnut and
"paanmasala chewing lead to mouth and throat cancers and can ad­
versely affect other organs too.
A public interest litigation filed in the Delhi high court in March this
year submitted a plea to ban the production, distribution, storage, sale,
'advertisement and consumption of this product, quoting the shocking
case of four college students whose tongues had surgically tobe re­
moved as the boys were afflicted ’with oral cancer induced~by chewing
paan masala and gutkha regularly for just two yearsfit seems failure to
remove their tongues would have provedTaCal.Two decades ago, when
commercially produced paan masala changed the profile of paan
shops throughout the country, it was trendy for Members of Parlia­
ment to pass around their tin dabbas filled with heady granules of
buff-coloured masala.The product’s success led several manufacturers
to enter the market with their own recipes and brands. Paan shops
were recognisable from a distance, decorated with garishly coloured
paan masala pouches. Today our parliamentarians should take the
lead in limiting the damage being caused by this product. Kerala has
already banned paan masala from the state. Public awareness is the
key to public health; the government should, therefore, step up mea­
sures to create this awareness as a blanket ban may prove impractical
in the near future.The consequenLdeclinejn.excisejtev.enue and displacement of the labour involved in production will have to be taken
intoascount while framing an appropriate policy. Some pouches al­
ready carry a statutory health warning that chewing the product is in­
jurious to health; this should be made mandatory and its sale to minors
^should be prohibited.
(

T>75

TIMES OF INDIA

1 4 MAR 1999

CSpurt in tongue cancer
,slvjn young people^
ln

■ ,

By Kalpana Jain
The Times of India News Service

NEW DELHI: Four college friends, aged 20 to 24, recently had to lose a
part of their tongues. The reason—all of them were addicted to pan.
masala.
,,0ne after another, all of them developed symptoms of cancer on their
tongues, explains Dr S. Khanna, director of the Qlmramshihi Cancer Hos­
pital and Research Centre, Delhi.The four friends who had been together
smctFscliool days, had formed it habit of excessive eating of pan masala,
she said.To avoid the cancer from spreading further a part of their tongues
had to be removed. Dr Khanna is one of the experts attending the eighth
national conference of the Indian Society of Oncology...
Concern over the continued use of‘gutka,’ pan masala and tobacco use
in various forms has been voiced by experts from time to time. But the in­
creasing use of these products by younger people calls for more than mere
concern, they say. It needs urgent government policies to ban the use of
some of these items. Head of the department of oncology at B. Nanavati
Hospital, Mumbai, Dr Ashok R. Mehta, said that tongue cancers are being
seenmore and more in young people. And this may well be very early
z signs of a much larger increase in tongue cancers in young adults.
It takes several years for the effects of life-style related cancers to ap­
pear. For instance, says Dr Mehta, women started smoking only after
World War II, but the effects of it were seen much later.
These experts also criticised the advertisement of cigarette companies
by cricket stars, who are role models for millions of youngsters.

J) 7 5
- 4 May 1399
TIMES OF INDIA

Deputy mayor

On his campaign against
gutka
ow do you propose to create

awareness among people
Habout
harmful effects of gutka?

I am trying to persuade the mem­
bers of the paan and beedi asso­
ciation to observe June 4 as antigutka day. On that day, no paanbeedi shop in the city would sell
gutka and negotiations are cur­
rently on with their president
Sharad Rao. The campaign
against gutka is a long one. Even
as the chairman of the health com-1
mittee, I tried to create awareness
among citizens to abstain from j
gutka. But a larger effort Is •
required from the sellers as well. ,
ow many people In Mumbai
consume gutka?
The statistics show that in
Maharashtra, 72 per cent of the

St

H

people use tobacco, of which 16
per cent take It In the smokeless
form, that Is gutka. It Is Important
that we curb this addiction, espe­
cially among teenagers, as it brings
a lot of problems along with it.
sn’t the lobby of gutka owners
and sellers very powerful?
We had two meetings with the
owners of various tobacco giants
in the country at the Food and
Drug Administration office. It was
agreed upon that just like ciga­
rettes. gutka packets should also
carry statutory warning at the bot­
tom. Some regulations were also
worked out. It was pointed out that
no tobacco should be sold within
500 metres of a school or temple.
The ground work is ready and now
in my capacity I plan to execute it.
ut banning might be difficult as
the government earns huge
revenue from them.
This is a hitch, but steps need to
be taken. I have written to
Parlinment to consider this pro­
posal. Till that comes through, I
will create awareness in the city
on the harmful effects of gutka.
The Tata Memorial hospital and
various NGOs are helping this
process.
Kanlza Lokhandwala ,

I

B

3

7D7£
liiVx-S CF

I MAR 1333

3)7j~/Tor

>i3.m

THE TIMES OF INDIA, MUMBAI,

Students fight gutkha menace
By Somlt Sen

MUMBAI: Twelve-year-old Nalin
(not his real name) loves to play
cricket and admires the batting
style of Sachin Tendulkar. But now,
chewing gutkha after school has be­
come more important to him than
playing a game of cricket.
Nalin, a slum resident, was intro­
duced to gutkha by a close friend a
few years ago. He now suffers from
oral cancer and can barely open his
mouth.
“There are several more children
like Nalin who need to be educated
about the consequences of chewing
gutkha,” said Ms Himanshi
Dhawan, who along with a team of
10 other students of social commu­
nications media department of
Sophia Polytechnic presented an
audio-visual, programme, IGutkha
and Orali Cancer’, at .k_
the college
premises recently.
“The public should be made
aware of the dangers of chewing
gutkha. Prolonged chewing can
sometimes lead to oral cancer,” Ms
Dhawan said. The team of 11 stu­

dents researched the subject by re­ Thaker resolved to quit the habit.1
ferring to books, newspaper arti­ I le has now succeeded in persuad­
cles, and meeting doctors at Tata ing over 40 other residents to_‘_saj^‘
Memorial hospital, Mumbai, and nojogutkha\_ .
other health centres in Delhi and
“Through the audio-visual pre­
Pune.They took nearly five months sentation, we want to alert citizens
to complete the project.
about the symptoms of oral cancer
“Children are tempted to con­ and the preventive steps that could •
sume gutkha either by friends or be undertaken,” Ms Tinaz Nooshi-'
the local panwalla, who might offer an stated. Some of the symptoms of 1
the first few sachets free of cost,” oral cancer were : white, red or
said another student, Ms Mridula black patches inside the mouth '
submucous
fibrosis); soreness
Palat. “Nowadays, gutkha_sa_chcts (oral
;
--- -------are available for as cheap as 50’ in the mouth; difficulty in chewing
paise— which is the price of a tof- and
■ J swallowing:
" ~
“* j■
persistent
change
feeTThis tempts children to buy in voice and lump in the throat and
more. It may later develop into a neck. Persons found with such
habit. Although children know that symptoms should be immediately
consuming gutkha might be detri­ taken to a doctor, Ms Nooshian
mental to their health, they arc not added.
,...r
aware of the symptoms
and dan“We want to reach out to as j
gers of oral cancer.”
many people as possible,” Sophia
yhe 15-minute audio-visual pro- Communications Media depart- '
gramme dealt with real life inci­ ment head Jeroo Mulla said. “Be- ■
dents. It narrated the horrendous sides television, we will also target
tale of city resident Manoj Thaker, re_sLdcnlsjnjhuns_ancLyillagcs of '
whose addiction to gutkha left him Maharashtra. We are expecting a '
with a disfigured face. After being few non-governmental organisa­
operated for oral submucous fibro­ tions and schools to assist us in this f
sis (OSF) on three occasions, Mr project,” she added.

JA
g

7

State Govt to seek ban on gutkha
nl'IQT &

jdis/ie

■ 82 samples of gutkha found substandard by FDA; up to 2.36 % of nicotine found in it
PRAFULLA MARPAKWAR
pqT.IT. Maharashtra Food Adulteration (Preven­
MUMBAI, JAN 18
~l~ tion) Rules, 1962, which will be forwarded to
the Central Committee for Food Stan­
aharashtra has decided to
dards.
move the Centre to amend the
“Since the original law is a Central legis­
Food Adulteration (Prevention)
lation, it is necessary to take a permission
Act, seeking immediate ban on consumpfrom the Centre. In view of the ill-effects of
tion and sale of gutkha iqthe.entire state.
consumption of gutkha, I think the Centre
“No doubt, following the ban, we will
will concede our proposal,” Aher said.
i
lose quite a large amount of revenue as stiles
Aher said following in-depth analysis of
tax, but it was essential to take a drastic step
the samples of gutkha by Food and Drug
for protecting the health of the society and
Administration (FDA), it was revealed that
also from preventing the younger genera­
they contained magnesium carbonate, used
tion from becoming gutkha addicts,” Health
as anti-caking agent and nicotine (0.67 to
i
Minister Daulatrao Aher told The Indian
2.36percent). The Food and Drug Admin­
Express.
istration also found that 82 samples of
Aher said the government has drafted a
gutkha were substandard.
1 comprehensive amendment to the Food
“The consumption of these two items is
I Adulteration (Prevention) Act, 1954, and
injurious to health. Besides, studies con­

(F U M B A Y )

M B1AN EXPRESS

j
I

M

ducted by leading organisations have re­
vealed that in 90 per cent of the cases, cancer
was caused by consumption of gutkha or to­
bacco,” Aher, who is also; a qualified sur­
geon, said. The HealthMEuster saidwhe'n
The proposal for imposing a ban on con­
sumption and sale of gutkha was being dis­
cussed, the question1 of loss of revenue also

figured prominently;
According to records, if the ban is im­
posed, the loss of revenue will be to the ex­
tent of RsT8.lt> crore for the State and Rs

49.91 crore to the Centre towards the excise
duty
"
“Out of the 400 gutkha manufacturers in
the country, 20 are in Maharashtra and their
'turnover is estimated at Rs 179'crore, while
1050 persons are involved in manufacture
and distribution ofgutkha,” the Health Min­

ister pointed out “Since it is adversely affects
the health of persons consuming gutkha, we
should ignore the loss of revenue, which can
be recovered from other avenues,” Aher
added. The Health Minister said there was
nojales taxon tobacco-based gutkha as of
ilow.
, ■
“We are charging fiyeper cent luxurytax
on gutkha, while we arelevying 13 percent
sales tax on pan masala,jtudies by leading
research institutions have revealed con­
sumption ofboth can cause oral cancer,” he
said. Replying to a question, Aher said mere
banning the sale ofgutkha will not serve the
purpose as there is no agency to implement
such a prohibitory order effectively.
“Under such circumstances, consump­
tion as well as sale of gutkha should be
banned.” he observed.

THE A S’AN AGS
BOMBAY

1 5 JUN Ws

Gutka is pre=canceroos, no

cure in sight: TIFR study
—

By Preeti Deshpande
Mumbai, June 14: Studies con­
ducted independently by the Tata
Institute
of
Fundamental
Research and the Tata Memorial
Hospital has concluded that regu­
lar and prolonged consumption
of gutka causes sub-mucous
fibrosis, a pre-cancerous condi­
tion. The studies, conducted
independently by Dr Surendra
Shastri at TMH and Dr P.C.
Gupta at TIFR, researched data
collected over 30 years and
established that rhe incidence 7>f
SMF had- increased-ten-fold in
India. Dr. P.C Gupta, head,
department of epidemiology,
TIFR, says, “In front of our eyes,
we have seen the disorder change
from a little known enigmatic
disease to a virtual epidemic.” Dr
Gupta’s study included randomly
examining the mouths of com­

muters outside CST station o’n
Tobacco Day, to check for the

incidence of SMF. Dr Gupta con­
cluded that the affected age
group was between 25 and 35
years of age, a huge shift from
earlier studies, where the disease
was restricted to people over
forty years of age. Even more
alarming is the fact that there is
no known or accepted cure for
SMF.

'^SPOTLBGHT
SMF is a condition found only
among Indians, or people of
Indian origin. Dr. P.C Gupta
says, “Since it was confined to
the Indian population, its cause
had something to do with Indian
habits. As the symptoms included
a burning sensation in the mouth,
it was initially thought to be
caused by chillies.”
Explaining the effects of SMF,
Dr Shastri, head, department of
preventive oncology, TMH, says,
"Regular and prolonged use of

137S/AA

gutka, say about four to five
packets a day, over eight or nine
months, will cause SMF, a precancerous condition that causes
the. tissues in the mouth to hard­
en . Eventually the patient cannot I
open his mouth, as the mucous
membrane lining the mouth cavi­
ty becomes inelastic and cannot
stretch. In such case the patient
may not be able to speak, or eat
without a straw.”
"Since the disease is highly pre
cancerous, an afflicted person is

400 limes more likely to get oral
cancer than one not afflicted. In
oilier words since gutka contains
about 60 per cent tobacco it~~is
already highly carcinogenic. As
gutka has a high probability of
causing sub mucous fibrosis, the
chances of a gutka user getting
cancer are that much higher.”
Gutka comprises roughly of 50
per cent areca nut, 50 per cent
Tobacco sandai~~wood powder.

■Turn to Page 11

Gutka is pre-cancerous, no cure in sight
■Continued from page 9

I^Msiuni carbonate, and flavouringagents and additives.
Says Dr Shastri, “Many of these •
ingredients irritate die sensitive
mucous membrane and fibrous tis­
sues in the mouth, which over time
harden and become inelastic, so
that patients cannot open their
mouths, causing sub mucous fibro1 sis. Tell tale symptoms are dis­
coloured patches on the palate and
I the inside of the cheek. These may

be white or dark coloured. Other individuals showed symptoms.
Then it was mainly a disease of
signs are non healing ulcers or
legions in the mouth. Since only 2(1 the older generation. A sixties .
per cent of the tobacco consumed- _study put its highest incidence "at
i n India is in the formof_cig arc tics. 03 per cent in parts of Kerala . In
Jbaifon cigarette smoking.is inef- ‘94 its incidence had jumped to
lective unless you curb other forms one in three individuals. Dr Gupta
like gutka or pan masala. As these adds a study done in rural Gujarat
are more socially acceptable than ,still under publication, revealed
cigarettes, their use is harder Io that eighty per cent of those afflicted were below 45 years of age, 45 •
Research on the disease started in •per cent below thirty ’five.
Estimates say that 65 per cent of
the early sixties whe.n.nne-in-thirty

,jr-C2D: Thia photo oopy la being aupplla-'
or voor personal rafaranoo and study

Indian men use tobacco in some
form, the most common being
beedis. gutka. and masheri. Con­
trary to public opinion, cigarette
smoking is restricted to a minus­
cule percentage of the population.
90 per cent of oral cancer patients
are tobacco chewers, who use
tobacco in either pan or gutka or
other variants. Moreover. 55 per­
cent of all cancer cases in India are
preventable, and arise largely due
to tobacco use in its desi forms.

Health Ministry isolated on gutka ban
NIRMALA GEORGE
NEW DELHI. MAY 8
HE Health Ministr}'seems

INDIAN EXPRESS

Tto have bitten off more

than it can chew on the is­
sue ofbanning gutka with a host of
ministries opposing the move.
An inter-ministerial meeting
held last week revealed the kind of
pressures that have come to bear
on the Ministiy ever since an ex­
pert committee ruled that chewing
tobacco and pan masala flavoured
gutka are carcinogenic and recom­
mended a ban on its production.
Opposition to the move has
mainly come from the Labour.
Agriculture. Commerce and In­
dustry ministries.
According to Health ministiy
officials, ultimately the decision on
the ban will be a political one. The
government will have to decide
whether it can afford to face the
outcry that would ensue.
The gutka industry which is ag­
gressively campaigning against the

move is appealing to the 'swadeshi ’
terest litigations (PIL) seeking a
And this is quite apart from the
Ban on gutka pending before the
sentiments held dear by the BJP.
numerous state farmers’ delega­
Madhya Pradesh arid Maharash­
They feel that since gutka is a onetions and gutka and pan masala
traHigHcourts respectively.
hundred per cent ‘stwnfa/n’indusmanufacturers, who have taken
* In the light of the activist role
try. the BJP would not let it down.
their protests on the move to ban
taken on by the courts, should ei­
At the meeting. Labour min­
gutka to no less than the Prime
ther of these courts decide to go by
istry officials did some plain-speak­
Minister.
ing about the more than 4 lakh
the findings of the earlier expert
The Health ministry has
bought itselfsome rime Eyseeking
committee and ban the sale of
workers employed in the gutka
and related industries who will be
chewing tobacco, then the Health
expert views on steps to curb the
ministiy will have
rendered job­
a way out of the
less. The Agri­
Any decision on the planned gutka ban
culture min­
problem.
Groups like
istry was no threatens to be a political one as the
All India Pan
less vehement
gutka lobby quotes swadeshi backed by the
MasaTa and To­
about
the
bacco Manufac­
plight of thou­ many ministries including Labour
t
urers
Associa^
sands of farm­
tion feel that the
ers currently
government should not impose a
consumption of chewing tobacco
growing areca nut and spices for
and the socio-economic pros and
ban till it finds conclusive evidence
the pan masala industry.
about the carcinogenic nature of
cons of ordering a ban on the sale
Not to be left behind, Finance
pan masala containing tobacco.
ministiy mandarins fretted about
of such products.
And as proof they cite historical
But a way out of the current ‘to
the loss in excise revenues. Com­
evidence that tobacco chewing has
ban or not to ban’ dilemma that
merce and Industry ministries
the Health ministry finds itself in,
been common in India and large
wrung their hands about the effect
parts of the world since thousands
may come from an unexpected
on the Rs 6.000 crore pan masala
quarter. There are two public in­
ofyears.
industry and other related sectors.

The Association recently met
Prime Minister Atal Behari Vaj­
payee to plead their case and to
press for an in-depth study before •
any decisions are taken.
For the numerous fanners’ del- ■
egations that have been entreating !
Union Health Minister Dalit
Ezhilmalai, a ban on gutka could i
be a matter of life and death.In
some states like Karnataka, espe­
cially the Shimoga and North and i
South Kanafa areas, farmers have i
in recent years tumedto areca nut
famringeversincelhe-popularityof |
pan masataandgutka, caught on.
Health experts say the govern- j
mentis well within its rights under j
the Prevention of Food Adulter­
ation Act, 1954, which empowers it 1
to prohibit the sale of any sub- i
stance which may be injurious to I
health. But gutka manufacturers )
feel the law should be applied i
equally arid a ban on gutka should
be matched by similar action
against known carcinbgens~Uke,
cigarettes, bidis and even alcohol..

fm TXLEGK i>-ll
CALCUI I -

Tobacco lobby suffers setback

Govt mulls ban
on gutkha ,v:>
FROM OUR SPECIAL
CORRESPONDENT

meeting to decide the issue. The
participants met to come up
with a policy statement, which
New Delhi, May 5: The govern­ the health ministry will place
ment will soon mount a massive before the Union Cabinet, for
radio and television campaign further action.
But it is the data provided by
against tobacco-chewing as a
first step towards a ban on the the labour ministry that is wor­
manufacture and sale of zarda, rying the officials. If the gutkha
gutkha and smiilar products.
trade is put under a blanket ban,
The Union health ministry it will create serious problems
dccidedto ban’ chewing-tobacco for nearly four lakh workers in
about a couple of months ago? the organised and the unorgan­
The ban was proposed during the ised sectors, an official said.
United Front government’s term
Health ministry officials,
ahd was tmfielast stages ofpro- however, reminded their coun­
cessiiig when_theZBJP._gOY.em- terparts in other ministries that
ment was sworn in.
some measure had be taken to
The BJP government was hes­ curb the trade, in view of . the
itant about an instant and blan­ recent courLJudgmentsin a
ket ban due to pressure from the number of public interest litiga­
tobacco lobby and worried abouT tions relating togutkha.
its repercussion on millions of
Health ministry sources said
addicts across the country.
that it was the PILs that had
“East-evening, the health min­ prompted the government to con­
istry convened a meeting which sider the’ban;---------- ~~
MeaSwhfie. tlie All-India Pan
was attended by officials from '
several other ministries. All par­ Masala and Tobacco Manufac­
ticipants, including those from turers’ Association has demand­
the departments of labour, indus­ ed a countrywide survey of oral
tries and finance, agreed on the cancer patients to find out if
peed to discontinue sale of these chewing of tobacco is behind the
products, but they were unsure growing incidence of such cases
.-A\
of the wisdom of an immediate of cancer.
A ban, the association insist­
ban on their manufacture.
An1 inter-ministerial commit- ed, could only follow such a com­
. tee ~Was~Tofhied at yesterday’s! prehensive, countrywide survey.

^r.>nsT-CBDi This photo oopy lo being supplier
• r<M« end atudv

J>?5
THl B'N®0

n3 APR w

f Ban on pan masala not now: Ministry
chewing tobacco labelling it totally bad for

By Our Stall' Reporter
NEW DELHI. April 12.
The Central Government is actively consid­
ering a move to ban the use ofchewing tobacco
in pan masalas and gulkas. The ban. if imposed.
will have far-reaching social and political impli­
cations as nearly 10 crore people .(kpeudent on
the industry, direfily of indirectly, stand.tolose
their livelihood.
The inter-ministerial committee is scheduled
to meet to consider the matter. The approval by
the committee is being regarded as a mere for­
mality. However, while confirming that the mat­
ter was under the consideration of the Health
Ministry, a senior official said there was no ques­
tion of such a ban being imposed in the near
future. The meeting, scheduled for tomorrow.
part of the consultative process. A proper
^Rcedure, which includesinviting and clisposmg of objections woukLhave to be~followed as

'part of the consultative exercise before a nolification imposing such a ban was issuedT the
official, said.
A committee of experts appointed in 1994

has affeady recommended a ban on chewing
tobacco faking the view that it is not only harm­
ful for health but is a causative factor for cancer.
The committee's recommendations have al­
ready been endorsed by the Central Committee

of Food Substances (CCI S)._ On lhe oilier band.
the committee itself stales that the pan masala
industry was likely.to touch the Rs. f.OjKlcmcemaflCin 1997.-However, the'committee makes
nb" mention of the more harmful effects of smok­
ing tobacco nor has it taken into account the
consequences of such a ban.
The expert committee has favoured a ban on

nocrOST-CBD: Thin photo copy
..
far your personal rel

n<dp£AtataJsde/BXsJie claimed it had suggesl-

health. Interestingly, it states that epidemiolog- eilTHat, in fact, chewing tobacco could be used
ical studies linking oral cancer with the use of as a way to wean'hway peopfe~Irom the harmful
pan masala are currently not available. It goes .addiction of smoking. The detrimental health
on to explain that the habit of chewing pan effects of cigarette smoking including the in­
masala containing tobacco is of recent origin creased risk of cancer, heart and circulatory dis­
and the suspected disease (oral cancer) has a orders and respiratory diseases are well
long incubation period and_anyepidemiologlcal ■ established.
study carried out at this lime will no the useful.
The study states that a public heath policy
“Similarly, it“gocs on to equate the Mainpuri
tobacco and the 'mawa' habit as having the that recognises smokeless tobacco as an alterna­
same harmful effects and has put the pan masa­ tive would benefit individuals confronted with
the unsatisfactory option of abstinence or con­
la and gutka brands in the same category.
Pan masala and gutka manufacturers have tinuing to smoke.

opposed the move of the Centre, saying it will
Mr. Aggarwal said scientists in the Central
adversely affect crores of people connected with Tobacco Research Institute. Rajamundry, And­
the trade. The worst-hit will be the agriculturists hra Pradesh. Mr. Murty Rao and Mr. Gopalchari.
from Gujarat. Karnataka and Assam.
have stated that" such chewing of tobacco or its
Arguing their case, the Zafrani Zarda Manu­ presence in gutka is far less harmful, if at all. in
facturers Association's organising secretary. Mr. comparison to the direct smoking of tobacco
Ashok Aggarwal. said around two crore individ­ such as cigarettes, cigars and bidis". Figures
uals comprising of panwalas, vendors, hawkers with the association point out that 1,51.000
and distributors, whose livelihood depended on smokers developed cancer compared to 6.000 in
this industry would be out of work. The tobacco the case of smokeless tobacco users. Similarly,
industry provided employment to over 50 mil­ heart and circulatory problems occurred in
lion people, including tobacco and areenut 1,80,000 people and respiratory complications
growers, processors, transporters, silverbeaters, in another 85,000 whereas no such diseases
perfumeries, packers and sellers. It contributed affected users of smokeless tobacco.
nearly Rs. 700 crores last year in the shape of
excise duties. The States collected more than Rs.
He felt the ban was being Imposed at the beh­
300 crores in the shape of sales tax.
est of multinational companies to wipe out the
Industry
and r
provide
For its part, the Association pointed out that- "domesticchewifig'tbbacco
,
o
_
since smoking was more harmful than chewing • an open fieldtoTheMNCs which are planning to
tobacco It should be banned first. The experts, market
' * *'their
L’- cigarette products. He asked why
they felt, had “conveniently overlooked" the only the smokeless tobacco Industry was being
harmful repercussions of smoking tobacco for meted out this step-motherly treatment and the
reasons best known to them.
tobacco industry, with a strong lobby, had been
Quoting from the study in the American ]our- left out.

INDIAN EXPRESS

'Govt likely to ban gutkha |
and chewing tobacco
I
AJAY SURI
NEW DELHI. APRIL 11
COURTING controversy, the
Union Health Ministry is working
on a proposal to ban the manufac­
ture and sale of chewing tobacco
and Gutkha across the country. A
draft notification is ready and is ex­
pected to be soon presented to the
Cabinet for its approval.
But before that, an inter-minis­
terial meeting has been called.
Slated for next week, the meeting,
to be chaired by Health Secretary
K B Saxena, wfiTseek the opinion
of the Agriculture, Commerce,
andFinaiice Ministries.
This is being done in view of the
far-reaching consequences the
proposed ban will have - affecting
the livelihood of millions of farm­
ers as well aspaan and Gutkha sell­
ers, and countless consumers
across the country.
The decision also threatens to
pose a political fallout given that
most of the estimated 1,000 to­
bacco and Gutkha companies op­
erate from Uttar Pradesh, Maha­
rashtra, Gujarat and Rajasthan all BJP-ruled states.
The basis of the Health Min­
istry’s move is a report of an expert
committee set up in 199‘t3ufing'

.cgD: Thio Photo copy
_
___» n.r.nnal rel

points out association secretary
J
Ashok Aggarwal, is not of recent
»
origin but has been “on since the
<
Mughal times, and even before.
Certainly, tests could have been
<
carried out long ago.”
$
Aggarwal alleges that the.gov•
emment’s move is at the behest of
i
thecigarettemanufacturers’lobby
;
who want to capture new markets. ‘ j

the tenure of then Prime Minister P
V Narasimha Rao. This commit­
tee which is now headed by Direc­
tor General of Health Services
(DGHS), S P Aggarwal, recently
submitted the report to the gov­
ernment recommending a blanket
ban on all chewing tobacco prod­
ucts. Incidentally, this committee
has met only four times in the last
fouryears.
The committee, ironically, has
admitted it doesn’t have conclusive
evidence to link chewing tobacco
wi t h orafcanceri
According to tire minutes of its
last meeting in September ’97
made available to The Indian Ex­
press: “It was brought out that epi­
demiological studies linking oral
cancer with the use ofpaan masala
containing tobacco are currently
not available...since the habit of
chewing paan masala containing
tobacco is of recent origin and the
suspected oral cancer has a long in-’~|
cubation period, of 15 to~2(J years,
any epidemiological study carffedj

“There is evidence to show that
cigarettes cause cancer. But the
cigarette lobbyjs.more-poweriul,
they are untouched.”

»
J
'
[

The committee’s report has
drawn its conclusions on the adverse affects of consumption of
chewing tobacco and Gutkha
based on studies conducted by
three institutions : National Institute of Nutrition, Hyderabad; Regional Cancer Institute, Tfrivandrum in collaboration with Johns
Hopkins University, USA; Chittaranjan National Cancer Institute, Calcutta.
The committee, constituted to
go into the‘use ofchewing tobacco

J
<
J
•
■,
!
<
J
j•
;
<
j
;
j

out at this time would not be use­
ful.”
The chewing tobacco lobby—
it recently formed an umbrella as­
sociation called Zafrani Zarda
Manufacturers Association—de­
bunks this. Tbbacco chewing,

inpaan masala and Gutkha and its
effect on public health’, reports
there has been a “tremendous
growth” in the chewing tobacco in­
dustry from Rs 200 crore revenue
in 1992 to well over Rs 1,000 crore
in 1997. .

>
’•

study

By Our Special Correspondent
CHENNAI, April 1.
A ban on pan parag was demanded in the
i^^AssemblyTbday by the L)MKr~CPI~5nd~CPf(M)
.

i^^rnembers who expressed their deep concern over
the alarming speed at which the chewing habit
spread, especially among the student popula­
tion. Mr. K. Subbarayan (CPI) asserted that no
ope had the right to play with the lives of the
people as pan parag promoted cancer.
The Health Minister. Mr. Arcot N. Veerasamy,
expressed the Government’s inability to impose
the ban as there was no such, ban on liquor and

cigarettes

The Minister said that pan parag

promoted the disease "sub mucous fibrosis”
which was a prelude to the onset of cancer
The Cancer Research Hospital at Kancheepuram and the Chennai Government Denfal ColTege had done_extensive7research on theHisease
promoting qualities of pan parag and“cautioned
the people through the Government-sponsored
dental camps.
Mr. Chengai Sivam (DMK) insisting on a ban
cited the opinion of world health experts which,
he said, testified to the fact that pan parag pro­
moted cancer more than liquor or cigarettes.
The CPI(M) member. Mr. D. Mony said that
another product Manikchand was also catching
up with the people and it was being sold, partic-

ularly in front of schools and colleges to lure tl
youth. He said the Government should create .1
awareness among the people and the yo> th
about the harmful effects of these products.
Mr. Veerasamy said constant use of th' «
stimulants would result in the shrinking of 4e
muscles controlling the mouth resulting in diffi­
culty in swallowing food. This would be before
the onset of regular cancer.
The Minister said the Government would ex­
amine whether it could get funds from World
Bank and Central Government for launching a
campaign for creating awareness .about the
harmful effects of pan parag as it did in the case
of AIDS prevention.
_•

T hio p h o to

THE HINDU

Members seek ban on pan parag .

ID 71
2 1 m W8

State bansi^tta
sale near schools.
Vajpayee government will
bring in tobacco ban: Aher
By Our Special r
CORRESPONDENT. '-’^ 'jv.

government at best takes notice of
the issue raised and assures appro­
priate action. Dr Aher had to be
pouches of less than half a kilo
prompted by Mr Pramod Navalkar
will be banned and so will the sale
to urge Mr Mungantiwar to with­
of gutkha within 100 metres of draw the motion.
educational
institutions,
slate
Considerations like handsome
health minister Dr Daulatrao Aher revenue from the sale of such
assured
legislative- Assembly
pouches will not come in the gov­
members on Friday. With the new
ernment’s determination to stop
sale of gutkha, . he added.
Atal Behari Vajpayee government
“Maharashtra is capable of col­
in New Delhi, Dr Aher was confi­
lecting : enough revenui'through
dent that the state proposal for a
complete ban on gutkha and
other sources,” he said when a
tobacco will be accepted.
member pointed out that public­
welfare, schemes of prohibition in'
The niatter came up during a
non-govemment motion moved
other slates like Haryana and
Andhra Pradesli Had collapsed
by Bharatiya Janata Party MLA
from
Chandrapur
Sudhir under revenue considerations
Mungantiwar', who has raised the ' from such sales.
demand for ban' on gutkha in
Making a strong plea for stop­
almost every session of the legis­
ping : gutkha
sale,
Mr
lature? Dr Aher.irThis reply, said
Mungantiwar said, “Tobacco sells
at Rs C600 a kilo wlule the best of
''the state was determined to ban
dry
fruit
is
priced
at
Rs
450
a
kilo.'
gutkha, which is responsible for
It is a shame that money is wasted
I oral cancer and general ill-effects
on.sucliTiannfurhabits."
on health, especially of youth. The
minister was so carried away with “ Members from all political par­
ties made a strong pleaJo ban
his support to the cause, that he
advertisements'of gutkha and even
announced his willingness to
itr~consumptronznrpublic~buildaccept the motion. Traditionally,
ings like Mantralaya.
~
~non-govemment resolutions are

Mumbai, March 20: Gutkha

_ Aicn. Thia photo copy
pOCt OST-CBDpersonal tel

Ban on gutka, chewing tobacco on the way
Varsha Gupta
MUMBAI 11 FEBRUARY
HE UNION health ministry’s Central

TCommittee on Food Standards (CCFS)

has passed a resolution to ban the
manufacture, sale, distribution and storage
of diewing tobacco and gutka. The resolu­
tion is expected to become legally effective
after the new government is in place at the
Centre.
The health ministry’s move follows hecI tic lobbying by consumer societies and the
Food and Drug Administration (FDA) and
a prolonged public debate.
The resolution is backed by the Preven­
tion of Food Adulteration Act, 1954, which
empowers the Union government to pro­
hibit the sale of any substance which may
be injurious to health when used as food or
as an ingredient of food.
Speaking to The Economic Times, Ma­
harashtra FDA commissioner Anil Lakhi­
na said that a countrywide ban would af-

.

-

miso

feet 400 manufac­
der the chairstrong correlation between intake of to­
turers of branded .................................. .............................................................. manship of the
bacco (in any form) and cancer, Mr Lakhi­
gutka and pan ► CCFS has passed a resolution to ban gutka,
dirvect°F §e“?ral na said.
masala who con­
Adding to the pressure on gutka manu­
chewing tobacco
; of health services
trol 65 per cent of ► Will become legally effective after the new govt
facturers was a public interest litigation
<D<Th^’Commitfiled in May 1997 by a consumer activist
the market that
is in place
tee had entrusted jnTEOurangaEScp.urt^seeking a.ban on
branded products
a
ChandigarhgutkaTThe court ruled in favour of a total
account for. In ► Resolution is backed by the PFA Act 1954
based institute to
addition, it will ► Countrywide ban will affect 400 manufacturers
bgn-on-gutka.
'
■
of branded gutka
■ ' undertake chmlead to a revenue
Mr Lakhina said that the new govern­
<,cal studies in
loss of about Rs ► It will lead to a revenue loss of Rs 300 cr
ment will have to give legal effect to the
.
multiple species
300 crore for the
Spouse to the rulings of the Rajasthan and
exchequer.
Aurangabad courts.
There are some 80 brands of gutka, ac­ ~itym experimental animals. The commit­
counting for sales of a staggering Rs 1,500
tee also asked the Gujarat Cancer Research
If the government failed to take the nec­
Institute, AhmedaEad to undertake studies------,---------crore in Maharashtra alone. .Gutka manu­
essary
action,, the courts would do so, Mr
m~collaboration with institutes in Bihar
Lakhina said.
facturers are expected to seek legal re­
dress.
and UP to examine the cancer-causing efObservers
™
said the ban could result in
-facts of tobacco on humans. Also roped in
an increase in cigarette sales as consump­
Rajasthan High Court issued directives to
was
— the
— Indian Council
--------of■;Medical Re- -----tion-----------------would shift■------to other
- ------------tobacco
>------------substir
thecentral government to appoinLaconfc " search-(lCMR-),-which contributed to the
tutes. in response to aquestion on the immittee to examine the use of tobacco in pan
findings of this committee by proving that ' nnct
anvpmmpnt revenues.
pact nfThp
of the han
ban nn
on government
revenues,
Mr Lakhina responded: “Thousands of
masala and gutka and its effect on public
gutka is associated with oral cancer.
health. The committee was appointed unAll
*” the
’ studies
‘
concluded that there was
lives will be saved.”

Weeding Out Health Hazards

Centre chews on State’s plea for gutka ban
MANJIRI KALGHATGI
MUMBAI. OCT 11

« injurious to health. This means
by the gutka ban is also negligible
facturers Association AIPMTMA
that tobacco and artificial flavours
and can be accommodated else­ said: “The Centre cannot bah
and colours in gutka are not al­
where. For instance, the annual gutka until a direct link with cancer
HE Government of Maha­
lowed.
revenue collected from Rahul
is proved.” Despite this claim,
rashtra has recommended
Fine products was Rs 2 lakhs, Rs
India is the largest producer of
Thakkar admitted that spurious
to'theCentral government
20 lakhs from Johnny Walker to­ ingredients used in grata could be
tobacco in the world with over 80
thatgrata should be banned in the
bacco and Ks / lakfrfrom Sanket
million kg tobacco cleared for con­
harmful.
State? Maharashtra Minister for sumption inthe country.
Food products. The number of
J M Joshi, Founder Chairman
' Health; Dr Dtmlatrao Aher, told — The. grata1",induStry'_has~ a ■ • wSrkers in these companiesis only ■ of AIPMTMA suggested that the
' government specify whichingedi-'
The Indian Express that he had' . turrioverRjFRs 1500 crb'reS "and '~74.65hnd 46 respectively., .
written.to-the-Centre in July and _ .generates arevenue of300 crores. xr^figutka is banned in the state, - - ents are to be banned. "Gutka can
permits to set up pan shops will be
alsospoken to Union Health Min­
be manufactured leaving out those
400 manufacturers-of-branded
materials” he said.
ister Rennka Chourihary in thisrrs gu/ta?(ho!ding 65.per-cent-of-the giveShnly after ensuring that it is
Suggesting a middle path, Joshi
not sold there.
gard. However, there has been no
market share) employ 10.000 em­
According to Dr Aher, such
said a General Manufacturing
reaction from the Centre yet. Aher
ployees in the country. In Maha­
outlets will have a list of products .Pr.acticejGMEl.should.be-.introrashtra, there are 20 manufactur­
informed.
they are permitted to sell and shop
duced to ensure quality produc­
ers ofgraA-a.
Qutka is a propriety food which
licenses will not be renewed if tion of grata, “Atpresent, inspec­
Banninggrata will be compara­
metins it has not been standardised
tors appointed by the government
.under the Prevention of Food? tively easier for the State Govern­ grata is being sold.
However, maintaining that
are paid off by factory owners
ment as the revenue generated
■Adulteration Rule (1955). Accordwhile workers continue to have
from it is very low and most of the gutka is harmless.BharatThakkar,
ling to this act,pan masala should
Frnir^rJDymjiriator of All India
long dirty nails and handle chuna
income is undeclared. The num­
■be free from added coaltar colorPan Masala and Tobacco Manuwith bare hands,” he remarked.
■ing matter and other ingredients
ber of labourers rendered jobless

T

rnSTIMSSOFINDt
*

'5 M )997

Kerala set to bah
pan masala? gutka
By P.K.Surendran
municipality, again In Ernakulam,
The Times of India News Service hSs’banned the sale of pan masala
KOCHI: Kerala is set to ban pan in its area. At least three panchayats
masala and gutka. The Kochi have so far folfowed suit. It may be
Municipal Corporation has banned p'eftihent to note that Koolimad vil­
the sale of these items while a num­ lage of Kozhikode ha3~b~anned~all
ber of municipalities have followed * tobacco- based-items two yearsago-—————■suit:
■—What makes the effort different is - 'T.K. Ravindran, secretary, Kochi
the fact that the entire merchant Corporation told TOINS that
community seems supportive to health inspectors and food inspec-'
the cause even at the obvious loss tors had begun checking-shops
dr considerable profit.
especially kiosks, to ensure the
The alacrity in action against pan banned Items were not stocked.
masala followed some studies by The existing stock is allowed to be
both consumer fora and-indepen­ ’ sold. The secretary said violators
dent organisations on how pan would find their licence suspend­
masala, gutka, and their varities, ed.
are catching on among teenagers.
The Kerala Vyapari Vyavasai
The masalas have special attrac­ Ekopana Samity, the apex body of
tions as compared to cigarette or the Kerala merchants, which had
pan. They come in handy satchets till recently been fighting Hindus­
and priced low. They can be con­ tan Lever Limited, has turned its ire
sumed without ostensible effect against the pan masala recently.
and the chances of detection are The’Samiti leaders of Ernakulam
had indeed approached the corpo­
less.
A recent survey by Regional Can- ration with the promise of cooper­
cer Centre, Thiruvananthapuram, ation if the corporation would pro­
' found lour per cent ot girls and 10 hibit the sale of all masalas. The
per cent of boys in four colleges Samiti has 124 units in Ernakulam
were addicted to ‘Tan Parag" and’’ and all of them have been asked to
other varieties of masala. Many shnTTtheT>UTchase~an~d sale ofpan
——more admitted to have “tasted masalas.
“It sure Involves considerable
them’’ at least once. The study said
Uthese varities were far more habit loss of profit?’ agreed secretary of
forming and harmlul than cigarette 'tlre~Safhitl7'riBut we have a social
Hand beedi.
responsibility too," he said.
^While the Kochi Corporation lias, According to the Samiti pan masala
in its council meeting last week, and its many varieties had been the
passed a resolution unanimously top earner of profit to small mer­
to ban sale of pan masala, the chants. The sale of such masalas'
North Paravoor municipality in were to the Tune ot Rs 30 lakhs a
Ernakulam district was the trail month In Ernakulam.
The SamTti’s Thiruvananthapu­
■blazer. The municipality -banned
the tobacco-based habit-forming ram unit has also sent a directive
stuffs a couple of months ago set- touts unjts to discontinue buying
tifigT&THolion a “chain of similar pan masala varieties. Efforts are on
action by municipalities andpan- to induce Kozhikode Corporation
cfiayals._
too to follow the example of
'^On Monday the JCalamasserl Kochi.

-fj

X

-5 Ikv

mi

Ban gutkha, says Central panel
SVATICHAKRAVARTY BHATKAR
DECEMBER 4

HE high-powered Central Commit­
tee on Food Standards (CCFS) has
demanded a nationwide ban on
gutkha and pan masala. Declaring the
tobacco products as carcinogenic capable of
causing oral cancer, the government body,
chaired by the Director General Health Services,
conveyed its views to the government through a
resolution passed on November 27.
Anil Lakhina, Commissioner, Food and
Drugs Administration (FDA) and a member of
the CCFS said, “The Committee is the apex
body of experts authorised to take such a deci­
sion. After reviewing all the evidence on pan
masala andgutkha, we came to the firm conclu-

T

sionthattheproductisharmful.Itcausescancer.
Therefore, we have recommended that it should
be banned.” Armed with this verdict, the govern­
ment can now amend the Prevention of Food
Adulteration Act (1954) and empower the state
governments to ban both products.
The CCFS resolution is significant, especially
since the government cannot ignore the sugges­
tions. However, anti-tobacco activists
are
*
scepti­
cal and expressed doubts about an effective ban.
Dr P C Gupta, a cancer researcher and sci­
entist at the Tata Institute of Fundamental Re­
search (TIFR) said, “There’s many a slip be­
tween the cup and the lip. First, the ministiy has
to accept the demand, then the law has to be
amended. Even if an order is passed, the pan
masala makers will definitely move the courts.
They are bound to take the matter up to the

SupremeCourtandthatwilltakeyears."
Faulty implementation is another pitfail,
point out anti-tobacco activists. They cite the ex­
ample ofbanned toothpastes laced with tobacco^.
The legal challenges toihe baiTdragged qnTof
jears as the manufacturers took appeals up to
the Supreme Court. Months ago, the,$_Cpassgd
an order upholding the ban. But the banned_
Toothpastes are frcely.available.
' Scepticism about a real ban is also fuelled by
the fact that pan masala is a money-spinner for
the central and state governments. In the year
1990, the World Health Organisation (WHO)

had estimated I

asaia market to

be worth Rs 20 billion. Today, the revenue department expects to net close to Rs 500 crore
additional excise from the pan masalaindusffy'
in tfic current financial year.

(THE statesmam

2 DEC 1997

Pan masala banned in Kochi
; i

day.
Samples of pan masala products
were tested in laboratories to prove
KOCHI, Dec. 1. — The Corporation
that they did contain harmful ele­
of Cochin has banned the sale of
ments, he said.
pan masala in all areas within its
Special squads have been
jurisdiction. The resolution, which
formed under the Food and Health
was moved and unanimously
inspectors to conduct random
adopted at a council meeting on 25
checks in kiosks known to sell
November is effective from today.
these products. Those retailers
The decision was adopted fol­
found selling pan masala products
lowing a series of complaints from
parents of school children and vol­ 'and “thambakk'u”'wiH have their
trade licenses cancelled and thenuntary social organisatioins. They
goods seized, Mr Panicker said.
claimed that many students were
streadily getting addicted to “chew­
While the ban has so far been ef­
able” tobacco products like pan
fected within the corporation juris­
diction, efforts are on to spread it in
masala and “thambakku” (tobacco).
the outskirts of Kochi have taken
“These products contain un­
healthy substances, which are not
similar steps.
While the Corporation of Cochin
only carconogemic, but addictive
is thejirst of_the_three corporations
and even intoxicating. Sincecomplaints have been pouring from
in Kerala to adopt such a resolutibnTtllFother two, Trivandrum
many social organisations that a
growing number of youth are
and Calicut, were also considering
similar steps to give it a State-wide
falling prey to these products, we
character, Mr Panicker said.
decided to take a firm stand," Mr K
One of the first such moves was
KSomassundara Panicker, Mayor
noted in January this year in the
of Kochi, said to The Statesman to­
STATESMAN NEWS SERVICE

Pallipuram gram panchayat on the
'outskirts of Kochi, where”tbbacco
products, like pan masala, we?e
banned following a sustained cam­
paign by voluntary organisationsreported by The Statesman on 4
February.
The campaign which kicked off
on 18 January was led by a volun­
tary
organisatioin
called
Kaliarangu, which began an aware­
ness programme in the area by
putting up posters and signs cau­
tioning people against these prod­
ucts. The “social" ban was made ef­
fective ’from3lTJanuary.
The ban hassfiaken pan massala
dealersjnthe.state,_who_hayech al ■
lefiged in the court and even petitioned_to_the_ChieLMinister, Mr T
K Narayan. In areas under Cochin
Corporation, however, they hav.e
have removed posters of pan parag
till a settlement is heard on their
appeal.
The ban may severely affect
their profits, believed to be of about
Rs 200 a day.

Gutkha nromotion continues unabated

By Rakshsndo Italia
MUMBAI: Even as gutkha manufac­
turers have agreed to refrain from
using event sponsorship as a means
•*
of product promotion, advertise-' after consuming the product.
ments for gutkha continue with una­
Advertising industry insiders say
bated vigour. Faced with a glut of ag­ that besides the one-line statement,
gressive gutkha ads, anti-tobacco
which is “clearly eye-wash,” there is
lobbyists are sceptical of the indus­
no way entrants are going to be
try's promise to tone down hard-sell
screened into non-gutkha and gut­
of the health-injurious gutkha.
kha eaters. .
Activists have been shocked by a
high-profile
“contest”' recently
launched in the print media by a gut­
kha company. The only concession
to the industry's agreement to reduce
marketing hype is a line in the ad
which states that the contest is open
“only to gutkha eaters."
This has enraged a section of con­
sumers and activists as well as adver­
tising circles. They say that the line
"is clearly an attempt by the manu­
facturer to steer clear of any messy
legalities and to shirk moral obliga­
tions towards society."
Kesari Tobacco Pvt. Ltd., which

Says advertising agency Sistas
Saatchi and Saatchi chairman S.V. Sis­
ta: "First and foremost, the advertise­
ment is not brand advertisement but
a lifestyle one. It has all the attributes
of the gutkha enlisted in it and one
sells products by selling the benefits
and the virtues, which is attempted in
this ad. Moreover, if you do not want
to increase sales, you would not
spend thousands of rupees advertis­
ing. Thisisnota. public seryiceadyertisement."
(The
advertisement
shows a young couple in the back­
ground with a line that says "....Dilki
pasand zabban par ruki.'")

sued advertisements in leading pa­
pers <uuivu
announcing
a contest with
uvu.e <.
-----Iris Advertising, which created the
tempting prizes - the first and sec- ad?clalms the line was inserted to deond prizes are gold (20 and 10 gms 'ter non-gutkha eaters. Iris Advertisrespectively). To enter, one has to at- ing chief Parvez Waris maintains that
tach three empty pouches of the gut- gutkha advertising does not lure
kha brand and send in a short state- non-gutkha eaters, but induces existment describing one’s “experience" ing gutkha eaters to switch brands.

.....

J575/VO!

muo

Goa after the Wills Cup revealed star­
tling findings. While many adoles­
cents thought that most of the crick­
eters smoked the brand, there were
others who would be actually indu­
ced to buy the brand and try it out.

“This Gsnapati one hopes will be
different," says Brihanmumbai Mu­
nicipal Corporation public health
committee chairman Ram Barot, who
feels that the lure of fancy prizes such
as gold could Induce impressionable
people to try the product. He adds
that gutkha manufacturers have been
asked to desist from sponsoring
events. There is also a plan to ban the
sale of gutkha within two hundred
metres of schools.

This argument does not hold
much water for die hard gutkha op­
posers. Says^Cancer Patients Aids As­
sociation representative Viji Venkafeshr"These contests are a modern
way of advertising traditional forms
of tobacco eating." According to her,
these advertisements are targeted at
first-timers and younger adolescents.

"Cancer is also only for gutkha ea­
ters,” she adds vehemently.
Ms Venkatesh states that studies
have shown that young children view
cricketers and filmstars as role mod­
els, and whether one likes it or not,
they do tend to be lured into buying
products endorsed by their heros. In
fact, a study conducted by a group in

However, Mr Barot says that as
there is no legislation in Maharashtra
banning the sale and advertising of
gutkha, it is still a moraijssue which
people need to adhere to.
Activists say that this is~a matter
that the Union government needs to
immediately implement. But with
the slate government earning Rs 300
crores from tobacco and gutkha
sales, one wonders if legislation ban­
ning this hazardous product will ever
be introduced.

Pan mdsdici, gutka can
leave your mouth stiff
Sriranjan Chaudhurl
BANGALORE: When Varadaraj
(name changed) visited oral and
maxillo-facial surgeon Dr K.
Umesh he could barely open his
mouth. Just a straw could pass
through to the mouth. He suffered
from oral sub-mucous fibrosis
(OSMF) developed from consum­
ing smokeless tobacco.
Says Dr Umesh,“This condition is
pretty common and affects about
one per cent of population. It is seen
among young males, usually below
35 (60-70 per cent of cases) who use
smokeless tobacco for long. Accord­
ing to a recent data, 30 to 60 per cent
of OSMF is seen among gutka and
pan masala chewers.”
Sub-mucous fibrosis is a perma­
nent hardening of the inner lining
of the mucosa of the mouth. The
. substances used in pan masala and
gutka cause irritation to the mouth
.then to the skin inside mouth.
’ Gradually, capacity to open mouth
-reduces and the person may not be
able to open his mouth at all.
Says Dr Umesh, “Smokeless to­
bacco is as dangerous as smoking
cigarettes, beedies or cigars,
whether taken along with areca or
betel nut or used as gutka, pan
masala or zarda. In fact, even to­
bacco placed between the cheek

and mouth could lead to OSMF.”
Initial signs of OSMF are, burn­
ing sensation when consuming
spicy food and a progressive inabil­
ity to open mouth because of scar­
ring of cheek skin. The skin of
mouth is easily irritated when eat­
ing S]5Icy food.
According to Dr Umesh, “Fibro­
sis and scarring of mucosa leads to
reduced ability to open mouth and
sinking of cheeks. The inner surface
of cheek is commonly affected,
However, it can also affect all areas
of the mouth, like under the surface
of the tongue, gums, hard and soft
palate, floor of mouth and some­
times even pharynx."
According to studies carried out
on OSMF, it has been proven that
paan contains mutagens which can
be cancerous. “OSMF itself though,
is not carcinogenic, but it makes the
skin of the mouth prone to cancer.
Research shows that 5-8 per cent of
OSMF cases may progress into oral
cancer,” stresses Dr Umesh.
A few common signs indicating
malignant changes are: Ulcers in
mouth; red lesions that undergo
changes; burning sensation in
mouth; mass of tissue forms a cauli­
flower shaped growth.
(For more information Dr K
Umesh can be contacted on
6681088 or 98440-12671).

mpucauons

among

otner .

Maharasfetr^^

restriction on
sale of gutka
The Times of India News Service

MUMBAI: In a significant deci­
sion, the Democratic Front govern­
ment on TUesday announced a ban
on sale, consumption and adver­
tisement of gutkhAwit.fimTQQ.metres_oLeducalional.institutions.and
government offices.
“The addiction to gutkha had
reached
alarming proportions
among youngsters. A recent survey |
shows that 40 per cent of school stu- >
dents and_70per_cen.t-OLthei:olle- ■
gians are addicted to gutkha.
The government has, therefore,
decided to prohibit its sale in the
neighbouhood of educational insti­
tutions and also near government
offices,” Chief Minister Vilasrao '
Deshmukh said at a press confer­
ence on TUesday.
'The ban on gutkha will also
cover government and semi-gov- .
ernment offices, government-run ,
corporations and state undertak- ,
iiigsi he“said“after'a_meeting of the
cabinet.-The ban will come into
force immediately.
, Those found violating the ban.u
will be liable for criminal, prosecu- 1
tibn under Sections7.andl0.of.the
Food Adulteration Act- The punishment for offenders will range be­
tween six months to 2 years of im\ prisonment or a fine of Rs 1,000.

Kick the butt - Drop the Weed

0B 2200 smokers died in India today. So did 10,000 of to­

market I To advance 3 steps challenge your peer group with 4

questions.

00

deaths than HIV, TB, maternal mortality, motor vehicle acci­

With Western markets shrinking, tobacco MNCs are
targetting Third World youth. 7.5m youth between 15-24 in

dents, suicide and homicide combined. Advance 3 steps.Tell

Karnataka smoke and 60,000 more begin every year I Alan

bacco related diseases I By 2020 tobacco will cause more

people of our daily tobacco death toll.

Landers, the Winston Man, quips, "If 4 million customers die

an Tobacco use becomes a powerfully compulsive

compose resistance songs on "To oblige or not / To die or not."

every year, won't you try to get new ones?" For another turn,
behaviour.A BAT official commented:" Because of the nico­

00

tobacco or not as we would choose to walk on one pavement

You think you now smoke a milder brand of cigarettes
which still guarantees nicotine satisfaction? Miss a turn.'Mild,

orthe other. He can no longer make an adult choice." (1980).

light, low yield' are misleading terms to make smokers feel they

Miss a turn. Ask consumers how they feel about being reduced,
by tobacco companies, to zombies facing severe health risks.

are using a healthier safer product I You have been fooled I

tine level in the blood a person simply cannot choose to use

H0

Smoking early builds a strong nicotine dependence
within a year. Lung damage is also much greater.Surveys show
half the youth in Chennai smoke at private parties, girls in­
cluded. Repeat 6 tobacco related diseases, or move back 2
steps.

00

00 For another turn, repeat these acute health risks of to­
bacco use : increased heart rate and carbon monoxide levels

in the blood, shortness of breath and worsening of ashtma,
impotence, infertility, gangrene which results in more amputa­

tions than accidents.

00 To advance 6 steps, repeat these long term risks: a nar­
rowing of the blood vessels, a drop in oxygen levels in the blood,

In Jaipur, 53% of the girls in a group of 200 youth, aged
21 - 22, smoked. The $ 6 m annual investment of tobacco
com- anies telling girls that smoking makes them relaxed, at­

tion of free radicals, increased kidney damage resulting from

tractive, slim, successful and accepted has paid off I Miss a

diabetes, an increased white blood cell count and a decrease

turn. As a girl, reflect on their efforts to dupe you.

in the NK cells which fight tumours in the body.

00

loss of appetite, cholesterol plug formation in the arteries, crea­

□0

youth Rs.250 an evening to hand out cigarette packs of their

Advance a step. Reflect with women on these risks of
tobacco use during pregnancy : birth disorders, spontaneous
abortions, premature babies, retarded mental and physical de­

premier brands. Youth are targetted because they are the
largest block in our population pyramid - the largest potential

velopment of the child in the womb, low birth weight,and sud­
den infant death syndrome. Smoking around the infant causes

Tobacco companies subtly promote smoking among
youth at discos, private parties and pool clubs by paying a

respiratory problems, and middle ear infections.

□0 This is no trendy mouthwash 14 college students in Delhi
had their tongues surgicallly removed. In two years chewing
pan masala and gutka had led to mouth cancer. Advance 4

trying to stop smoking. He 1) knows he has to stop but makes
excuses; 2) seriously thinks of stopping, 3)decides to stop, 4)

actually stops, 5) tries to avoid a relapse. Kicking the butt for 48
hours ensures success. To advance 6 steps explain why.

steps. Publicize gutka ingredients: a mixture of tobacco, areca

00 Miss 2 turns to provide those in stage 1) motivation; in2)

nut, lime, lead, arsenic, and magnesium carbonate. Some lead­

information; in 3) a cessation programme with a definite quit

ing brands even add cadminium and lead 1 Note, gutka sales

date, no tapering off; in 4) help to remove things around him

are much higher than cigarettes and bidis put together 1

associated with tobacco; 5) support to avoid places, situations,

□0

In India 53% of all adult males smoke making half the
children in the country passive smokers. Smokers inhale only

and persons which could bring on the temptation to smoke.

15% of the smoke - the rest is in the air. This side stream

00 Go back 2 steps. For 48 hours after the last cigarette,

smoke has 40 times more carcinogens than mainstream smoke.

advise the quitter to spend time in places where smoking is

00 Surveys show that 80% decide to quit, but only 35%
actually do and less than 5% succeed. Advance 4 steps to

prohibited: places of worship, libraries, hospitals. It helps.

00

spread the good news of Nicotine Replacement Theraphy to

Advance 2 steps to the Quit & Win Competition where
Appiah is sharing how and why he decided to quit tobacco and

those willing but not able I Use skin patches, chewing gum,

the strategies he used to quit successfully. Personal testimo­

lozenges and inhalers but for never more than 8 weeks I

nies have a strong appeal and are a good motivating force.

SQ What is NRT ? An habitual smoker gets used to a cer­

OB Advance 2 steps.Tell smokers about this Quit Smoking

tain level of nicotine in his blood which falls when he stops

Theraphy. They smoke during specific hours during the day.

smoking, causing withdrawal symptoms within hours of the

Over 3 - 4 weeks, the intervals between these smoking slots

last cigarette. So he smokes again. NRT maintains a low blood
nicotine level to’ eliminate these withdrawal symptoms.

day. They are then ready to kick the butt.

00 You think Ashok is difficult, irritable, impatient. Go back

00 Dr. M.S.Khan, known as the 'nashewalla doctor1, in Hauz

3 steps for not recognizing his withdrawal symptoms. He could

Rani, Delhi, has de-addicted 8000 chain smokers with his own

also be depresssed, anxious, unable to concentrate. Tell him

strenuous exercise will bring relief even without NRT.

00 Psychologists say a smoker goes through 5 stages while

are lengthened until the smokers are down to 2-3 cigarettes a

medicines restoring the electro-magnetic balance of the body

and creating a revulsion to tobacco. Patients stay away from
gadgets emitting electro-magnetic pulses(mobile phones,etc)

during treatment.Have 2 turns. Send smokers to visit him.

BQ Repeat these facts for 2 turns. 20 minutes after his last
cigarette, Anup's blood pressure and pulse rate as well as the

00

Monitoring sales at the village outlets and talking to the
villagers, a group of Sri Lankan youth assessed the total an­

temperature of his hands and feet became normal. 8 hours

nual expenditure on tobacco and alcohol in the village at Rs.

later, the carbon monoxide level in his blood dropped to nor­

80,000 - enough to provide educational and medical facilities,

mal and the oxygen level increased to normal. 48 hours later,

electricity and roads to access the village I They showed the

he was less irritable. His sense of taste and smell improved as

villagers how tobacco was a major threat to sustainable devel­

hisnerve endings had adjusted to the absence of nicotine.

opment. Miss 2 turns to see what you can do.

00 Anup breathed more easily 3 days late. His bronchial

000 The British took opium to China. The Portuguese

tubes were relaxed and his lung capacity increased. Walking

was easier. Repeat these further benefits to advance 6 steps.

00

Go back 4 steps.Stop nagging Amit for his 'bad' hab­
its. Smoking is not totally an individual decision. Take time to

brought gutka to India in the I7th cnetury from Mozambique
and sold it in Goa to buy textiles for Portugal. Advance 3 steps

to join Dr. Sharad Vaidya's struggle against gutka. It goes be­
yond health to the economic, political, and finance dimension

of the problem.

help him see how his decisions are influenced; how the mar­
ket subverts health messages; how global trade policies sub­

000

vert national decison making. Both the tobacco user and the

After tobacco sponsored cricket matches, 15-20% of
the students interviewed said gutka improves the memory,

Government are addicted I Health educators must empower
people to refuse to be enslaved and to help liberate the Gov­

sions I Alan Landers strongly condemns sponsorhip by tobacco

ernment from tobacco bondage, too.

companies. Ask 5 players to comment on his condemnation of

00 Tobacco earns big money for India : Rs. 8,000 crore in
exports and Rs. 7,000 crore in taxes. But nearly Rs. 22,000
crore is spent on treating tobacco related diseases. Is the blood

money worth it? Your father, a tobacco user, has lung cancer.
Ask 3 why questions of a relevant Government official.

00

and cigarettes make you a good cricketeer. Strange conclu­

blood money.

000The Advertising Standards Council of India introduced
a new code. No ad is to suggest that tobacco is safe, healthy,

natural or necessay and that it leads to extraordinary success
in various areas of human effort, including sexual success. Miss
a turn to compose spoofs on the claims of tobacco ads.

Despite 2 harvests a year, Kenya imports food. Farmers
grow enough tobacco to chew, smoke, and sell, but not enough

000 Review images of the hero on the big/ small screen

food to eat 1 Indian farmers receive a support price of 450% for
tobacco but only 150% for rice.Are we heading in the same

from the mouth ; blowing smoke rings up into the air; puffing

and the stage: talking authoritatively with a cigarette dangling

direction ? Advance 2 steps to organize a debate on : Tobacco

and chewing on the comer of a cigar; tapping, filing the pipe

versus Food.

withstudied movements. And the heroine ? Puffing away,

flicking the ash off the cigarette with class I Organize skits pro­
voking reflection on how these media images shape day to day

behaviour and thought.

000 Since 1998,court cases have exposed internal docu­
ments of tobacco companies proving they knew the health risks
of tobacco for more 20 years.They suppressed, denied ordeni-

grated unfavourable health research. 39 articles in scientific

journals between 1980 -1995 claimed passive smoking was not
harmful. 29 of these were written by those connected with the
industry. Advance 4 steps to make known this information.

000

Advance 2 steps. Join the campaign for these to be
declared criminal offences: targetting youth with tobacco prod­

ucts; spiking tobacco with ammonia; raising nicotine levels.

000ln June 1999, the Railway Ministry banned the sale of
cigarettes I gutka on trains and railway platforms where 30%

of the total sales of these tobacco products took place. Em­
powering people is the only way to help implement these bans.
Public awareness is the key to public health.

000 Singapore, Australia, New Zealand and parts of USA
now use a shock theraphy to stop smoking: strong slogans
with gory pictures of the damage done to the body. A picture
of bleeding brains goes with the slogan : Get this into your

Head. Smoking can lead to a Stroke. Miss a turn to use avail­

able information for similar strong slogans for your neighbour­

hood.

ORAL HEALTH PROBLEMS OF
TOBACCO CHEWERS
p
R. Varalakshmi'

R. Jayasree2

T. Mamatha Rani3

"Our teeth in our mouth

Are the guardians of our health"
i-------1 ral health problems affect the quality of life. According

O to WHO (1992), for maintaning healthy life style it is
I

I essential to maintain the most desirable levels of oral

health (WHO Report;

1992).

An even and bright set of teeth can make a world

of diffenrence, so far as our looks are concerned. Diseases
of the teeth and the adjacent oral structures are among
the most common maladies affecting human beings
perhaps because they are so common and seldom life

threatening, they usually do not receive the attention
they deserve.

Habits like irregular brushing, improper brushing,
avoiding rinsing of mmil.h liftin' mania or outing hwuuI.ii or
alter tobacco chewing, lends to bud oral health and the mouth
invites several micro-organisms responsible for carcinogenic
activity leading to dental problems like dental caries, bad

breath, cracks, dental decaying etc.

Heavy use of tobacco is a well established factor in
the development of oral cancer. (Graham et al; 1977, Madh

Berg 1981; Wyder et al., 1977). More recently viruses like

cytomegalovirus, epstein barvirus, papillomavirus have been
associated with intraoral carcinoma and that may play a
significant etiological role. The various ways in which tobacco

is used, held in mouth, chewed are associated with the location
and type of malignancy.

While in most Asian countries oral malignancies constitute
some 5 per cent of all cancers diagnosed, among the Indians

1.

Associate Professor, Dept of Home Science, S.P. Mahila University,
Tirupati

2.

Professor, Dopl.

3.

M.Sc Student, Dept of Home science, S.P. Mahila University, Tirupati
k./ QJHC
4

Health Education

Women's Rtudies, S.P. Mahila Unlvoralty, Tlnipnll

&

25

the relative frequency of oral cancer is closer to 45 per cent
(Pindborg et al., 1977). Even in India the variation in frequency
is groat in different parts of the country and in different
population groups.
Over

80 per.

cent

of India's

mammoth

100

crores

population suffer from dental caries. It is time to shift our
focus on to this problem and organise efforts to prevent oral
health problems. The need of the hour is a well planned
educational

interaction

on

a

massive

scale.

The

planned

intervention should involve both mass media and interpersonal
channels of communication.

In this context the present paper tries to find out the
oral health problems of tobacco chewing adult rural working
women in the age group of 20 to 40 years in Noolukunta
village of Kuppam mandal in Chittoor District of Andhra
Pradesh. This paper is based on an empirical study.
The main objective of the study was to find out
the incidence of oral health problems of tobacco chewers.

The study also assessed the knowledge and practices
regarding oral hygiene and demonstrated few intervention

strategies to improve the oral health status among the
women.

Methodology
A sample of 100 adult women in the age group of 2040 years were selected. The sample women were screened
from the general population on the basis of tobacco chewing
habits. The dental examination was carried out in natural
light using dental probe and mirror and the dentition status
was recorded.

An interview schedule was prepared to collect the
information such as socio-economic status, dentition status,
knowledge and practices of dental care, chewing practices and
oral health problems. After analysing oral health practices
and tobacco chewing habits, an intervention (education)
programme was launched to explain the negative effects of
tobacco, good oral health practices like the right way of
brushing, proper rinsing of the mouth after chewing tobaccco,
brushing after eating food atleast twice a day to promote
26

April 2003

oral health and make them aware of curative methods to
prevent further damage to teeth.

Results and Discussion
Socio-Economic Status of the Respondents
Age: For the present study, the sample population was
selected purposely from adult women in the age group of
20-40 years, because they are the potential age group getting
addicted to chewing habits and it is essential to change their
behaviour and habits without further damage to their health.
Among the total sample, 53 of them were in the age group
of 20-30, and the rest (47) belonged to 30-40 years age group.
Education: Regarding ’the educational status of the
respondents, more than half (55%) were illiterates followed
by 33 per cent with primary level education and. only 10
per cent of them had secondary education.

Occupation: As Indicated earlier, the respondents of
the present study were rural women working in unorganised
sectors. The majority of the respondents wore working in the
agricultural sector (38%), followed by dally wagers (3(1%) and
another 26% of them were engaged in petty business, or as
sweepers and domestic maids.
Income: All the respondents belonged to low socio­
economic group. Among them, 30% had family income of
Rs. 5000 per annum, another 30% had income ranging from
Rs. 5000 to 10,000 and another 40% of the respondents had
family income ranging from Rs. 10,000 - 15,000 However none
of them had family income above Rs. 15,000.

Habits of Tobacco Chewing
Motivation for Tobacco Chewing: Environment and
personal influence are responsible to a ' great extent
to cultivate the habit of tobacco chewing. The major
factors observed were; influenced by neighbours (43%)
and influence of family members (32%) another 25% of
them started this habit in order to avoid eating snacks
and to got stimulation wlillo doing hard work.

Health Education

27

Consumption of Tobacco
Consumption of tobacco at a time range from 20 gms
to about 100 gms. The highest percentage of the respondents
(46%) used to consume 50-100 gms of tobacco for a single
chewing, another 20% of the respondents consumed about 2050 gms of tobacco in one serving, nearly a quarter per cent
of them (23%) consumed above 100 gms of tobacco. 11% of
them consume below 20 gms of tobacco for one serving. On
an average they consumed 5 to 6 times a day. This high
consumption of tobacco clearly indicates the high prevalence
of oral health problems among the rural women. The high
frequency of chewing habit is directly related to the

occupational status of the respondent because the rural
labourers habituated for chewing while working in the
fields

were getting stimulation to

worh.

Materials used for Cleaning the

Teeth:-

A variety of materials used for cleaning the teeth among
the respondents of the present study, 95 per cent use locally
available and traditional materials like charcoal, sand, neem
stick. Only 5 per cent of the respondents used toothpaste
for cleaning their teeth. Among the traditional materials,
charcoal stands first, nearly half of the respondents (49%)
indicated that they use charcoal for cleaning the teeth, other
materials like sand (30%) and neem stick (16%) were also
in use. This data indicated that the use of charcoal and sand
were the major determinants for high prevalence of oral health
problems among the population. However, the use of neem
sticks is scientifically good for oral health but its use is low
compared to charcoal and sand, though neem sticks are easily
available in this area. Hence necessary awareness should be
created to the use of neem sticks in the rural area in-order
to promote oral health.
Regarding the habit of rinsing the mouth after chewing
and eating food, it is sad to know that nealry (80%) of the
respondents do not have the habit of rinsing the mouth after
chewing tobacco / eating food. This bad habit also determines
the high prevalence of oral health problems. However, it is
interesting to note that atleast 10% of the respondents have
the habit of brushing twice a day. It has also been noted
28

April 2003

that 3/4th of the respondents have the habit of chewing during
sleep. The poor hygienic practices are also responsible for the
high prevalence of oral health problems.
Types of oral health problems: Through scientific
studies, the positive relationship of tobacco chewing and oral
cancer has been proved. In India more than half of the cancers
in men and 20% of cancers in women are tobacco related.
Poor oral hygiene is an added factor for different kinds of
oral health problems such as bad breath, dental caries,
deterioration of teeth, recession of gums, ulcer, etc. Cent per
cent of the respondents of the present study were identified
with one or the other dental problems as mentioned earlier.
More than half of the respondents (52%) were identified for
the problem of dental carries, 80% of them have recession
of gums, however 30% of them had ulcer, only a neglible
percentage (5%) were identified for the problem of oral cancer.
However, the habit of tobacco chewing for a long period of
time leads to the formation of ulcers in the oral cavity and
it may leads to the pre cancer and cancer stages if they
continue the habit of chewing without taking proper medical
care. It was also noted that half of the respondents were
identified with multiple problmna like bed hrenth, dol.oriuinl.ioii
of tooth and recession of gums. Thus the data revealed that

chewing of tobacco leads to a scries of oral problems.
Knowledge of Oral Health Problem

Nearly half of the respondents were unaware of the
oral problems. Regarding the reasons for oral health problems,
only 32% reported the chewing of tobacco as the reason for
oral problem, another 13% of them reported improper or
irregular brushing as the reason for oral problems. This clearly
indicates the poor knowledge of oral health problems among
the respondents.
Intervention Programme:

On the basis of .the knowledge and practices of the
women about oral hygiene,- an intervention programme was
carried out to bring about desirable behavioural changes. This
programme was Organised through Audio Visual Aids focusing
on the impact of tobacco on tenth and oral health problems,
To teach the basic concepts of tooth, a model tooth sot was
Health Education

29

used and effect of tobacco on teeth was explained through
visual aids and the respondents were asked to examine their
teeth through a - mirror. After examining the teeth through
mirror they identified the problems of their teeth because
of tobacco chewing. This intervention helped the women to
know about the concept of healthy teeth, and decaying- of
teeth due to tobacco chewing, besides oral health problems.
By the end of the session, women were convinced that oral
problems are caused mainly due to tobacco chewing.
Another awareness programme focused on food habits
and oral hygiene. From the data it was found that women
do not know about mouth rinsing and carcinogenic foods.
These women wore given proper orientation about mouth
rinsing after consumption of tobacco / sweets / sticky foods
etc. They were also motivated to use tooth brush and the
technique of brushing was also demonstrated. They were also
encouraged to use neem sticks and discouraged the use of
sand, charcoal and other harmful materials. Impact of the
sessions was positive.

Conclusion
From this study, it may be confirmed that tobacco
chewing has a positive influence on oral health problems.
Proper and effective intervention programmes may change the
habits of chewing and help the women to adopt better lifestyle
practices.

References
World Health organisation (1992). "Recent advances in oral Health
care" Technical Report Series, 94 (1) 6.18.

2.

Pindboard, J.J., Kiar, J. Gupta, PC., Chawla, TN., Studies in oral
leukoplakia among 10,000 persons in Lucknow, India, with special
reference to tobacco & betel nut. Bulletin of the world health
organisation (1972): 47 : 13.9.

3.

American Dietetic Association Reports (1996). "Position of the American
Dietetic Association : Oral Health & Nutrition", Journal of the
American Dietetic Association, 96 (2), 184-188.

4.

Towari, A., Gauba , K. Goya, A (1992). "Evaluation of KAP for oral
hygiene measures following oral Health Education through Existing
health & Educational infrastructure", Journal of India.

30

April 2003

Table: No:l Motivation for
Motivation

Influence of

neighbours

Tobacco Chewing
Number

%

43

43

Influence of Family members

32

32

lb stimulate work

25

25

Total

100

100

Table No: 2 Knowledge of Oral Health Problems

Number

%

32

32

Irregular Brushing

13

13

Not aware

55

55

Reasons

Tobacco

Eating

Table No: 3 Quality of Tobacco Consumption
%

Quality
(gms)

Number

Below 20

11

11

20-50

20

20

_____ 40_

50-100
above 100

23

Table No. 4 Materials Used For Cleaning

40
23

Teeth
%

Materials

Number

Tooth paste

4

4

Neein stick

16

16

Coal

50

50

Sand

30

30

Total

100

100

Table No: 5 Type of Oral Health Problems
Problem

Number

Dental
Caries

52

Recession of Gums

80

Ulcer

30

Cancer

5

Multiple'problems were reported by the respondents.
Health Education

31

GLOBAL YOUTH
TOBACCO SURVEY
KARNATAKA, INDIA

The use and the consequent adverse health effects of tobacco is a

major public health concern that demands urgent action. Tobacco is a silent
flUer that is fest becoming a greater cause o? death and disability than any
other single disease. It is a known cause for snore than 25 different diseases
affecting human beings. Tobacco and smoke should concern not just

smokers but also non-smokers as well. The harmful effect of tobacco is
turning out to be a global threat. In every region, while new markets are

being opened by the tobacco industry activities, old markets have not yet
been closed.

Tobacco contains about 4000 chemicals. Many more toxic

chemicals are formed when it is burning, including at least 250 chemicals
known to be toxic or capable of causing cancer. It is the major cause in

diseases like lung cancer, oral cancer, bronchitis and emphysema. Tobaccorelated cancers account for about half of all cancers among men and onefourth among women. Oral cancer accounts for one-third of the total

cancer cases, with 90% of the patients being tobacco chewers. India has
one of the highest rates of oral cancer in the world, and the number of cases
fe still increasing. It is now known that over 60% of heart disease patients
Wio are less than 40 years age have been tobacco users. Tobacco

consumption has been explicitly linked to high incidence of heart diseases.
Among women, consumption of tobacco leads to spontaneous abortion

and cervical cancer. Apart from these, tobacco usage is responsible for
many more disease conditions.

Tobacco is used in many ways: Smoking is one of the commonest
forms; People also chew tobacco commonly along with betel nut, lime and
leaf or apply tobacco (Snuff). According to some studies in India, nearly 30
to 40% of men were found to be using some form of tobacco. Amongst

them nearly 50% were smoking tobacco (75% using beedies and 25%

using cigarettes) and remaining used smokeless tobacco. Amongst Males in

India, smoking rates tend to be higher in rural areas than urban areas.
Studies done in the year 2001 showed that in urban areas more number of
females had started using tobacco as compared to those in rural areas. The

overall smoking prevalence has increased in the recent years: the percentage of
smokers amongst ma

adolescents this incr >ase is

:d by 13% over a 8 year period. Amongst

significant. Changing life styles, increased

money availability, Ax-r-.-i-.sing parental control, growing influence ofgs
television, films and such other factors have contributed to this dangerou^
trend. Unfortunately, smoking is considered a status symbol among urban

educated youths. Most appear to be unaware of the hazards of smoking,

whether it is beedis or cigarettes.
Environmental Tobacco Smoke (ETS) or Second hand smoke is the
complex mixture of gases formed out of the smoke escaping from a burning
tobacco product (Lighted Cigarette / beedi). The smoke exhaled by the smoker is

another component. Exposure to ETS is referred to as “passive smoking” or
“involuntary tobacco smoke”. For nonsmokers inhaling tobacco smoke is equally

harmful (1) It contains the same carcinogens / toxic substances that are inhaled by
the smoker, probably even more and (II) it causes lung cancer and other diseases,

aggravates allergies and asthma as in the case of a smoker.
In India, as in many other countries, information on tobacco use and
behaviours of tobacco users is lacking. This is a major limitation to formulate any
tobacco prevention and control programmes. The Global Youth Tobacco Survey

(GYTS) under the Tobacco Free Initiative is a major effort by the WHOjg

document the problem and determinants of tobacco use. The GYTS survejR

being undertaken in many countries of the world. In India, the Ministry of Health,
Government of India has launched the

“Tobacco Free Initiative”. The

Department of Psychiatry, NIMHANS is one of the centers involved in treating

tobacco users to cure and prevent tobacco dependence. The Department of

Epidemiology, NIMHANS is undertaking the GYTS in Karnataka. It is being
undertaken in randomly chosen educational institutions across Karnataka to
determine the usage and influence of tobacco amongst the students. This would

help to understand the problem and plan interventions.

JOIN US IN THIS CAMPAIGN TO MAKE
THIS WORLD FREE OF TOBACCO.

WHAT CAN YOU DO

£&'

CREATE a healthy, and smoke free environment. Make your
institution Tobacco free and proudly say “Ours is a tobacco free school I
college

5 T BAN the sale / marketing of tobacco products near your institution.

0/ At every opportunity IMPRESS upon the members of the community/
leaders about the harmful / addictive effects of tobacco use. Strive for
establishing more and more 'Tobacco free schools / environment'.
C3T CONDUCT debates, quizzes, drawing and painting competition and such

other extra-curricular activities with the theme being anti-tobacco. Start a

wall magazine, which provides information about the harmful effects of
usage of tobacco, methods of stopping use of tobacco and advantages of

quitting the tobacco habit.

As a Class / School Teacher you can:
INFORM children about the harmful effects of using tobacco not just in the
long run (Lung cancer, Other Lung diseases) but also the problems they have

to

face

immediately

(cough,

exacerbation

of Asthma,

Yellowish

discolouration ofteeth, etc).
By BE A ROLE MODEL & HELP STUDENTS to develop the desirable
attitudes

to life and living (Smoking a cigarette is not being strong and

imitating heroes / heroines is not always beneficial).
US’ LISTEN

EMPATHETICALLY to students personal and academic

problems. Conduct sessions on Life skills development.

'

OS’ ORGANISE programmes for giving anti-tobacco messages (Quiz, Painting,
drawing, poster, wall papers, etc.,)

usy EQUIP students to face life/crisis situations WITHOUT TOBACCO

US’ If you smoke or use tobacco in any form: STOP SMOKING / STOP

USING TOBACCO
OS’ EXPLAIN to your child the harmful I addictive effects of tobacco use.
US’ ENCOURAGE your child to be part of the anti-tobacco campaigns.
US’ HELP your child to assert and demand a tobacco-free environment.

OS’ EQUIP your child to face life/crisis situations WITHOUT TOBACCO

If you are a student
US’ STOP SMOKING and HELP YOUR FRIENDS to quit smoking.
US’ DO NOT EVEN EXPERIMENT Do Not use tobacco in any form
(Gutka, pan masala, etc.). UNDERSTAND the harmful and addictive

effects of tobacco use.
US’ PREVENT your friends from even trying once;

US’ Organise

and

participate

in

ANTI-TOBACCO

ACTIVITIES

(debate, quiz, poster, painting, etc.)

At National Institute of Mental Health and Neuro-Sciences,
Bangalore 560 029
for further details please contact
Global Youth Tobacco Survey
DEPARTMENT OF
EPIDEMIOLOGY,
Phone : (080) 6995244/6995245
/ 6995299

E-mail: guru@nimhans.kar.nic.in

or gisrishn@nimhans.kar.nic.in

Eliminating Tobacco Dependance
TOBACCO CESSATION

CLINIC
Phone:(080)6995311
E-mail: tccbanqalore@rediffmail.com
Consultation : Between 2 PM to 4 PM
on MONDAY-WEDNESDAY-FRIDAY

Though this information pertains to schools; it is equally valid for
all; Replace Head of institution / teacher / student with your social
position and as said earlier DECIDE NOW. ITS TIME TO ACT

Institute of Tropical Medicine
Master’s in Disease Control
2001 - 2002

Public Health
Part 1. Basic Concepts in Public
Health

Notes gathered by Vincent De Brouwere
Department of Public Health

Table of contents

CHAPTER 1. HEALTH, PUBLIC HEALTH AND PUBLIC HEALTH APPROACH.................... 3
Health................................................................................................................................................................ 3
The W.H.O. definition.......................................................................................................................................... 3
Alternative definitions?...... ................................................................................................................................ 3
2.
PUBLIC HEALTH..................................................................................................................................................4
3.
The health problem and disease.......................................................................................................... 5
4.
The public health approach................................................................................................................... 6
1.

CHAPTER 2. SUFFERING, CARE DEMANDS, SUPPLY, AND NEEDS............................................ 9
1.
2.
3.
4.
5.
6.

Suffering and the demand for care.................................................................................................... 9
The needs..........................................................................................................................................................9
Needs and demand: “felt needs”........................................................................................................... 9
The provision of care.............................................................................................................................. 10
The utilisation of health services................................................................................................... 11
Coverage and utilisation rates......................................................................................................... 13

CHAPTER 3. HEALTH ACTIVITIES

IS

The typology of health activities.................................................................................................... 15
The specificity of preventive medicine............................................................................................ 17
2 /. The concept of risk...................................................................................................... ............................... 17
2.2. The concept of initiative......................................................................................................... ................. 18
3.
Epidemiological surveys, Screening and Case finding........................................................... 18
3.1. Definition ofconcepts................................................................................................................................ 18
3 2 Critical point in the evolution of a disease.......................................................................................... 21
3.3. Development of the Hutchison mode!.................................................................................................. 23

1.
2.

CHAPTER 4. AN INTRODUCTION TO MISCELLANEOUS BASIC CONCEPTS USED IN
PUBLIC HEALTH......................................................................................................................................................27
1.
2.
3.

Effectiveness, efficacy and efficiency........................................................................................... 27
Economic concepts....................................................................................................................................27
Values.............................................................................................................................................................. 29

MDC - Public Health. Part 1. Basic concepts (2001)

2

Chapter 1. Health, public health and public
health approach

1.

Health

The W.H.O. definition
The World Health Organisation has defined health as “a stale of complete physical, mental
and social well-being, and not merely the absence of disease or infirmity" This definition presents
certain important aspects. Health is no longer defined as the opposite of disease. It is not
defined in terms of “normality”. The “normal” state could have been that to which one
is accustomed, the one that appears “normal”. This is very different from a good state of
health. For example a mild degree of protein-energy malnutrition in a child is not always
felt to be a bad state of health by the mother. The W.H.O. definition has therefore a
positive approach to health. In addition it integrates physical, mental and social aspects,
e. it considers health in its holistic terms. This implies a notion of balance between these
i.
three components.
Nevertheless the WHO definition is not one that is useful in practice1
2 as it assumes a
state of health that is ideal, universal, good for all, that it is difficult to define in an
absolute manner. But, it is a dynamic notion that must be upheld because the state of
health is appreciated by a given society as a function of multiple factors that influence its
value system.

Alternative definitions?
It is difficult, indeed, to define health in a positive way (see Box 1). We know, now,
following the work of Rene Dubos3 (1959), McKeown4 and Record (1976), that health is
primarily influenced by socio-economic factors. These authors showed that the steepest
decline in mortality in England and Wales occurred in the nineteenth century', before
medicine was established on scientific foundations, and few gains were made in the third
quarter of the twentieth century despite huge investments in medicine5. For example, the
treatment of tuberculosis by streptomycin (the first effective therapy, which was
introduced in 1947) contributed only 3.2 percent of the total reduction of deaths from
that disease in the period 1848 to 1971 in England and Wales (McKeown, 1976).

But if it is clear that health is not primarily, or even largely, the product of health
services, it is also clear that health care influences health. Daily' examples of people
treated, and sometimes cured, bring the evidence that health care alleviate suffering.

1 World Health Organisation Constitution. Geneva: WHO, 1946.
2 For a more operational definition see the Alma-Ata Declaration, article V
’ Dubos R. 1959. Mirage ofHealth. New York: I larper.
* McKeown T. 1976. The role ofMedicine- Dream. Mirage or Nemesis. Nuffield Provincial I lospitals Trust, I ondon
’Turshen, M. A new vocabulary. In: The politics ofpublic health. l.ondon:Zcd Books Ltd, 1997, p. 9-32.

MDC - Public Health. Part 1. Basic concepts (2001)

3

Box 1. Health and mortality (from Turshen M.6)
There is no positive definition of health in the conventional literature. When one looks at
the available definitions, including the WHO (UN World Health Organisation) motto “Health is
a state of complete physical, mental and social well-being, and not merely the absence of
disease or infirmity”, one finds health described in terms of absence of disease or disability or
in terms that are general, descriptive, subjective, individual, and unmeasurable. If one cannot
define health, one cannot measure the success or failure of efforts to improve health.
If there are no acceptable or globally recorded measurements of health, there are several
of disease, some of which have been in use for more than a century - incidence (the number
of cases over a period of time), prevalence (the number of cases at any point in time), age­
specific morbidity (the numbers of cases in an age-group such as infancy), and age-specific
mortality (the numbers of deaths in an age-group). England and Wales have registered the
cause of death since 1838. The central and critical contemporary question for public health
workers is whether a relationship exists between documented falls in disease-specific
mortality (that is, the conquest of specific diseases, of which the most spectacular example is
the global eradication of smallpox) and improvement of health. The question is crucial
because, despite medical and technical advances, the evidence of persistent and widespread
ill health world-wide is persuasive.

Powles (1973), McKeown (1976), McKinlay and McKinlay (1977), and others explain the
fall in mortality before 1950 in terms of the improved diet and hygiene that accompanied rising
standards of living in England and the United States. They arrive at their conclusion by
examining disease-specific mortality in order to assess the factors that contributed to the fall
in death rates. Their purpose is to identify the relative role of medicine (immunisation and
therapy), which they find to be very minor. But this method is misleading because it gives the
overall impression that the aggregate fall is the sum of these parts (drops in the leading
causes of death), when in fact the parts are interchangeable and do not, in this sense,
account for lowered total death rates.
It is only that specific diseases are not always accurately diagnosed. Tuberculosis, for
example, is a poorly defined constellation of symptoms with multiple causes. McKeown (1976,
31) says, “there must be doubts about the diagnosis of tuberculosis at a time when it was not
possible to X-ray the chest or identify the tubercle bacillus". And in the conditions obtaining in
many parts of the Third World, or given the summary diagnosis offered to minorities in many
advanced countries, such doubts must persist.

Nor is it only that the particular composition of the death rate is specific to a society in a
given historical period. What people die of is associated with the kind of work they undertake,
with social stratification, and with the organisation of everyday life. For example, E.P.
Thompson (1968, 352) writes of early nineteenth century England that “The industrial town­
dweller often could not escape the stench of industrial refuse and of open sewers, and his
children played among the garbage and privy middens”. As could be expected, infectious
diseases contributed heavily to child mortality in these circumstances.

The type of disease is a separate issue from the burden of mortality and morbidity. If
English and American mortality rates fell in the nineteenth century because standards of living
improved, then, very simply, high mortality is due to low or falling standards of living. The
radical conclusion to be drawn from the work of McKeown and his followers is that mortality is
not disease-specific. What the distinction between types and numbers of deaths comes down
to is the underlying cause of health or illness.

2.

Public health
According to Winslow7 (as soon as 1920), “Public health is the science and art ofpreventing

disease, prolonging life and promoting mental and physical health and efficiency through organised
community efforts for the sanitation of the environment, the control of communicable infections, the
‘Turshen, M. z\ new vocabulary. In: Thepolitics ofpublic health. London: Zed Books Ltd, 1997, p. 9-32
1 Winslow C.E.. 1923. The evolution and significance ofthe modem public health campaign. New York, Yale University Press

MDC - Public Health. Part 1. Basic concepts (2001)

4

education of the individual in personal hygiene, the organisation of medical and nursing services for the
early diagnosis and preventive treatment of disease, and the development of social machinery to ensure to
every individual a standard of living adequate for the maintenance of health, so organising these benefits
as to enable every citizen to realise his birthright of health and longevity’. Later, in 1966, a EURO
symposium8 suggested that the definition should be expanded to include the organisation
of medical care services.
In a wide sense, modern public health can be defined as the synthesis of all the
specific activities that aim at re-establishing, maintaining or promoting health in a
community. The four main public health strategies which are expected to influence
health in a community consist in i) the prevention of diseases and health promotion, ii)
the improvement of medical care, iii) the promotion of sound attitudes and iv) the
sanitation (control of environmental hazards).

3.

The health problem and disease

The concept of a “health problem” is different from that of “disease”. Disease is a
biological or psychological process, the consequence of which is a bad state of health for
the individual that will prevent him or her from enjoying a state of well being. Disease is
the cause of the health problem and is seen as the disruption in the equilibrium of an
individual.

Certain authors define therefore the health problem as « a prevailing unsatisfactory state of
health of a community and the difficulties involved in improving it ». It can also be defined as “the
consequence of a process which disturbs the basic state of health and causes individual and/or collective
suffering’.
To attack the disease is not necessarily to resolve the health problem. For example,
solving the problems of the elderly or of diabetics is more a matter of teaching people
how to live with their illness or infirmity than of curing all their diseases.

The concept of a health problem must take into account individual suffering and the
social consequencesfor the community (i.e. the social cost both in terms of loss of activity and in
terms of deleterious effects on the family), whether these sufferings are actual or potential.
An example of a potential suffering is that of yellow fever in a country where the disease
has been absent for many years but which cannot be said to have been definitively
eradicated. If immunisation levels are not maintained, the risk of resurgence of the
disease exists. Vaccination is therefore maintained to resolve a potential problem. It is
this notion of risk that enables the importance of this type of potential health problem to
be appreciated. It is possible to summarise the differences between disease and health
problem like in Table 1:

Table 1. The differences between disease and health problem
Disease

Dimension

biological / psychological

Health problem
psycho-socio-cultural/ socio-economic

Suffering

cause of suffering

actual or potential suffering

Classification

by mechanism
(physiopathological)

by solutions proposed to cope with the
problem

8 The Education of the Public Health Physician in Relation to his Work in the Communit)’. 1966. Report of a symposium,
Lisbon, EURO, 337, p.3.

MDC - Public Health. Part 1. Basic concepts (2001)

5

4.

The public health approach

The Public Health approach may be defined as the synthesis of all the specific
activities that aim to re-establish, to maintain or to promote the health of a community.
The public health approach may be carried out on the basis of (Figure 1):
■ health problems (vertical approach)-, starts with a health problem and organises services
that deploy methods in order to solve the problem ;
■ methods or services (horizontal approach)-, starts with a service, this service is organised in
such a way as to respond to the various health problems encountered.

Figure 1. Vertical and horizontal approaches in a health system

The outset of the ITM DPH on health services organisation - according to the public
health approach - is well being, which implies a vision of health and health problems
which goes beyond the biomedical vision. Well being is related to a series of general
principles which underlie our understanding of HSO: principles of equity and solidarity,
effectiveness and efficiency of health activities, participation (or involvement) of
individuals and communities, interrelations of health and overall socio-economic
development, autonomy and self-reliance (see further). This course deals mainly with
health care. However, it should be acknowledged that care is only one of the
determinants of health.
The public health approach differs from the traditional medical approach of the
clinician by its responsibility to the community. In the traditional approach, responsibility is
limited to the patient (Table 2).

MDC - Public Health. Part 1. Basic concepts (2001)

6

Table 2 . Comparison between the Traditional approach and the Public health
approach
Traditional clinical

Public Health approach

approach
The population

patients

patients and healthy individuals

concerned

The responsibility of the
provider

only to those who
spontaneously consult

even to those who do not consult

The responsibility of the
people

comply with the treatment

participating decision making

Case management

at the time they consult

until the time of re-assimilation into
the community and the problem
has been controlled

Resource management

cost does not matter

takes into account resources that
are available and can be controlled

Responsibility towards the community involves elements that do not exist in the
traditional approach: health promotion, primary prevention, early diagnosis, continuity of
care, tertiary prevention, etc. We will return to these issues later.

MDC - Public Health. Part 1. Basic concepts (2001)

7

MDC - Public Health. Part 1. Basic concepts (2001)

Chapter 2. Suffering, care demands, supply, and
needs
1.

Suffering and the demand for care

Each community perceives health in a different way. What some people consider a
good state of health could very well be seen by others as impossible to live with and vice
versa (for example: the homes for die aged in Europe, or the conditions of hygiene in
Africa). These different perceptions of health correspond to different needs and different
responses: this makes up the health culture of a population.9
The perceived lack of health, real or potential, leads to a suffering (or a perceived risk of
suffering). One could say that suffering is every deficiency perceived by a population or an
individual as a lack of well being (it does not therefore only mean physical suffering). For
those experiencing the lack, in relation to their own criteria, it’s an objective notion. This
does not prevent suffering being the result of socio-economic factors and the prevailing
health culture.
Suffering in an individual or a population expresses itself by a demand. The demand
may be defined as the behaviour by which an individual or a community seeks relieffor its suffering.

2.

The needs

Faced with this suffering and the population’s demand, there are what are called the
needs of the population. The word “need” often leads to confusion because it is used in
two different ways.
Conceptually, the “need” is a condition characterised by the total or partial lack of a
necessary thing, requiring help or an external contribution. The term “needs” is therefore
used to speak of the suffering of a population. Suffering and needs are therefore
intermingled.

In public health the word “need” is used in its operational sense. According to T.Hall,
needs are “the estimation, in the opinion of the professionals and according to the state of medical
science; of manpower and of the quantity of services necessay to ensure an optimum level of health
care ”10. To this definition should be added: taking into account the available resources.
This operational definition is different from the conceptual definition. It is generally
accepted, in public health, that when speaking of “needs” one speaks of needs as they
have been defined by the health service. The term “need” implies therefore « as defined

by the health technician ».

3.

Needs and demand: “felt needs”

The response to the population’s demand, to its “needs” as defined by the health
technician, constitutes the basis for the planning of health care activities. The relationship
between demands and needs is presented in a diagrammatic form in Figure 2. It shows
9 The health culture of a population is of course a heterogeneous notion; this is not a fixed notion: it is in constant
evolution.
10 Hall T. and Mejia. 1978. Health manpowerplanning, principles. methods, issues. WHO, Geneva.

MDC — Public Health. Part 1. Basic concepts (2001)

9

that demands and need only partially overlap. The health technician will consider that
section of demand which, according to him, does not correspond to a need, as an
«irrational demand »; the section of need which does not correspond to a demand as
« unfelt needs »; the section where needs and demand correspond as « felt needs » or
« rational demand ».

Figure 2. The relationship between needs and demand

The relationship between demand and needs is not static; it is dynamic and changes
over time. It is on the basis of felt needs that health services can be organised. At the
interface between the population and the health services the health culture of the
population must be taken into account in terms of its capacity to resolve some problems,
and in terms of demand, even if irrational.
This requires, on the part of the health services, a capacity for empathy. Empathy is,
within the dialogue with the population, the ability to understand suffering, to perceive
the loss of well being of a person or of a group of persons and in this way to be able to
find adequate solutions. It is not a total identification with suffering. Sympathy does not
replace empathy. It tempers the technocratic attitude and allows an appropriate balance
to be found between demand and needs as defined by the health professionals.

4.

The provision of care

The provision of care (the so-called ‘supply’) is partially conditioned by demand
(people’s subjective perception), partially by needs (professional’s theoretically objective
perception), also by the historical and present environment (social, economic,
administrative, political, etc.), and in particular by the interests of social and professional
groups. The provision of services does not necessarily bring about a rise in the level of
health. This technical factor is not the only one that must be taken into account. There
are other factors - economic, political, social -cultural, operational - which determine
both the level of health and the action of the health services. Figure 3 represents the
relationship between demand, needs and health care supply.

MDC - Public Health. Part 1. Basic concepts (2001)

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Figure 3. The relationship between demand, needs and health care provision

The different figures may be defined as :

space 1 : unsatisfied «irrational demand »
space 2 : needs identified by the health technicians but without provision of services
space 3 : inappropriate provision of services
space 4 : unused supply, which corresponds to a need but not to a demand
space 5 : satisfied demand but which does not correspond to a need
space 6 : potential demand corresponding to a need but without supply by the sendees
space 7 : equilibrium between needs - supply - demand
It is to be noted that the supply of care generally covers neither all the needs nor all
the demand. Moreover, the health sector alone would not be able to achieve health
promotion. Other development sectors (agriculture, education...) also intervene.

5.

The utilisation of health services

The combination of health care supply and demand determines the use of health
services by the population. The operational relationship between the services and the
population depends on several factors.
The first factor is suffering, but all suffering does not necessarily result in a demand for
and use of a service.

MDC - Public Health. Part 1. Basic concepts (2001)

11

Next comes the behaviour of individuals, i.e. the translation of suffering into a desire
to receive care. This motivation is in itself a function of confidence in the health service (the
service offered is perceived as being able to relieve the suffering) and of its accessibility, i.e.
all the factors that overcome geographical, temporal, psychological or cultural barriers.
Generally, when speaking of acceptability one is speaking of psychological or cultural
accessibility. One could say that a service is accessible and acceptable when the positions
of the two parties concerned correspond. This is illustrated by Table 3
Table 3. The position of the population and the health services in relation to the
supply of services

POPULATION

HEALTH SERVICE

Perceives the problem ‘x’ as suffering

Perceives the problem ‘x’ as a need

Perceives the service as able to respond to this
problem

Services exist for responding to this problem

Can reach the health service easily

Services are organised close to the population

Can easily make themselves understood

The providers establishes an empathetic
relationship

Can afford the care

Health care is provided at a cost corresponding
to the population's income

The real accessibility of the supply of health care will be indicated by the utilisation of
the health services by the population. But we should not forget that the health seeking
behaviour of the patient is influenced by are numerous socio-cultural components many
of which are dependent on the supply of health care. Nuyens has suggested a model
illustrating this behaviour (Figure 4)

When symptoms appear, if they are recognised, the patient could, depending on a
variety of influences (degree of severity of the disease, socio-cultural variables, existing
services), adopt an active attitude (take on the sick role). If he adopts an active attitude,
he will call on one or more of the existing structures for a response to his problem
(health service, traditional healer, self-medication). The evaluation that he will make of
his experience will influence his future attitude and response.

MDC — Public Health. Part 1. Basic concepts (2001)

Figure 4. Health Seeking Behaviour in the case of illness (according to Nuyens)

6.

Coverage and utilisation rates

Two important terms quantify health services utilisation - the “coverage rate” and the
“utilisation rate”. These two terms denote two different ideas and must not be
interchanged.
A coverage rate indicates the extent to which a “service” or “episode of clinical care”
objective has been attained. It is the degree of use of an available service by those who
need it. It is taken for granted that this objective corresponds to a need. When there are a
certain number of problems to be treated or people to be served (denominator ), all or
only parts will be reached (numerator). The relation between numerator and
denominator measures the degree to which the objective has been realised. This figure is
expressed as a percentage. The coverage is therefore a proportion where the

MDC - Public Health. Part 1. Basic concepts (2001)

13

denominator expresses an objective. This objective could be ideal or operational (in
which case an objective that should really be reached is fixed). It is important always to
be extremely careful to define the numerator and the denominator. For example, an ante­
natal visit coverage of x% can signify:
■ that x% of pregnant women were seen at least once at the ante-natal clinic ;
■ or that x% of pregnant women followed the complete antenatal programme.

It is important therefore to define in each case the denominator as well as the
numerator that is appropriate with respect to that denominator.

One can understand that coverage rates may be more easily used for various
preventive needs. These may often be easily defined. However, this will be much more
difficult for curative care. Correctly speaking a « global curative cover » does not exist. In
fact it is not possible to say how many people need curative care given the heterogeneity
of pathology .
Instead of speaking in terms of coverage one would then speak in terms of utilisation
rate to measure within a defined population (denominator) the number of times a
curative service was used (numerator). Contrary to coverage, which is expressed as a
percentage, the utilisation rate is expressed in units per individual per year. In this case,
the denominator does not express either an objective or a need. As with coverage rates it
is important to clearly define what one is talking about. In this way an utilisation rate may
be expressed in terms of:
■ the number of contacts per inhabitant per year ;

■ the number of new cases of a disease per inhabitant per year ;
■ the number of people that have used the health service at least once during the
year.

Each alternative has its advantages and its disadvantages. The important thing is to be
vigilant that what is included in the numerator and denominator really expresses what
one wishes to measure.

11
One may sometimes speak of coverage for certain curative needs when a specific need has been defined and
translated into an objective to be attained.

MDC - Public Health. Part 1. Basic concepts (2001)

14

Chapter 3. Health activities
1.

The typology of health activities

Preventive and curative activities must be considered as being harriers to the natural
evolution of disease within the individual and the community. For each health problem,
technologies exist that enable the application of one or the other of these activities. It is
most important to consider the complete evolution of the disease process and find the
most judicious level of action (Figure 5). It is possible to use either the spontaneous
presentation of the patient (passive detection) or direct intervention (active detection).

Within this range of activities it will be possible to observe that:

■ there is no sharp distinction between the different types of prevention and
between prevention and cure.

■ the division of preventive and curative activities is artificial: it is even possible to
say that curative activities play an essential part in secondary and tertiary
prevention (Figure 6). Some intermediary methods (for example, diagnostic
activities) do not directly lead to a health benefit. These are strictly speaking not
health activities by themselves. Health education, whose objective is to “change
behaviour” , is not a health activity in itself, but an intermediate method which
could be useful within each health activity.

Figure 5. The natural history of disease and health care

classical history

MDC - Public Health. Part 1. Basic concepts (2001)

simple evolution

15

Figure 6. Public Health Methods .
1. Health promotion
= improvement in the
basic level of health.

2. Primary prevention
= prevention of the
appearance of morbid
condition, maintenance
of the basic level of
health

3. Secondary prevention
= prevention of the
extension of a morbid
condition
- re-establishment of the
level of health

Housing, education, etc.
Certain basic hygiene activities, e.g. control of air
pollution.
Certain individual health activities, e.g. physical
exercise, anti - smoking campaign
Correct nutrition/diet
Certain environmental health activities e.g. Vector
Control, environmental surveillance etc.

Certain individual health activities e.g. fight against J
tobacco
isolation of contagious people
vaccinations, chemoprophylaxis, preventive
medication
treatment of contagious sick people
T
case-finding and surveillance of high risk individuals

Early diagnosis
• Active case finding
• Passive case-finding (Reduction of the
threshold for consultation based on
symptoms)

4. Curative medicine

5. Tertiary prevention
= prevention of the
Physical rehabilitation
consequences of the
Social reintegration and readaptation
morbid condition
- re-establishment of
the level of health
Analysis of the different acts = necessary to establish an inventory of the possibilities and choice of the
priority methods.
Synthesis of the priority methods leads to a programme.

MDC - Public Health. Part 1. Basic concepts (2001)

16

The specificity of preventive medicine

2.

Conceptually there is no defined separation between preventive and curative activities,
and the artificial barriers (administrative) erected between the two can only reduce the
effectiveness of the services. Nevertheless prevention does have some specific
characteristics that are useful to recognise:

The concept of risk

2.1.

Preventive activity responds to a potential problem (hence, the notion of risk, of
probability), whereas curative activity responds to an actual problem.
This concept of “risk” results in two major consequences, economic and psycho­
logical.

The economic consequences

1.

The number of people that benefit from a preventive activity does not correspond
to the number of people that are subjected to it. It is equal to the number of people
who would have fallen ill, if they were not subjected to the preventive activity. In this
way, when a vaccination campaign is evaluated, it is the number of people protected that
is important not the number of people vaccinated. For example, let us suppose that in
a population of 1000 children, 100 children are at risk of contracting the disease. If
1000 of these children are vaccinated with a vaccine that is 80% effective, 80 children
would have been protected .... thus 920 unnecessary vaccines have been given. 900 to
children not at risk and 20 ineffective vaccines to children at risk. All that remains to
be done is to compare the cost of vaccinating 1000 children and treating 20 cases with
die cost of treating 100 cases (the 100 children that will present with the disease if
they had not been vaccinated). To this one must add the social cost of vaccination.

This example enables us to understand:

Q that a curative act corresponds to the person who will benefit from the
treatment (according to its effectiveness), therefore: 1 cost unit = 1 benefit unit
■ that a preventive act corresponds to several people at risk. The only real
beneficiaries are those who would have fallen ill if the activity had not taken
place. If the risk (probability) of falling ill is 1/x, then: x cost units = 1 benefit
unit

The unit cost of a preventive activity must therefore be x times lower than the
cost of a curative activity for there to be an economic advantage to prevention.
2.

The psychological consequences:

The result of the preventive activity is:
B negative: often concretely imperceptible if the problem is avoided. This reduces
the acceptability by the population and lowers health personnel stimulus.
■ random: people are not convinced that they will personally benefit from the
preventive activity (which is correct). This reduces acceptability.
■ delayed: a present effort is made for a future gain. This reduces the interest of
people who always give priority to their present problems. It is the notion of
the importance/value given by people to one problem in relation to another.

MDC - Public Health. Part 1. Basic concepts (2001)

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2.2.

The concept of initiative

Preventive activities are undertaken on the initiative of the health service, Curative
activity however takes place as a result of an initiative on the part of the patient. This has
both ethical and administrative consequences.

1.

The ethical consequences : a curative activity is a response, using the means available,
to a request. In prevention, the initiative of the health service is its moral
undertaking: it cannot suggest to the population an activity without having
carefully weighed up the advantages and disadvantages. The scientific base on
which the decision has been taken must be sufficiently strong to be able to affirm
that the advantages outweigh the disadvantages.

2.

The operational consequences ', in the field of curative care, some aspects of a strategy
are self-defined by the patients’ initiative (objective, target population, health
service personnel contacted, etc ) and others are defined by the relatively
standard character of the situation (complete clinical examination).

With preventive activities the health service must define a complete strategy (why? to do
what? to whom? where? when? by whom?) without which nothing will happen. An
objective must be defined without which there is a risk that the activity will not be
appropriate. The complete clinical examination, for example, does not correspond to any
objective defined within the context, and so is completely unnecessary.

These activities also have a consequence on health service organisation', a preventive activity
can be organised on a periodic basis (possibly mobile). A curative activity on the
contrary, must be integrated within a service which is permanently accessible in order to
respond to the patient’s initiative which motivates him to make contact with the health
service at the time of the appearance of the problem

3.

Epidemiological surveys, Screening and Case finding

3.1. Definition of concepts
Epidemiological surveys involve the measurement of demographic, social,
behavioural, and biological characteristics of representative samples of carefully selected
populations. These measurements may be unrelated to specific diseases entities, and,
because the objective of the survey is new knowledge, no health benefit to the
participants is implied. Thus, although the survey teams usually include medically
qualified investigators, and citizens found to have important and clear-cut health
problems are usually referred to their physicians, the health information gained through
epidemiological surveys is as privileged as any other -those who fear its effects upon
their employability or insurability (e.g. those with haemoglobin S) have the right to
demand confidentiality 12.
Screening, on the other hand, is the testing, not of carefully selected population
samples, but of apparently healthy volunteers from the general population for the
purpose of separating them into groups with high and low probabilities for a given
disorder. Screening was defined by the Commission on Chronic Illness (1951) as “the
presumptive identification of unrecognised disease or defect by the application of tests, examinations or
otherprocedures which can be applied rapidly”. As in the epidemiological surveys, the encounter
is initiated by those who do the tests. However, the objective of screening is unique: the
early detection of those diseases whose treatment is either easier or more effective when
12 Text from Sackett D.I.. and I lolland W.W. 1975. Controversy in the detection of disease. Lancet II, pp. 357-9.

MDC - Public Health. Part 1. Basic concepts (2001)

18

undertaken at an earlier point in time. There is thus an implicit promise that those who
volunteer to be screened will benefit (i.e., that they will be followed up to exact diagnosis
and long-term care and will receive treatment of proven efficacy).

A screening test is not intended to be diagnostic, thus. Screening can be conducted on
the whole population or on a major subgroup (e.g. adults), when it is called mass screening,
or it can be carried out on selected subgroups of the population (selected as being at
relatively high risk on the basis of epidemiological research) when it is called selective
screening (e.g., selected by age, sex, genetic history, occupation). With both these forms of
screening, the programme may offer one or a limited number of tests (e.g. cervical
cytology, mass miniature chest radiography) or it may extend in some programmes of
mnltiphasic screening to include a medical history and physical examination and a range of
measurements and investigations (e.g. chemical and haematological tests on blood and
urine specimens, lung-function assessment, audiometry, and measurement of visual
acuity), all of which can be performed rapidly with the appropriate staffing organisation
and equipment'3.

The aim of screening, in other words, is to detect disease before symptoms present
and before the patient presents with the disease. The initiative lies essentially with the
medical professional, not the patient. Case-jinding (see below) is ‘opportunistic’ screeningthe application of the test procedure (be it enquiry', examination, or investigation) during
a consultation by a patient for another reason13
14.
The basic principles of screening and the criteria which should be satisfied by a
screening programme were drawn up by Wilson in 1965 and summarised by Wilson and
Jungner in 1968 (Table 4).

Table 4. The principles of screening
The condition sought should be an important health problem
There should be an accepted treatment for patients with recognised disease

Facilities for diagnosis and treatment should be available
There should be a recognisable latent or early symptomatic stage
There should be a suitable test or examination

The test should be acceptable to the population
The natural history of the disease, from latent phase to declared disease, should be adequately
understood
There should be an agreed policy on whom to treat as patients

The cost of case-finding (including diagnosis and treatment of patients diagnosed) should be
economically balanced in relation to possible expenditure on medical care as a whole
Case-finding should be a continuing process and not a 'once for all' activity

Source : Wilson J.M. and Jungner G. 1968 Principles andpractice ofscreening far disease. WHO, Geneva

Screening has the potential to do harm as well as good. Before a screening programme
is introduced, therefore, both benefits and disadvantages need to be assessed and efficacy
and feasibility evaluated. Cochrane and Holland (1971) suggested seven criteria for
assessment of any screening test (Table 5).

13 Text coming from Whitby I..G. 1974. Screening for disease. Definitions and criteria. Lancet III, pp.819-22.
14 Text coming from Fowler G. 1997. Screening. In: Oxford Textbook of Public Health, edited by R. Detels, W. W.
Holland, J. McEwen, and G. S. Omcnn, New York'.Oxford University Press, ch.29, pp. 1583-99.

MDC - Public Health. Part 1. Basic concepts (2001)

19

Table 5. Criteria for assessing a screening test
Simplicity - a test should be simple to perform, easy to interpret, and where possible, capable
of use by paramedical and other personnel

Acceptability - since participation in screening is voluntary, a test must be acceptable to those
undergoing it

Accuracy - a test must give a true measurement of the condition or symptom under
investigation
Cost - the expense of the test must be considered in relation to the benefits of early
detection of disease
Precision and repeatability - the test should give consistent results in repeated trials

Sensitivity - the test should be capable of giving a positive finding when the person being
screened has the disease being sought
Specificity - the test should be capable of giving a negative finding when the person being
screened does not have the disease being sought

Source : Cochrane A.L. and Holland WAV. 1971. Validation of screening procedures. British Medical Bulletin,
27, 3-8.

In contrast with screening, case-finding is the testing of patients who have sought
health care for disorders which may be unrelated to their chief complaints (e.g., the
measurement of blood-pressure in an MDC participant who has come to the surgery to
have his ears syringed). The encounter is initiated by the patient and the purpose here is
comprehensive assessment of health. While the results of the manoeuvre may require
long-term arrangements for clinical services, the execution of case-finding does not carry
an implied guarantee that the patients will benefit, only that they will receive the highest
standard of care available at that time and place. So, while case-finding15 may be
considered an option, especially for the very busy clinician or when no efficacious
therapy exists, diagnosis is not. Diagnosis is the application of a variety of questions,
examinations, and other tests to patients who have actively sought health services in
order to identify the exact cause for their chief complaints16. Early diagnosis occurs when
the disease, identified in patients (who initiated the encounter) by a clinician, is at an early
stage, at a moment when it is easier to cure the patient.

Table 6 summarises the concepts presented above.

15 Some authors distinguish ‘active’ from ‘passive’ case-finding. 'Hwy say case-finding is active when signs - unrelated
to die chief complaint of patients - arc sought, that is in our vocabulary a screening. And they say passive when it
actually is a diagnosis.
16 Text from Sackett D.L. and Holland W.W. 1975. Controversy in the detection of disease. Lancet II, pp. 357-9

MDC - Public Health. Part 1. Basic concepts (2001)

20

Table 6. Summary of concepts: early diagnosis, early detection (case-finding and
screening)
Early diagnosis
Who does take the
initiative?
Who is the target of the
action?

The patient

Sought stage of
disease

A disease at an early
stage but already with
symptoms
Central (they suggest
the possibility to early
diagnose a disease)

Place of symptoms or
complaints presented
by the patient in the
process
Ethical basis

The patient who
consults

The patients will benefit
appropriate health care
but without guarantee
to get profitable result:
they will get the best
available standard at
that time and place.

Early detection
Case-finding
Screening
The patient
The clinician (or the
health service)
General population
All the people (or a
subgroup of high risk
(mass screening) or a
subgroup with a defined
people) who
(high) risk in the
spontaneously consult
for any health problem
general population
(selective screening)
Risk factors or ‘pre-symptomatic’ stages of defined
diseases

None (clinician seeks
None (a priori people
something else, taking
are healthy)
the opportunity of a
contact with the patient)
Guarantee is given (at least implicitly) that patients
will benefit from the (active) early detection: they
will receive follow up to exact diagnosis and
treatment of proven efficacy.

Prescriptive screening
Other names
Opportunistic screening
Individual detection
Preventive screening
1________________________
Passive detection
Active screening
Source: Grodos D. 1991. Prevention, depistage, diagnostic precoce. Mice ait point theoriqiie et tenninologiqne. Health
& Community Working Paper. N°21. ITG Press, Antwerp.

3.2.

Critical point in the evolution of a disease17

In 1960, Hutchison18 presented a model of the natural history of a disease clarifying
the issue of early case-finding programmes (Figure 7). Hutchison specified that his model
should only be applied to a disease which is already running its course. Therefore, it
should not be applied to ‘pre-pathological’ stages of a disease, i.e. to risk factors and to
precursor stages.

Figure 7. Natural history of a disease according to Hutchison

A

B

P

X

D

I

4__ 4__ 4__ 4__ 4__ 4
Point A (biologic onset) is the beginning of the pathogenesis and point I the final
outcome (recovery, chronic disability, or death). Clinical signs appear in point P and the
disease is usually diagnosed in point D.

17 Adapted from Grodos D. 1991. Prevention, depistage, diagnostic precoce. Mise an point theoriqne et tenninologiqne.
Health & Community Working Paper. N°21. ITG Press, Antwerp.
18 Hutchison GB. 1966. Evaluation of preventive services. In: Lilienfeld AM and Gifford AJ cd. Chronic Diseases and
Public Health. Baltimore. TheJohn Hopkins Press, pp. 147-55.

MDC - Public Health. Part 1. Basic concepts (2001)

21

The definition of point P has to be clarified. Indeed, it is in point P that the disease
undergoes a pathological recognisable modification. This can be the beginning of
symptoms, the modification of an organ identifiable by physical examination or the
change in some laboratory data. The event occurring in point P is usually neglected or
misunderstood, be it because of the patient or because of the doctor, and the diagnosis is
not made till point D.
Point B is the first moment we can apply the most sensible detection means for this
disease. It is the first moment an early detection test may be applied, so before any
clinical sign of the disease (i.e. before point P).

The interest of the Hutchison model lies in the introduction of the critical point X in the
course of the disease. In point X, a critical event occurs: a treatment given before this
point is less difficult or more effective than given after point X.
More specifically:
if it is a vulnerable disease, treatment applied after point X can’t achieve any longer
the reversibility of the current pathological process;
if it is a disease involving, at one given time in its evolution, a permanent invalidity or
disability, treatment applied after point X won’t be able to prevent this disability or
malformation;
if it is an incurable disease, but for which it is possible to slow down the evolution,
treatment applied after point X won’t offer any advantage compared to a treatment
given in point D (the usual moment when the diagnosis is made);

It is possible, for a particular disease, to have several critical points X (X, X’ or X”),
located between A and X. Treatment established before X or X’ is still more effective or
easier. These points X’ or X” can correspond or not to identifiable modifications in the
pathological process.
Hutchison drew lessons from his model: the four basic conditions that should be met
before proposing an early detection programme:
1.

there should exist, for the disease in question, a known effective treatment

2.

there should exist a detection means at an earlier moment (B) than the usual
moment when it is diagnosed in the studied community (D)

3.

there should exist, in the natural history of the disease, at least one critical point X
beyond which the treatment becomes less effective or more difficult to establish

4.

such a critical point should occur after the moment when detection becomes
possible (B) and before the usual moment of diagnosis (D).

Moreover, he noted two important things:
a) The longer the interval between B and D, the greater the chance to early detect
cases through the implementation of a screening programme. The shorter the
interval between B (possibility to detect) and D (the usual time at diagnosis), the
more frequent the early detection activities are necessary if we want to keep the
programme effective.

b) The chance to get a real prevention effect is proportional to the length of the
interval BX. This probability is lower than the probability to find early cases
(depending on BD). Indeed, the number of cases found earlier than usual (by
‘passive’ case finding) will generally exceed the number of those for which the

MDC - Public Health. Part 1. Basic concepts (2001)

22

prognosis will actually be improved because some cases can be found earlier than
usual but already too late (between X and D) to have a useful consequence.

But point D can occur earlier. It should be noted, indeed, that the natural history
events described here are dependant on the environmental setting, including the generally
available medical care, as well as on the biological characteristics of the disease. The time
of usual diagnosis will vary with education of the population, alertness of physicians, and
scientific development in medicine.

Development of the Hutchison model

3.3.

There exist situations in which the critical point X is not located between point B
(possible detection) and point D (usual time at diagnosis) (Figure 8).

Figure 8. Critical point X outside the space B - D

B

A

P

I

D

I______ I_______I______ I______ I
X1

X2

If the critical point is situated in X„ that is between the onset (A) and the first time
when a detection test is positive for the disease (B), any early detection is useless: the
moment a possible detection test can identify the disease is beyond the critical point.
On the other hand, if the critical point is situated in X2, beyond the usual time at
diagnosis, that is between D and I, then any early detection effort is a waste of energy,
money and credibility: ‘passive’ case-finding is sufficient.

But how to know where point X is situated? Randomised controlled trials can answer.
If mortality in the experimental group (submitted to the detection programme followed
by treatment) is less than mortality in the controlled group (treated after the usual time at
diagnosis), we can consider that there is a critical point X between B and D. Instead of
mortality, we can compare morbidity, but this is more difficult to get the evidence.
It is possible to define more specifically the nature of events occurring in the disease
process. Flutchison described two kinds of points: some belong to the nature of the
disease (points A, P, X and I), others come from an external intervention, be it the
physician or the health system (points B and D). It is possible to consider a third series of
points related to the perception of the disease by the patient (illness), splitting points P
and D as follows.
Generally speaking, point P corresponds to the emergence of an objective sign; it can
be simultaneously accompanied by subjective signs, but the latter usually occur later in
the course of the disease. Let’s call S the time when subjective symptoms emerge.

Between the emergence of signs (P), or symptoms (S), and the usual time at diagnosis
(D), two further steps can take place. The patient may feel sick and will decide after a
period of time to seek health care. Let’s call C the time when the patient decides to
consult.
The interval SC (or PC if the objective sign is perceived by the patient) corresponds to
the diagnosis delay attributable to the patient (patient’s delay) and the interval CD the
delay attributable to the doctor or the health system (iatrogenic delay or doctor’s delay).
Finally, it is possible to extend the Hutchison model to possible precursor stages that
can be, in some situations, early detected. Let’s call ‘a’ precursor stage of the disease. This

MDC - Public Health. Part 1. Basic concepts (2001)

23

can lead to a new model (Figure 9) in which the location of point B will depend on the
current technical advances and point X on the potential development of every particular
disease.

Figure 9. Natural history of a disease, adapted from Hutchison

a
1

A
1

,
1
B

PS
1______ 1

C
1

1
1

D
1
X
Illness

•>

Patient's delay
Doctor's delay

Legend

S: emergence of subjective symptoms (can take place in P)

a: precursor stage of disease (possible)

C: decision to consult

A: beginning of the pathological process

X: critical point beyond which treatment is more difficult or less effective

B: early detection test possible

D: usual time at diagnosis

P: recognisable pathologic change (objective signs)

1: final issue (recovery, diability or death)

Taking into account the natural history of disease and the levels of prevention
according to Mausner and Bahn (Figure 10) and the Hutchison model (Figure 9), it is
now possible to suggest an ‘integrated’ model (Figure 11).

Figure 10. Natural history of a disease and levels of prevention

Source: Mausner JS and Bahn AK. 1974. Epidemiology. An introductory text. WB Saunders, Philadelphia,
London, Toronto, pp. 237-63.

MDC - Public Health. Part 1. Basic concepts (2001)

24

Figure 11. Natural history of a disease according to Hutchison, Mausner & Bahn

Source: Grodos D. 1991. Prevention, depistage, diagnosticprecoce. Mise an point tbeoriqne et terminologiqne. Health
& Community Working Paper. N°21. ITG Press, r\ntwerp.

MDC - Public Health. Part 1. Basic concepts (2001)

25

Chapter 4. An introduction to miscellaneous
basic concepts used in Public Health

1.

Effectiveness, efficacy and efficiency19

Much effort has been devoted by WHO committees, working groups, etc. to defining
these three terms and distinguish between them.

Of the three terms, efficacy is the most limited in sense. It was defined as follows:
“Efficacy is the benefit or utility to the individual of the services, treatment regimen, drug, preventive or
control measure advocated or applied’ (WHO Expert Committee on Health Statistics, 1971).
Efficacy requires that a clinical procedure achieve benefits to individuals in defined
populations (dften narrowly defined) when it is applied under ideal or optimal
circumstances; this is the familiar terrain of RCTs20. Efficacy is constant for a given
intervention carried out in theoretically ideal and controlled circumstances.

Effectiveness is the degree to which a plan, a programme, or a project has achieved its
purpose within the limits set for reaching its objective. Effectiveness is thus related to the
results achieved (or planned to be achieved). Effectiveness requires that - if it is a clinical
procedure - a clinical procedure do more good than harm for the typical patient in
ordinary or average settings and circumstances.
Efficiency is the effects or end-results achieved in relation to the effort expended in
terms of money, resources and time. In other words, it is the ratio between the result that
might be achieved through the expenditure of a specified amount of resources and the
result that might be achieved through a minimum of expenditure. Efficiency is thus
related to the cost, in terms of resources, of achieving the results.

2.

Economic concepts

As far as the choice of activities is concerned we have already touched on certain
economic aspects (see Chapter 3, economic consequences of the concept of risk). In
order to go further, we will now cover other fundamental aspects of health economics:
the concepts of cost-effectiveness, opportunity cost, marginal costs and cost benefit.
Cost Effectiveness
To reason in terms of cost effectiveness means comparing the relative effectiveness of
different methods at a given cost, or, in other words, identifying the method which, for a
given amount, will be the most effective. One would say, a treatment that cures more
patients than another for the same price, is more “ efficient”, i.e. it is more cost-effective.

19 Hogarth J. 1978. Glossary ofhealth care terminology. Regional Office for Europe. WHO, Copcnhaen.
20 K. Lohr, K. Eleazer, and J. Mauskopf. 1998. Health policy issues and applications for evidence-based medicine and
clinical practice guidelines. Health Policy 46:1-19.

MDC - Public Health. Part 1. Basic concepts (2001)

27

There is thus a tension between effectiveness (responsibility for one individual patient,
related to evidence-based medicine if it is a clinical procedure) and efficiency
(responsibility for a population, related to evidence-based purchasing).

Example:
Treatment A has an effectiveness of adding 5 years of (quality) life for a cost of 1,500
euros. While treatment B has an effectiveness of adding 10 years of (quality) life for a
cost of 7,000 euros. Product of A costs 300 euros per added year of life while product of
B costs 700 euros per added year of life. We can also see the equation as: the advantage
of B over A is 5 extra added years (unfortunately, at a cost of an extra 5,500 euros) or at a
marginal cost of 1,100 extra euros per extra added life (see below).

Marginal cost
When, for example, two treatments are compared, one could be satisfied with the
comparison of the average cost per treatment. Treatment A cures 100 out of 1000
patients at an average cost of 15 ; treatment B cures 110 patients at an average cost of 25
a patient. The real question in this case is not, to know if we are ready to spend 25
instead of one per patient to have more chance of a cure, nor if we are ready to spend 19
or 10 5 per cure; the real question is to know if we are ready to pay 1000 5 more in order
to have 10 more patients cured: « the additional effect» of 10 more cures will involve a
“additional cost ” of 1,000 more dollars, or a marginal cost of 100 5/case. This example
reveals that the interpretation of the cost and effectiveness data of various interventions
can be difficult.
Opportunity cost
Spending money on one treatment means, unless we have unlimited resources, there
is another treatment for which that money is no longer available. When a programme is
chosen on its direct cost, to this cost must be added that which is lost by giving up
another programme which will no longer be possible. This could be the situation, for
example, of a university teaching hospital financed through international aid. The
financial resources necessary for it to function must be taken from somewhere, from
other hospitals’ budgets. Or if, for example, one should abandon the treatment of 1,000
tuberculosis patients in order to carry out plastic surgery, to the cost of this operation
must be added the social cost of the non treatment of the tuberculosis patients. This is
the opportunity cost: the cost of the opportunity lost for treating the tuberculosis
patients because there are no more resources available.
Cost benefit
The fourth key concept to be taken into account within the economic aspects of
planning is that of “ cost-benefit”. It is more complex and its practical use is limited to
the planning of long term investments (mass campaigns, vaccination or nutrition
programmes, for example). The principal is that an action will only be undertaken if the
benefits out-weigh the costs. In order to do this the costs and the benefits must be
expressed in the same way. One must, therefore, and this is the difference with cost­
effectiveness analysis, express the effects (immediate and future) as monetary values,
including results of a social nature (which is the weakness of this method, as many of
these advantages cannot be expressed as a monetary value). Let’s study the example of a
family planning programme. One can calculate the cost of each avoided birth (how much
a child will cost in terms of food, housing, education, etc. until he is 14 years old) where
the cost-advantage will obviously be favourable. But if the age limit for the calculation

MDC - Public Health. Part 1. Basic concepts (2001)

28

were increased to adulthood, the productive age, would this relationship remain
favourable? In this case the employment situation, industrial or agricultural growth, etc..
must be taken into account. The complexity of the method and the underlying choices
which it involves is obvious.
Economic analysis does not offer guarantees for automatically choosing “the best”
solution, but it contributes to compose the “evidence-base” for “rational” decision
making.

Values

3.

Equity^1

Equity is a term frequently used, though usually extremely loosely. It is often confused
with equality. Equity however though related, is different, in particular through its
incorporation of the idea of social justice. A variety of possible definitions of equity exist,
including the following:
•

Equal access

•

Equal access to health care

•

Equal utilisation of health care

•

Equal access to health care according to need

•

Equal utilisation of health care according to need

The first of these at first sight accords most closely to the [Alma Ata] WHO goal;
however, it has to be recognised that it is unattainable. While possibly a desideratum, it is
of little practical use to the planner seeking criteria against which to develop plans. The
second and third definitions are also unworkable, and possibly undesirable. One would
not, for example, regard a situation as equitable where everyone used health care the
same number of times (equal utilisation), irrespective of their degree of ill health.
Similarly, equal access to health care, in a world of limited resources, may imply unequal
access relative to need. Given the importance of social justice in the concept of equity, it
is fair to suggest that the last two definitions come closest to the philosophy of primary
health care.
Which is closer depends in part on how broadly ‘access’ is defined. If it is defined
narrowly to imply physical access alone (albeit this is impossible to achieve - it is
impossible to envisage a health system where everyone with equal needs lives at exactly the
same distance from health facilities!), then the presence of any other factor inhibiting the
take-up of health care is likely to make ‘access’ alone an unacceptable definition. If the
health system, for example, charges a fee, then utilisable access is dependent on ability to
pay as well as on proximity to the service.

The alternative to that concerned with access concerns utilisation. Utilisation of
services is recognised to be related to a variety of factors, including distance from the
service. Analysis of such factors suggest that three overall underlying factors that
incorporate various of these more specific factors are the class, race, and gender of an
individual. Social epidemiological studies have been conducted to examine the
importance of these factors. In the UK, for example, one study demonstrated marked
difference in the utilisation of health services between different classes (the poorest the

21 Text coming from Green
Oxford, pp.55-9.

1992. An introduction to health planning in developing countries. Oxford University Press,

MDC - Public Health. Part 1. Basic concepts (2001)

29

least). Studies in Zimbabwe also showed differences in both health status and utilisation
according to race.

If access is more broadly defined to incorporate such factors, the both the definitions
of equity, whether couched in terms of utilisation or of access, are likely to have similar
implications. The difference between them is reduced to individual decisions to utilise
health care. The importance of this depends on the degree to which one believes such
decisions are affected by one’s environment.
A useful distinction has been made between ‘vertical’ and ‘horizontal’ equity (West,
1981). Horizontal equity implies equal treatment for equal need. For example, all pregnant
women without complications would receive similar care. Vertical equity implies the
unequal treatment of unequal need. It suggests that differing levels of health provision be
made available for pregnant women expecting no complications from those with likely
complications. It also suggests different levels of care for pregnancy as compared to
other health needs, such as coronary patients. In planning services it is relatively easy to
understand the concept of horizontal equity, although it may be difficult to achieve.
However, the concept of vertical equity is far harder to apply, requiring a working
definition of need, and value judgements about how to react and how to prioritise
services for relative needs. To continue the example above, similar provision of services
for all pregnant women with no complications is easy to understand and to monitor.
However, decisions as to the relative emphasis and hence resources to be placed on
services for pregnant women compared with coronary care require a judgement as to the
relative needs of and priority to be given to each group of patients.

In planning for PHC, the first key essential must be a clear, well-defined and workable
understanding of equity, and resultant criteria for monitoring movement towards it. If,
for example, the utilisation-based definition is employed, horizontal equity would suggest
that utilisation rates by different groups (by class, location, occupation, gender, or race)
should be similar for similar health needs.
In summary, equity can be understood either as equity to each according to his merits,
contribution or equity to each according to his needs. In the Primary Health Care needsbased approach, there is an implicit recognition that equity (as distinct from equality)
requires that within the spectrum of health needs, individuals with equivalent needs
should receive (or have equal access to) equal care, and that by implication, individuals
with less needs should receive less care22. This has been described as horizontal equity “the equal treatment of equals” - together with vertical equity - “the unequal treatment
of unequals”.

This social value lies on a perception (theory) of justice. The question is in fact to
characterise the equity: equity in liberty? Opportunity? Endowment? Income? Power?
Rights? Fair chances? Access?

Solidarity
According to the dictionary, solidarity is a “unity based on shared interests and
standards” or a “relation between persons who are aware of a common interest which
results in the moral obligation not to do harm to each other and to come to their aid”.
This means that it would result in some willingness to accept responsibility for the fate of
(from the most focus to the most extended) other members of the family, the extended
family, the society, the nation, the cultural identity, race, continent, human species. In

- Collins C. and Green A. 1994. Decentralization and primary health care: some negative implications in developing
countries, bit,J.Health Serv. 24 (3):459-475.

MDC - Public Health. Part 1. Basic concepts (2001)

30

solidarity, there is some acceptance to do for others what they are not likely to be able to
do for you. There are links between equity, solidarity, health and development.

Participation

It can be understood as sharing in contribution (providing resources) or as sharing in
decision making (using resources). It can be individual (direct) or collective
(representative).
The necessary condition is information. That implies:
willingness to share information and make it available
willingness to place decision making between “providers” and “clients”.
There is of course a link with autonomy, determinants of health, ‘holistic care’ or
“whole person medicine’ and development (capabilities).

If restoring or preserving health (well being) aims at “optimising people’s capability to
undertake valuable and valued doings and beings”, this implies the capacity to make
conscious choices, without undue dependence on others.

A balance has to be found between:

security (possibly - extreme - in a state of total dependence)
and “autonomy” (possibly — extreme — in a state of total command)

Autonomy
Dictionary': “self-determined freedom and especially moral independence”.

It is both an essential element of well being (reduced by illness) and an (ethical)
principle of freedom/liberty (at stake in the doctor-patient relationship).
Balance between cure, care and autonomy. Cure has to be in balance with care; both
cure and care can lead to more dependency; both need to be balanced with consideration
for autonomy.

Autonomy can also be seen both as a right and a fact. As a ‘fact’, it needs to be taken
into account in pursuing effectiveness (compliance, appropriation).

MDC — Public Health. Part 1. Basic concepts (2001)

31

Public Health Education Network Event
31st December 2012

Introduction

;

[

SOCHARA School of Public Health Equity and Action (SOPHEA) is glad to

1

i
j

have been part of public health related networking events and initiatives in
Bangalore/Karnataka/India. Many of the organisations which are part of

,
i

i

this emerging public health education and research network have been

[

i

initiating field projects, academic training programs, health
communications, research projects, and many other initiatives that are

i
j

i
]

helping to strengthen the public health system in the state using various
approaches and engaging with the public health system in various ways.

,
j

i

SOPHEA believes that Bangalore is emerging as the public health education,

[

1 research, and policy activism hub of the country and we invite you all of you, I
i

who have been part of these initiatives to join us in a day's reflective

1

i

celebration of this emerging network. We hope to provide a platform for

|

i

organizations to share about their work during the year, there future plans

1

i

and share documents/reports and education materials that have emerged

,

from their activities.’

I

I

As a background to this event a set of the documents are circulated which

]

I

helps contextualize the current public health education and related

i

initiatives in India/Karnataka.

Venue: CHC -SOCHARA, Madiwala, Bangalore.
No. 85/2,1st main, Maruthi Nagara, Madiwala, Bangalore -560068

Tel: +91-80-25531518 +91-80-25525372
Email: chc@sochara.org Website: www.sochara.org

;

;

Content list

Capacity building on Public Health in the Asia pacific
region-2004
Public Health Definition and Dialogue on Public
Health-2011
Public Health Competencies for health professionals
in India-2011
Beijing Statement from the Second Global Symposium
On Health Systems Research-2012
i 5. Extracts from Report of Mission Group on Public
,
Health MGPH
I
- Public Health Charter
i
- The Way Forward
i 6. Public Health information source

i 1.
I
i 2.
i
i 3.
1
'4.

,
I
12 i
I
20 ■
1
22 1
1

28,
,
32 i
37 i
43 ■

CAPACITY BUILDING FOR PUBLIC HEALTH
IN THE ASIA PACIFIC REGION
-Dr. Thelma Narayan
A Policy Document prepared for UNESCAP office in Bangkok in 2004. The UNESCAP had initiated measures to strengthen
public health, including public health education In the 62 countries that come under the Asia Pacific region.

Introduction
1.

The historic sixtieth session of UNESCAP held in Shanghai, through its resolution 60/2 on 28th April 2004 gave a

"Regional Call for Action to enhance capacity building in public health".

It recalled the Millennium

Development Goals, especially those that were health related, and the UN General Assembly resolution 58/3
of 2003 to enhance capacity building in global public health. In a significant step it has mandated the
formation of a Health and Development subcommittee which is scheduled to have its first meeting in

December 2004.

2.

The Asia Pacific region, with 62% of the global population, has several strengths.

The region has shown

consistent economic progress and dynamism over the past few decades, which in turn has contributed to
improved living conditions and health of people. It also has a wealth of rich cultural, spiritual, health and
healing traditions. However poverty, hunger, disease and disability continue to afflict significant proportions

of the population, with growing intra and inter-country inequities in income levels.

Current global macro-

economic policies and trends have also affected the region, resulting in loss of livelihoods, increased rural
distress and migration, environmental pollution and destruction, and an increase in conflicts. These deeper
socio-economic and environmental determinants have a major impact on the health of people and enhance

the transmission and incidence of disease.

3.

The cost of diagnostics, drugs, and of health care in general, are increasing, while public expenditure on health

and health care is declining.

Health gains achieved over five decades are beginning to reverse in some

population groups and countries. Inequities in health status and access to health care are growing.

4.

In more recent times HIV/A1DS, SARS and avian flu provide a wake up call and a challenge to the health
systems of countries In the Region. Older, long standing problems such as tuberculosis, malaria, diarrhea,
anemia and under-nutrition take a heavier toll in suffering and death but do not attract media or political

attention. There is therefore an urgent need, and an opportunity to revitalize public health and its practice,
and strengthen health systems, building on the infrastructure, experience and expertise, developed over the
decades.
5.

Capacity building for public health and strengthening of health systems in response to the emerging problems
and social context will need to be done through a process of dialogue, consultation and international
cooperation. This will be undertaken within the region, with public health professionals in the region and with
community participation. Collaboration with WHO, UNICEF, FAO,UNDP, ILO and other international and
bilateral agencies will be explored with a strong focus on building local capacity and self reliance, rather than
being dependant on external experts and consultants. Special focus will be given to the needs of least

developed economies, landlocked and island developing economics and economies in transition. Sharing of
human, technical, knowledge-based and financial resources within the Region will be encouraged through
institutional mechanisms.
Given the mandate and traditions of ESCAP multi-ministerial support and
involvement will be sought for capacity building in public health. Reviews using participatory, qualitative and
quantitative methods will be undertaken with strengthened monitoring and evaluation systems, in order to

assess the health, social and economic impact of the strategy an to learn from innovative approaches and
processes that may be used. ESCAP and its member countries will work in close partnership with the World
Health Organization, including its regional and country offices. The public health expertise of the WHO is a

valued asset. It will be drawn upon extensively for strengthening public health capacity in the Asia Pacific

Region.

ESCAP

in

turn will contribute through its mandate of working on the economic, social and

environmental determinants of health. It can assist capacity building of public health systems in the region by
expanding horizons beyond a disease focused approach, to include policy action directed at the broader
determinants.

Evolving Definitions of Public Health and Primary Healthcare
6.

Public heath is an evolving, dynamic concept. The practice of public health, together with improved economic
and living conditions, have resulted in major health gains for populations in several countries around the world
since the early nineteenth century.

This took place through social policies introduced even before the

development of vaccines and antibiotics.

They included measures to improve sanitation, hygiene, water

supply, housing, nutrition, social security etc.

7.

The Primary Health Care (PHC) approach as a strategy to attain the international social goal of Health for All by
2000 was articulated at the landmark Alma Ata Conference organized by WHO and UNICEF in 1978. It drew on
community level experience sand challenges from countries in different continents including the Asia PaciM|

It received a mandate from 134 member countries. PHC expanded the scope and strategies for public healm

through increasing social control and democratic political processes over health and related services.

It

attempted to give communities greater voice in health systems through decentralization and institutional

mechanisms for participation in health decision making.

Moving beyond bio-medicine PHC stressed inter­

sectoral collaboration to address the deeper determinants of health. It was rooted in principles of equity and

social justice in health and health care. In order to reach the social goal of health for all, PHC emphasized selfreliance at individual, community and national level, and recommended the use of appropriate technology to

serve peoples needs. It promoted social means to reach these goals. Primary health care not unsurprisingly
met with resistance early on.

8.

The International Association of Epidemiologists also defines public health with a broad perspective "Public
health is one of the efforts organized by society to protect, promote and restore people's health. It is the
combination of services, skills and beliefs that are directed to the maintenance and improvement of the health

of all people through collective or social action. The programs, services and institutions involved emphasize

the prevention of disease and the health needs of the population as a whole. Public health activities change
with changing technology and social values, but the goals remain the same; to reduce the amount of disease,

premature death and disease produced discomfort and disability in the population" (JM Last, 1995).
9.

More recently the Oxford Textbook of Public Health (2002) describes public health as "the process (||

mobilizing and engaging local, state, national and international resources to assure the conditions in which

people can be healthy." It recognizes that public health is only one of the major influences on the health of
communities and that basic economic and social conditions impact directly on people's health and wellbeing.

10.

The initiative for public health capacity building can experiment with social arrangements for greater

involvement of people, particularly the poor and vulnerable, in the development of their own health services.
Thus the public can be brought back into public health. Public health has focused on improving the health of
communities and individual persons through comprehensive preventive, promotive, curative and
rehabilitative interventions addressing risk factors that could be social or behavioral. The present challenge is

to include the deeper layer of social, economic and environmental or developmental determinants of health.
The way has already been shown by some communities and countries. The need and challenges have been
articulated in the Peoples Charter for Health of the Peoples Health Movement. The World Health Organization
is making initiatives to set up a commission for social and environmental determinants of health. The

contribution of UNESCAP and its member countries in this regard would be pioneering and would help the
achievement of the millennium Development Goals. The current initiative offers an opportunity to further

build the concept, principles, and practice of public health in relation to the current times and challenges in
the regional context.

Strategies for capacity building in Public Health
11.

Human resource development- Developing a pool of well-trained, competent, highly motivated professionals
and workers in public health is a priority for all countries in the region. There is an urgent requirement for a

range of public health skills and competencies - including specialist epidemiologists, policy analysts, health

administrators, program managers, trainers, health economists demographers, statisticians, researchers,
social and behavioral scientists, public health nurses, health promoters/educators, laboratory technicians,
social workers, multipurpose workers, health assistants, community health workers, health animators and

others. While specialization in sub-sections of public health will be inevitable, the key focus should be on
training more multi purpose, integrated, socially relevant, public health generalists at different levels.
12.

Planning and forecasting the numbers of trained staff in public health required at different levels of the health

system is a task to be undertaken by each country. Based on a needs assessment, numbers retiring per year,
and overall attrition rates, the numbers to be trained every year can be calculated, keeping in hand a reserve
stock of personnel who can manage leave vacancies, respond to emergencies, undertake consultancies etc.

Most important is the policy recognition that in order to achieve effectiveness, relevance and quality, some
positions at specific levels in the health system will necessarily need professionals with competency and
training in public health. The tendency to appoint clinicians to public health positions, and to be susceptible to

political compulsions, needs to be avoided if public health objectives are to be met.
13.

Public health staffs are often given a lower social status as compared to clinicians, though their jobs may be

more complex and thankless. This results in lower morale and self-esteem and needs to be rectified through

an enabling environment with adequate recognition, remuneration, and encouragement. Considering the
complexity of their tasks and the multidisciplinary multi-tasking nature of their activities, they should be given
opportunities for professional growth.

Along with these reforms a realistic focus on outcomes, impact,

quality, integrity, and responsiveness to feedback from the community, is required.
14.

Team work in public health is crucial for it success. Adequate training is needed in team functioning with
clarity about roles and responsibilities and lines of communication. Supportive supervision, trust building and

problem solving exercises are essential.

Public health professionals can be drawn from both medical and

social sciences streams and should not become doctor dominated.

15.

Continuing education of staff is essential, given the rapid growth in knowledge and the contextual changes
that are occurring. Distance education courses, workshops, seminars, newsletters and access to electronic
means of updation need to be well developed. Accreditation systems at district or state levels for public
health staff will help to ensure basic standards with mandatory requirements for attending a certain number
of courses and achieving competencies required for different levels.

16.

Ability to work with communities and local government functionaries, with community organizations, and
community leaders both informal and formal, is an important skill for public health professionals. This is best
developed through experiential learning and in-service training.

17.

There is an urgent need to build capacity in developing an evidence based approach for public health
interventions. Investment is required in training and retaining research professionals competent in qualitative

and quantitative methods. Their findings would be used by a multidisciplinary policy team for developing,
reviewing and evolving public health interventions. Skill development is required for recording and reporting
systems to be strengthened, with adequately disaggregated data collection to measure differences in social
groupings. Analysis and utilization of data for decision making should be done as close to the point of data
collection as possible. This in itself will enable capacity development closer to the community.
18.

Capacity needs to be developed across sectors to deepen the understanding of the inter-sectoral dimension of
health and health action. We need to strengthen the ability to dialogue and involve counterparts in other

departments of development, be it food, water, sanitation, environment, women and children's welfare,

education, agriculture, labour, and other departments.

Training Methodologies for Public Health Practitioners for the Asia -Pacific Region
19.

An alternative pedagogical method that is participatory, reflective, transforming and located in a socio-cultural

paradigm, should be used in teaching public health workers and professionals.
20.

It is important for countries in the region to consider the underlying philosophy, educational methods and

processes of learning, adopted in the higher education of public health professionals.

Two foundational

premises that continue to have a major influence have been the biomedical scientific roots of public health
and its proximity with state power.

These developed historically within the then dominant social context

often linked with the industrial revolution, capitalism and colonialism. At the interface with people in the Asia
Pacific region, who have their won culture and knowledge base, there is often an alienation of philosophy,

concept and praxis. Public health practice is often perceived to be an expert driven, top-down, centralized,
prescriptive approach, implemented in a heavy handed manner by the government bureaucracy. This does

not win the hearts and minds of people and is often met with scepticism if not with resistance, non-action aruL
non-adherence. Development of pedagogical methods, and the learning environment and process, will ne^P

careful thought in order for students of public health to identify and retain the core principles and elements
of the discipline, to be sensitive to the cultural and social context of communities with whom they work and to

best utilize the right knowledge base and traditional health and healing practices in the region.

Since the

1970s much experience has been gained, particularly through community health and development projects in
the voluntary sector, in the use of participatory, experiential, reflective and transformatory learning processes.
While these methods initially evolved through working with communities, they have also been used in the

education of professionals who find it a more liberating, meaningful and motivating process of learning and

personal growth.

Besides theoretical content and competencies, it includes experiential learning in

community based programmes, self awareness and reflection, teamwork, social skills, understanding culture

and community dynamics, spiritual and ethical dimensions of health and public ethics, among others. This

qualitative change in the method of teaching-learning, enhances social effectiveness and community support
increases personal motivation, prevents burnout and helps the creation of a social network among public
health workers.

21.

These aspects have not been adequately stressed or integrated in public health training programmes in the
West. While international collaborative efforts to strengthen public health capacity in the ESCAP region will
involve linkages with training centres in the west based on a different history and paradigm, a creative

contextual local adaptation of theory and practice of public health is a necessary.

Training Approaches
22.

Medical officers of Primary Health Centres and other levels of government health centres play an important

role as leaders of health teams. They need to be adequately trained in public health and health management.
In practice in several countries a large proportion do not have a post-graduate qualification in the subject and
are more clinically oriented. They will need an in-service public .health training for at least 6 months which
would include the basic theoretical concepts and a period of experiential training under guidance. A

mentorship programme could be considered. Exercises in leadership training, communication, team-work,
gender sensitization, social analysis, understanding community dynamics and community organization, and
public health ethics are important to supplement the traditional public health components.

23.

Participatory training methods that are learner - centered, using principles of adult learning, and problem
solving and experiential innovative approaches are very helpful. Use of role plays, simulation games, case­

studies, films and field visits help the learning process.

Debriefing, with analytical reflections of different

experiences and method help in the personal growth and motivation of participants besides enabling a deeper
understanding of the issue.

24.

Team training of primary health care teams for up to 5 -7 days is also a useful method to enhance the quality
of public health work. Training is undertaken together as a team to understand each other and internalize the

goals and objectives of their collective endeavors. Their different roles and responsibilities are clarified.
Systems for communication, recording and reporting, measuring indicators of progress, getting community
feedback and of participatory reviews can be discussed. This process helps in bonding together and creating
better working relationships. Efficacy of public health work depends to a large extent on the cohesiveness of

the teams, their conflict resolution mechanisms, and the feeling of community among themselves, which need
to be constantly developed and nurtured.
25.

In several countries there has been good inter-action between health systems, and integration of indigenous
systems of health and healing into the national health system.

Indigenous systems and practices that are

beneficial to health cold find an explicit place In national health policies and systems, rather than being a
parallel system that is under resourced and sometimes subaltern. This spirit of mutual cooperation between

systems needs to be reflected in the training of health workers and health professionals.

Training Content
26.

Both traditional public health, as well as the new public health, recognize the close links between the
underlying determinants of health and the health status of populations. Teaching curricula for public health

however are still dominated by biomedical components, based on a reductionist paradigm. Consequently
public health interventions tend to be narrowly focused, vertical programmes; lacking a societal process

element. For instance the delivery or social marketing of public goods such as diagnostics, drugs vaccines,
condoms etc are given much greater importance than social relationships and processes through which

change can occur and where people have a voice.

The contextual complexities of social, economic and

environmental determinants of health are discussed and researched in very few schools of public health
across the world. The Asia Pacific region could be a potential leader in introducing systematic teaching and

research into these issues with a public health perspective in order to protect public interest and human rights
and to reduce social inequality, with resultant benefits to the health, and wellbeing of people.

27.

Content areas to be covered in the training would include

Guiding principles and values of public health, which include social justice and equity in health and health

•

care; health and access to health care as a fundamental human right; health as central to sustainable

development;

community

participation

and

self-reliance;

good

governance,

oversight

and

accountability.

28.

•

Public health ethics and law

•

Food security and nutrition

•

Poverty and health inter linkages

•

Gender perspectives on health

•

Macro-economic and trade policies and health.

•

TRIPS, GATS and implications for access to medicines and to health care

•

Conflict, violence, disasters and health

•

Environmental health issues with corporate and government accountability

•

Peoples social movements, peoples health movement

•

Environmental health movement

•

Population movement; migration, urbanization.

Preparation of learner friendly teaching material and modules; developing a critical mass of teaching staff in

the region; and establishing centres that research and intervene in these areas, will need to be undertaken in
a systematic manner. Enhancing and disseminating databases on these complex subjects will also need to be
undertaken.

Developing Centres of Excellence for Teaching and Research
29.

There is a need for a number of centres of excellence for teaching and research in public health and
community health in the Asia Pacific region. While countries with large populations may have more than one
centre, smaller countries could share a centre or send their professionals to recognized centres. Mechanisms

for generation of financial and technical resources could be developed.

Regular exchange and electronic

networking between academic and research centres in the region, and close collaboration with WHO regional

and country offices would be beneficial. Mapping of existing centres and resource groups in the region could
be initiated by the secretariat. Scholarships could be established for least developed economies. Electronic
methods of communication could be institutionalized so that whenever required rapid mobilization of
expertise and quick sharing of information is facilitated.

These centres will be the nerve centers for

knowledge generation and application, and will need to be very dynamic and alive. Countries are advised that
the leadership, management systems, library and information centres and financial security of these centres

are critical areas for development. Their purpose would be to be socially relevant to the public heath related
issues and concerns in their countries and neighboring areas. Interaction and alliance building with the local
health services, NGOs and social movements would enable them as a group to impact on the determinants of
health.

Strengthening Health Systems Financially
30.

Health systems form the basic skeletal framework for public health action. Over the past century public sector
health systems in the region have undertaken preventive health work, health promotion, communicable

disease and outbreak control, and other measures on a countrywide basis with resultant public health gains.

However over the past decade a weakening of the public health system has taken place in some countries
where decision makers have uncritically supported and promoted the privatization of the health services. In
other countries investment in public health systems has been consistently low and unproductive. In these
cases there is a need for strengthening of public health systems to meet public health goals, and to privatize

further. The Commission on Microeconomics and Health has pointed out the critical importance of adequate

investments in health in the public sector and the economic and social benefits of these investments.
Countries have been strongly encouraged to increase their public health expenditure up to the minimum
norms.

31.

There Is an urgent need for countries in the region to build national and local capacity in health financing and
in establishing and running National Health Accounts Systems. Capacity building in financial management with
accountability and transparency for health institutions at sub-district and district levels and for primary healtfi
care is also required.
■

Capacity Building for Priority Public Health Problems
Environmental health, water, sanitation and waste disposal
32.

Despite significant improvements, there is a long standing lack of access to water and sanitation facilities for a
significant section of the population particularly the poor in some countries of the region. This is compounded
by new challenges.

Groundwater is being used faster than it is being recharged.

If water conservation

strategies are ineffectively implemented, drinking water shortages are predicted to occur.

Contaminated

water is a vehicle for disease transmission. Poor quality and inadequate quantities of water are estimated to
account for about 10% of the total disease burden in developing countries. Privatization of water is reducing
access for the poorer sections of society. Industrial and chemical pollution of rivers, groundwater and water

bodies and agricultural runoffs contaminated by fertilizers and pesticides are rapidly growing areas of concern.

33.

Countries are encouraged to ensure universal access to safe, potable water supply by 2010.

Inter-sectoral

action between water supply and sanitation boards pollution control boards, departments of health, local

6

government bodies communities and consumer groups is essential to ensure adequate provision and
utilization of water, without wastage, and to undertake health promotion and public awareness campaigns so

as to reduce prevalence of water and sanitation related diseases.

34.

There is a need for adequate technical capacity in the region to work effectively and efficiently on this issue.
Time bound goals and indicators

could be set to reduce mortality and morbidity due to the following

conditions:

a)

water washed disease - scabies, trachoma

b)

water based diseases - schistosomiosis and dracunculiasis (guinea worm disease)

c)

water related diseases - malaria, filariasis, dengue fever.

d)

Waterborne disease - diarrhea, dysentery, cholera, typhoid, hepatitis A, amoebiasis, giardiasis, helminthic
infestation / intestinal worms, camphlobacter etc.

Prevalence and incidence rates will be collected and analyzed through the disease surveillance system / health
information system, for which capacity is also being developed.

35.

Capacities need to be strengthened for accelerated interventions to ensure access to household and
environmental sanitation facilities (toilets, drainage systems, sanitary waste disposal). This will help minimize
disease spread by the faecal-oral route of transmission, which continues to be widespread. Control of these
diseases requires a combination of interventions including improved water quantity and quality, sanitation

systems but also food hygiene and good personal hygiene. This requires health promotion, advocacy, social
mobilization in addition to infrastructure development and regulation. A multi-sectoral approach involving
public health engineers, sewage boards, and departments of urban and rural development, water supply and

elected representative and community members is critical.
36.

Capacities to handle waste management in a professional, toxic free manner are also urgently required to be
developed. This area has become very complex over the past few decades and encompassed household
waste; solid waste at village, town and city level, non-biodegradable waste; hospital and health care waste;

hazardous industrial and chemical wastes; nuclear waste; agricultural wastes etc.

Some waste disposal

methods, such as incineration are themselves toxic. Short and long term consequences on public health and

the environment are significant.
37.

In addressing issues of water, sanitation and waste disposal, the role of the state is important. Public health

specialists need to work in collaboration with public health engineers and a host of stakeholders, including the
environmental justice movement and legal advisors. Adequate sensitization and awareness regarding the
issues need to be ensured in the training and continuing education of all public health workers. A few would
opt for more specialized training in this area. This stream would need to have an institutional base wherein

their higher educationjob opportunities and career planning would be considered.

38.

The public health system would required the skills and capacity to pick up instances of impact on human
health following environmental pollution from industry, including the chemical industry, agriculture
(pesticides, fertilizers etc) and the dumping of toxic waste.
This is a major emerging social and health
problem in the region, which has become the global manufacturing base at low economic cost. Health and
safety of workers and communities need to be safeguarded. Other major environmental, issues affecting
human life, health and wellbeing including climate change, global warming, ozone layer depletion etc, need

urgent research and action. Health impact assessments of new technologies, industries and development
projects need to be undertaken. Environmental epidemiologists and occupational health specialists are still
scarce in the region and need to be trained in larger numbers. They would need to work closely with
government policy makers, health providers, NGOs, the environmental movement and communities.

Nutrition
39.

The public health systems of many countries in the region are inadequately equipped to address the

challenges of nutritional deficiencies and under nutrition, or the emerging challenge of non-communicable

disease which have a food, diet and lifestyle component to their causation. The magnitude of nutrition related
health disorders in the Asia Pacific region is large. The impact on mortality, morbidity, vulnerability to other

infections and disease, disability and economic productivity is enormous.

However the significance and

potential for positive health and development impacts through policy measures has often not been

adequately understood or acted upon by policy makers and public health practitioners.
sensitization, capacity building and effective action on nutrition deserve the highest priority.
40.

Advocacy,

Practical training on nutrition needs to be mandatory for all levels of health workers and professionals. The
teaching content will need to be relevant to the nutrition problems and issues obtaining in a country or area,
keeping in mind the dynamic changes that keep occurring. District-wise nutrition mapping would provide an

information base. Centers for nutrition research need support and the findings and recommendations from
their work need to be acted upon and also introduced into training programmes, public education and policy

interventions.
41.

Broader issues of agricultural policy, food diversity, food security, international trade and pricing of

agricultural products are issues of national and regional priority. Public health policy workers and practitioners

auk

need to have a general awareness about these issues. They need to understand their specific roles
responsibilities in regard to nutrition security, and in improving the nutrition status of people of different a^F

groups, at individual and community levels and through integrated health and nutrition interventions.

Disability
42.

The Asian and Pacific is home to an estimated 400 million persons with disability, the biggest number in the

world. A large majority are poor, and lack social opportunities and access to good rehabilitative care, that can
enable and assure a meaningful productive life. Many disabilities are also preventable.

43.

The first Asian and Pacific Decade of Disabled Persons (1993 to 2002), and the recently launched second
decade (2003 - 2012), have facilitated many positive regional and country level initiatives. These include a
comprehensive and integral approach to the protection of promotion of the rights and dignity of persons with
disabilities; improving disability measures for policy use, promoting active participation of women with

disabilities; poverty alleviation among people with disabilities; among others.

44.

The public health community in the Region needs to be capacitated and encouraged to join, support and

expand these initiatives.

Multi-ministerial and inter- country cooperation, already initiated, will be further

strengthened. Active participation of persons with disability in planning oversight and reviews will be ensured.
There will be a special focus on children with disability.

4|

Promoting Mental Health
45.

Mental illness takes a heavy toll through the long-term suffering of affected persons and their families.
Patients continue to experience stigma and discrimination, and the treatment and care of the mentally III
persons is still an orphan area in most health systems. Mental and emotional ill health, tobacco and alcohol
related problems and violence have been widely recognized during the past decade, as major public health

issues.

The time now is to act.

This is a complex issue of human behaviour and social relations in an

increasingly stressful environment. Health personnel working in primary care settings in both the public and

private sector need to be trained adequately to recognize and diagnose mental health problems. Treatment
options that are currently available should be widely accessible. In order to make this a reality there is a need
to enhance the number of psychiatrists, clinical psychologists, counselors and social workers, and also to take
appropriate measures to reduce their migration. Drug patenting issues will need to be considered to ensure
availability of newer drugs at affordable prices. More importantly initiatives to promote positive mental health

and to build caring, supportive communities need to be expanded through training of trainers and other
methods. These include parenting skills, life skills education, meditation and yoga. Parents, school teachers,

8

religious bodies, and community leaders all have an important role. Legal, regulatory and related capacities
will need to be strengthened to dealt with control of tobacco, alcohol and substance abuse.

Infectious Disease Control
46.

Old and new infectious diseases take a heavy toll in terms of disease burden and mortality in the region. The
risk of transmission within and between countries has become higher with social instability, conflict
displacement, migration and increased mobility. Capacity building for control of infectious diseases is one of

the highest priorities in the region. This needs to be implemented with a sense of urgency in a time bound
manner. Infectious disease control requires widespread public education and awareness, sharing the known

scientific features of the diseases, stressing preventive and control measures at individual and community
level, and minimizing misinformation which results in fear and panic.

Government departments of health

education and health promotion need to be alert, up-do-date, pro-active and creative, using a mix of

communication methods and interacting with mass media groups. Health systems need strengthening with
adequate budgets, trained health personnel, good laboratory facilities, supply systems for drugs and
consumables, communication systems and disease surveillance systems/heaith information systems.

Inter­

country collaboration needs improvement. However, most importantly there is a need to focus on the
developmental determinants of these diseases through intersectoral, multiministerial interventions, as many

of these diseases thrive in conditions of poverty. There is a need to ensure that dominant paradigms eg the

bio-medical

approach,

and

dominant institutions

do not monopolise

policy

making.

Independent

implementation audits and public hearings can be utilized to elicit peoples perspectives on how effective and
accessible infectious disease control efforts are. Capacity building is required for all these components.

47.

Tuberculosis, malaria, filariasis, dengue hemorrhagic fever and vector borne diseases need special attention,
and close collaboration with WHO control programmes. However, rather than managing a multitude of

vertical, single disease focused programmes, countries in the region could adopt an integrated primary health
care approach wherein early detection, complete treatment, recording and reporting systems function
through comprehensions primary health care centres dispersed in the community. Health promotion and
community participation are integral components of the approach. Most countries have over the past 3-4
decades established a primary health care infrastructure. This needs to be strengthened, guarding against
policy advice from international financial agencies and others who suggest a targeted approach with enhanced

privatization.

The international community and public health experts have universally recognized the

important role of the state in infectious disease control through public health systems, popular education and
people's participation. In the current neo-liberal context this role needs to be re-inforced.

48.

Newer problems of HIV/AIDS, SARS AND Avian flu have been addressed by the UNESCAP over the past few

years in its resolutions. The recent 3x5 initiative of the WHO, which aims to increase access to treatment is
welcome as a timely response to the severity and magnitude of the disease and to the treatment access
campaign. Dialogue between UNESCAP and WHO will help to enhance coverage and capacity building in Asia

as early as possible. Newer treatment protocols, simplified procedures, etc will be adopted, monitored and
constantly updated as new knowledge becomes available, after reviewing its social applicability. Most
importantly countries could use the existing provisions in the WTO clauses to ensure adequate supply of good

quality, generic drugs at affordable prices. Lessons could be learnt from Thailand, Cambodia, India and other
countries.

Health education efforts regarding these diseases should not generate fear but spread positive

messages. Methods of positive living for persons already infected could been encouraged. Use of adjunct
therapies such as herbal remedies, massage and other forms of healing that recognized not to cause harm will
be encouraged. Life skills education and women's health empowerment that has already been initiated in

most countries will be expanded through widespread capacity building.
49.

The region is faced with a double burden of diseases with non-communicable diseases (NCD) and traffic
accidents taking a heavy toll.

The Pacific island countries, Japan, China, Australia and New Zealand have

already initiated health promotion campaigns through the government, voluntary sector, private sector and
professional associations to bring about lifestyle changes such as adequate exercise, healthy diets, stress

9

management, compulsory use of helmets and seat belts, rules about drinking and driving etc. With an ageing

population these measures are necessary to reduce the burden of cardiovascular diseases, hypertension,
stroke, diabetes and other NCDs. Abuild up of capacity in the public and private sector for management of

these disorders is necessary.

Ratification of the Framework Convention for Tobacco Control (FCTC) and

implementation of bans on advertising and sponsorship of tobacco products, smoking in public places and

stringent curbs on smuggling, would help control the epidemic of tobacco related diseases, including cancers

in the Region. Other measures for prevention, control and care of cancer also need to be instituted.
50.

The health internet work project of the WHO has piloted the use of the internet and information and
communication technology (ICT) for providing easy access to research information on important public health

problems to health providers and citizens. ICT offers great potential and needs to be widely used. Internet

based public health training programmes are being designed.

The use of hand held computers by health

workers in the field for recording and reporting will greatly reduce their burden of work.

Community capacity building for public health
51.

Traditional public health has been critiques for being rigid, with a techno-managerial, bureaucratic approach
which leaves little scope for the creative, empowering and enabling involvement of communities

collectively address the deeper determinants of disease.

There is an opportunity now for a change in

paradigm based on greater community participation and control, with mechanisms for social accountability
and measurement of progress in achieving goals. We could move forward towards achieving the global vision

of better health for all, based on the universally accepted premise that the Right to Health and Health care is a
basic human right.

52.

Capacity building for public health is therefore understood in its broadest sense.

This will involve

representation from all sections of communities including women, children, persons with disabilities,

disadvantaged section of society, the elderly, and persons with HIV/AIDS and other illnesses, so that their
perspectives, concerns, and valuable suggestions based on lived experience, will help to evolve the strategies.
53.

Where elected representatives function at the level of local bodies and have responsibilities for health, there
is a need for innovative training to enable them to improve the governance of the public health system. This

exercise may take a few years, but has proved to be effective in several places such as Kerala state in South
India.

54.

Formation of self-help groups of women is widespread in the region. The value of adding a health and social
dimension to their economic activities has been shown to be effective in Bangladesh, Nepal and sever^
countries. This approach could be more widely used. Care needs to be taken that methods used a^|

empowering and liberating without adding additional responsibilities and burdens to women who are already
overworked and fatigued.

55.

Self-help groups of persons living with particular illnesses who also become advocates for preventive and

promotive action play an important role. Involvement of persons living with HIV/AIDS at all levels of health
decision making has significantly altered the public health discourse. Shifting the balance between experts,
health providers and patients from one of dependency to one of greater autonomy and equality has been an

important step forward.

56.

Involvement of school teachers and parent sis critical to health promotion. It is important for young people to
be touched or moved at a personal level, for personal motivation for positive health to be ignited. Training of
trainers for parenting education, life skills education, counseling and health promotion on the basis of the

Ottawa charter and subsequent charters would bear great fruit.
57.

Politicians and bureaucrats are often placed in positions where they make major decisions that impact on

health and health care. They may not have the requisite information and knowledge easily available to weigh

10

the matter objectively. Various lobbies and interest groups present them with sophisticated material favoring

their position. Public health groups need to prepare well-researched, objective policy briefs that protect and

promote public interest.

58.

Experience across the region has shown the great value addition of involving communities with health
institutions through a variety of institutional mechanisms that include:
a)
Setting up health communities at health centre and sub-centre level.

b)

c)

Establishing boards of visitors, help-desks and help-lines run by volunteers in hospitals and elsewhere.
Mandating local bodies or elected representatives with specific constitutional responsibilities for the
governance of health institutions and programmes

d)
e)

Making adequate provisions for the citizen's right to information to include the heath sector as well.
Establishing mechanisms for participatory management of health institutions, making space for

community voice to be heard and responded to.
All these efforts help to increase community ownership and management of health institutions.

59.

Information and communication technology (ICT) could be used proactively by governments to overcome the
digital and knowledge divide in health. The necessary infrastructure will need to be established and skill

training undertaken. A community participatory model to the Health Inter-network project being piloted by

WHO has shown that the sharing of health information with communities, health workers and staff from

health related departments using a mix of communication methods including ICT served an unmet information

need.
60.

Communities have also participated actively and effectively in participatory action research that study some of

the developmental determinate of health such as environmental an health consequences resulting from
industrial pollution, use of pesticides, mining etc. Community involvement in the research as river-keepers
measuring water quality, as community patrols measuring air quality or as bucket brigades has enabled them
to gather evidence and become agents for change in a positive manner.

61.

Public campaigns on health related issues have become increasingly common in the region as well as globally.
The women's movement has been effective In increasing gender sensitization of health policies, in promoting
reproductive rights, and in raising gender concerns in health research and in medical education. One of the

current campaigns is to increase women's access to primary health care and to reduce violence against
women. The people's health movement has been campaigning for a revitalization of the spirit and principles

of primary healthcare. The Peoples Charter for HIV/AIDS has resulted in formation of the Asian Peoples
Alliance for Combating HIV/AIDS (APACHA). The Peoples Charter for Health of the PHM has also become a
rallying point for a campaign to reduce wars, conflicts and violence.

The pulse of people can be felt and

responded to by listening to the issues raised by people's campaigns and movements. This is an important
third force that is countering the threats to peoples health caused by corporate globalization, liberalization

and the commercialization of health care.
62.

Use of the principle of subsidiarity in decentralization of health care services, with appropriate training,

management and preparation of people, helps to bring services closer to people. However it is necessary to
take adequate measures to ensure a focus on primary health care and public health.

References
ESCAP (2003 a) Tacking HIV/AIDS as a development Challenge (E/ESCA0/CESI/4).
ESCAP (2003 b) Investing in health for development (E/ESCAP/CEST/5).
ESCAP (2003 c) SARS: Lessons for public Health (E/ESCAP/CEST/6).
ESCAP (2003 d) Report of the Committee on emerging social issues on its first session (E/ESCAP/CEST/Rep).
ESCAP(2004 a) Resolutions adopted by the commission at its sixtieth session - 60/1 Shanghai Declaration.
Detels R. Me Ewen J.Beaglehole R, Tanaka H, (2002) Oxford Textbook of Public Health Fourth edition, Oxford University Press.
Last J.M (ed) (1995) A Dictionary of Epidemiology Third Edition. International Epidemiological Association. Oxford University
Press.

11

Public Health definition for India (a dialogue]
Various definitions of public health, community health and primary health care were looked for, reviewed and
considered in the Indian context. These definitions, along with their sources, are available in the appendix of this
document. Relevant themes were identified from these definitions and from professional experience in relation
to the Indian setting to come up with the proposed definition, which built further on the initial template

provided by Dr Farooque Ahmed and the suggestions of Dr Sanjay Chaturvedi (see appendices). The suggested

definition and compilation of phrases is as follows:

"Public Health is the science and art ofpromoting health, preventing disease, and prolonging life
•

-to ensure for everyone a standard of living adequate for the maintenance of a healthy and productive

life,
•

-by developing a social movement, as an integral part of community development,

through inter­

sectoral coordination and organized community effort emphasising equity, participation, ownership,

rights and responsibilities
•

while maintaining healthy environment; empowering people to maintain a healthy life style & behaviour;

controlling communicable and non communicable diseases;

•

-addressing social, cultural, economic, political, ecological and environmental realities having a bearing

on health;
•

formulating health policies, interventions and programmes; and by evolving and organizing human
resource and health care systems to facilitate health promotion, disease prevention, early diagnosis,

treatment and rehabilitation, through informed choices of our society, communities and individuals,

•

which Is available universally, distributed eguitably, ethical, socially relevant and accessible to all
irrespective of their ability to pay."

This definition has been submitted for peer review, comments and further additions/modifications.

Dialogue on Public Health Definition
Definition of Public Health: C.E.A. Winslow's Definition of Public Health as quoted in Hanlon & Picket 1984:

"Public Health is the science and the art of (1) preventing disease. (2) Prolonging life and organized community
efforts for (a) the sanitation of the environment (b) the control of communicable infections, (c) the education of

individuals in personal hygiene (d) organization of medical and nursing services for early diagnosis and

preventive treatment of disease and (e) the development of social machinery to ensure everyone a standard of
living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize

his birth right of health and longevity"
Farooque's modified definition: "Public Health is the science and art of Promoting Health, Preventing disease,

prolonging life, to ensure everyone a standard of living adequate for the maintenance of health and be

economically active life, and to enable every citizen to realize his birth right of health and longevity, by
developing

a social machinery, as on integral part of Community Development, through intersectoral

coordination and organized community effort & participation to maintain a healthy environment, to educate
people to maintain a healthy life style & behavior, to control communicable, non communicable diseases and

other social & behavioral maladies, by organizing a medical and nursing services to deliver a comprehensive

12

health care package consisting of health promotion, prevention, early diagnosis, treatment and rehabilitation of

diseases which is to be universally available, equitably distributed and accessible to all at an affordable cost".
Sanjay's modified definition: "Public Health is the science and art of promoting health, preventing disease, and
prolonging life to ensure for everyone a standard of living adequate for the maintenance of a healthy and

productive life, by developing a social movement, as an integral part of community development, through

intersectoral coordination and organized community effort, participation, equity and ownership - while
maintaining healthy environment; empowering people to maintain a healthy life style & behavior; controlling

communicable and non communicable diseases; addressing social and cultural realities having a bearing on
health; informing health policies, interventions and programmes; and by evolving and organizing human

resource and health care systems to deliver health promotion, disease prevention, early diagnosis, treatment

and rehabilitation, which is available universally, distributed equitably and accessible to all at an affordable

cost."

SOCHARA's modified definition: "Public Health is the science and art of promoting health, preventing disea^^
and prolonging life
•

-to ensure for everyone a standard of living adequate for the maintenance of a healthy and productive

life,
•

-by developing a social movement, as an integral part of community development,

through inter­

sectoral coordination and organized community effort emphasising equity, participation, ownership,
rights and responsibilities

•

while maintaining healthy environment; empowering people to maintain a healthy life style & behaviour;

controlling communicable and non communicable diseases;

•

-addressing social, cultural, economic, political, ecological and environmental realities having a bearing

on health;
•

formulating health policies, interventions and programmes; and by evolving and organizing human

resource and health care systems to facilitate health promotion, disease prevention, early diagnosis,

treatment and rehabilitation, through informed choices of our society, communities and individuals,
•

which is available universally, distributed equitably, ethical, socially relevant and accessible to all

irrespective of their ability to pay."
[please note that the items underlined in the above modified definitions by Dr Sanjay and SOCHARA are the
suggested changes/additions to Dr Farooque's original suggested definition]

Dr Farooque's explanation for modifications:

The modified definition of Winslow on Public Health by Indian Academy of Public Health is an overarching one

encompassing the whole gamut of Health activity enshrined in the HFA and its strategy document. The definition
has three distinctive sections. The first section depicts the Goal of public health as
"Promoting Health, Preventing disease, prolonging life, to ensure everyone a standard of living adequate for the

maintenance of health and be economically active life, and to enable every citizen to realize his birth right of
health and longevity". The second sections includes the broad strategy of "developing a social machinery, as an

integral part of Community Development, through intersectoral coordination and organized community effort &

participation"

The penultimate and the third section of the definition outlines the specific health intervention

activities "maintain a healthy environment, to educate people to maintain a healthy life style & behavior, to

13

control communicable, non communicable diseases and other social & behavioral maladies". And the last and
the fourth section depicts the service delivery system and the package and the manner of its delivery
"organizing a medical and nursing services to deliver a comprehensive health care package consisting of health

promotion, prevention, early diagnosis, treatment and rehabilitation of diseases which is to be universally
available, equitably distributed and accessible to all at an affordable cost"

To translate the definition of public health C.E.A. Winslow's or the modified one of IPHA one should refer to
the chapter on Organization of Public Health services of Hanlon's Book on Public Health administration. It states

of two distinct approaches for providing public health services in a community. They are "personal health care
Services" focusing on individual health services and "Public health care/ Community care services" focussing on
the community. One should have a clear understanding of the basic difference between the "personal Health

Care"& "Public Health/ community care services. The focus of personal health care service is to deliver the
health care package as described in the definition of Public Health which speaks of a "comprehensive health

care package consisting of health promotion, prevention, early diagnosis, treatment and rehabilitation of
diseases." And to achieve the characteristics of services as defined in Public Health "to be universally available,

equitably distributed and accessible to all at an affordable cost" the health service in India is organized on the
concept

of "Regionalized Graded Institution supported community based Health care System"

Briefly it

describes the Indian Health care system. The most peripheral service unit is the community (village), and a
community based health worker ASHA/AWW provides a support base and acts as a link worker to provide

essential health care services by the most peripheral trained health worker from her community based

institution of "Sub-centre".

The services and referral support is provided by a chain of health Institution in an

hierarchical pattern (Graded)and serving an ear marked catchment area (Regionalized). To start with it is the

Primary Health Centre manned by Medical Officers, supported by a Community Health Centre acting as a First
referral unit for treatment purpose which is manned by specialists (or trained generalist) of Obstetrics &
Gynecology, Pediatrics or Medicine, Surgery and , Anesthesia. The next health Institution is s Sub-divisional/

Taluka

Hospital with specialist in major disciplinesf not available all throughout) but which is universally

supported by a District Hospital having all the facilities of specialist care. The care given by a Female health
worker to an Antenatal mother in her area which includes delivery of Antenatal, intra-natal and post natal

packages both institutions based as well as at home if during this process she develops permanent disability she
is also supposed to provide some rehabilitative package (may not be included in the program). One can extend

the same thinking to other public health programs like RNTCP, Malaria, AID'S control etc. This type of workers
should essentially be equipped primarily with clinical skills to deal with the individual medical problem. And to

interact effectively with the patients, beneficiaries and the family members and the other members of the
health team he/ she should be equipped with a communication and behavioral skill. Besides these two specific

skills she/he should be familiar with the basic office management skills for reporting and recording and be
familiar with the public health programs and ready to cooperate.

On the other hand the Public/ community Health care service provider's focus is on the public/community. Its
main as per the definition of Public Health is to "maintain a healthy environment, to educate people to maintain

a healthy life style & behavior , to control communicable, non communicable diseases and other social &

behavioral maladies, by organizing a medical and nursing services and to deliver a comprehensive health care
package consisting of health promotion, prevention, early diagnosis, treatment and rehabilitation of diseases
which is to be universally available, equitably distributed and accessible to all at an affordable cost" . The job

responsibility of a public health worker is to monitor the health status & environment, disease surveillance, of
the community he serves and assist /arrive at a community diagnosis, devising and implementing a health
intervention program, organizing a health services to deliver the comprehensive health care package and to

ensure its effective utilization by the community at large. The core competencies required for such job will be
14

Basic human biology which should include social & psychological aspect, Environmental & Ecological science,

Behavioural sciences. Biostatistics, Demography, Epidemiology, Management sciences, History & evolution of
Health & Public Health services. The skills to be developed in a public health worker are epidemiological skill,
Basic Public Health skills, Communication skills Health system management skills. The health system
management skills should include skills to manage organizational, personal, material and financial issues.

Addressing the health needs of the community as well as for effective functioning of a health service system,

requires a seamless relationship between different type of service institutions like hospitals and the community
based service programs requiring communities participation and the support and coordination of other
departments related to human development. As such the public health worker should also have the ability to

interact with the public as well as other service providers.
At present all the existing health work force is providing both the personal and public health care. Can one

believe that the main players of the personal care service providers are also providing a complex package of
public health service ail throughout the country and implementing health programs galore including NRHM?

With the non existence (in most of the states) of Male Health worker the Female Health worker is the key
worker most inadequately supported by a dwindling species of Lady Health Visitors (in many a states and if at^P

they are mostly untrained promoted on attaining a service seniority) and the so called Public Health nurses. The

poor medical officer is blamed. But please examine the support he is getting in providing a community based
public health services. While for providing institution based Clinical care he has the option to have the support

of Nurse, Pharmacist, laboratory technician, OT technician, Blood bank technician, CT technician and hordes of

others but in public health none except a Computer and a Block extension educator under the Family welfare
program. They too are not formally trained. No one has to do another multi-centric study under the aegis of

ICMR or the Planning commission to find out the inadequacies of a dedicated public Health work force. This is

evident as it exists today in our health services.

This is because of our ignorance of the exact nature and scope

of public health and an "ostrich" like attitude for not listening to others' views on the issue. Understanding the

basic difference between the two and appreciating the necessity of these complimentary approaches to improve
the health services will be epoch making step in ameliorating the ruts afflicting the health care delivery system

and lead to fulfill the MDG goal as well as make the definition of Public Health as achievable.
Dr Sanjay's explanantion for modification:

reservations and explanation: (based on Winslow's definition):

Winslow inherited a lot. Will it be rational (or scientific) and fair to 'totemize' a whole heritage with one
name? Emancipation from a Eurocentric discourse may have other ideas and options too. Lingual structure and
framework do not belong to an individual. An if that has been a tradition, it needs to be stopped. Winslow's

work should be referred to, instead.
....and be economically active life,....:

‘ Why place a premium on 'economical' alone - and trap ourselves?
...every citizen..... :
Citizen is a loaded word. Public health should aim to reach out to non-citizen as well. To non-people (not people
like us) as well.
... to educate people...:

Betrays a patronizing sentiment. Empowering may be a better word.

15

SOCHARA's explanation for modifications:
We would also agree that we should not only refer to Winslow's definition, but to others as well. While putting

another document together from various sources (see document "public health definition database"), we also
felt the need to review two other terms that are now commonly being used in public health circles, sometimes
synonymously and sometimes with clarity of understanding of the subtle difference. These are the "new public

health" and "community health". While reviewing these we discovered that both Farooque and Sanjay have

already introduced these newer ideas and concepts, but there are three additions we would like to suggest to
locate the definition in today's context.

The first is to add the concept of both "rights and responsibilities" taking from the newer community health and
new public health definitions.

The second is to add "economic/political/ecological" when we mention "social and cultural realities". You will

recall, that this was accepted in the WHO SEARO meeting of Epidemiologists in the region in February 2009
when they accepted in the declaration of the meeting and added the following:

"The scope and reach of epidemiology, which is an integral part of public health must be expanded to include
the study of social, cultural, economic, environmental, ecological and political determinants of health, and
constitute the key stone for use of evidence for development of public health policy."

The third is to add "ethical and socially relevant" when we describe the system and not just make it "universal,

distributed equitably and affordable".
The fourth is to add words like "formulating/facilitating" rather than "delivering" to ensure that we are less

"top-down" and more process oriented, or bottoms-up in our policy making.
The fifth is to question whether "accessible to all at an affordable cost", is an acceptance of today's economic

policy since the Bhore committee had used "irrespective of their ability to pay". If IPHA is committed to "Health
for All" and not "Health forthose who can pay" we have to change this phrase as well.
While we are happy to move beyond Winslow's definition - we would like to emphasise that the original

definition also had an additional phrase which was - "informed choices of society/organisation, public and
private, communities and individuals". I feel this phrase emphasising both "informed choice" which is evidence
driven rather than idea, opinion or emotion driven, is very important in today's public health policy evolution.

The same phrase also shows the diversities of sectors - government, private and civil/community which
emphasises partnerships. We need to consider this aspect as well.

Public Health Definitions
Public Health (International Association of Epidemiology dictionary - JM Last, 1983)
Public Health is one of the efforts organized by society to protect, promote, and restore the peoples' health. It is
the combination of sciences, skills, and beliefs that is directed to the maintenance and improvement of the

health of all the people through collective or social actions. The programs, services, and institutions involved

emphasize the prevention of disease and the health needs of the population as a whole. Public health activities
change with changing technology and social values, but the goals remain the same: to reduce the amount of

disease, premature death, and disease-produced discomfort and disability in the population. (Public health is
thus a social institution, a discipline, and a practice).
Available from: http://www.merriam-webster.com/dictionary/public+health?show=0&t= 1317192822

16

Public health: the art and science dealing with the protection and improvement of community health by
organized community effort and including preventive medicine and sanitary and social science
Available from: http://medical-dictionarv.thefreedictionary.com/public-i-health
Public Health (pub I 1 k)

The science and practice of protecting and improving the health of a community, as by preventive medicine,
health education, control of communicable diseases, application of sanitary measures, and monitoring of
environmental hazards.

Source: The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company.
Published by Houghton Mifflin Company. All rights reserved.
Public Health

a field of medicine that deals with the physical and mental health of the community, particularly in such areas as

water supply, waste disposal, air pollution, and food safety. In the United States there are more than 3000 state,
county, or city public health agencies. The U.S. Public Health Service was organized in 1798 to provide hospital
care for American merchant seamen. Subsequent legislation has expanded the role of the federal agency to
include such services as the Food and Drug Administration; the National Library of Medicine; health care fojL
Native Americans and Alaska Natives; protection against impure and unsafe foods, drugs, cosmetics, a|^

medical devices; control of alcohol and drug abuse; and protection against unsafe radiation-producing projects.
Source: Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.

Public Health
the field of health science that is concerned with safeguarding and improving the physical, mental, and social
well-being of the community as a whole. The United States Public Health Service (USPHS) is a federal health

agency that is part of the United States Department of Health and Human Services. State and county public
health agencies function under the supervision of and with financial support from the Department of Health and

Human Services.
Public Health Nursing the branch of nursing concerned with providing nursing care and health guidance to
individuals, families, and other population groups in settings such as the home, school, workplace, and other

community settings such as medical and health centers. The nurse in this field, a community health nurse, must
have a baccalaureate degree and training in public health nursing theory and practice; employment is typically
with a local agency such as a nonprofit proprietary organization or with an agency under the United States
Department of Health and Human Services. The work involves implementing such programs as school and
preschool health programs, immunization and treatment of communicable diseases, maternal and child health
clinics, and home visits for the purpose of providing health education and nursing care. There is also frequeijO
participation in educational programs for nurses, allied professional workers, and civic organizations, antP

involvement in studying, planning, formulating public policy, and putting into action local and national health
programs.

Source: Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. ©
2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved.

Public Health: In a field of medicine that deals with the physical and mental health of the community,
particularly in such areas as water supply, waste disposal, air pollution, and food safety.
Source: Mosby's Dental Dictionary, 2nd edition. © 2008 Elsevier, Inc. All rights reserved.

Public Health: The field of human medicine that is concerned with safeguarding and improving the physical,
mental and social well-being of the community as a whole. There are marginal roles for veterinarians in this
service, especially in the area of zoonoses.

Source: Saunders Comprehensive Veterinary Dictionary, 3 ed. © 2007 Elsevier, Inc. All rights reserved
http://www.medterms.com/script/maln/art.asp?articlekey=5120

17

Public health: The approach to medicine that is concerned with the health of the community as a whole. Public
health is community health. It has been said that: "Health care is vital to all of us some of the time, but public
health is vital to all of us all of the time."

The mission of public health Is to "fulfill society's interest in assuring conditions in which people can be healthy."
The three core public health functions are:
•

The assessment and monitoring of the health of communities and populations at risk to identify health

•

The formulation of public policies designed to solve identified local and national health problems and

problems and priorities;
priorities;

•

To assure that all populations have access to appropriate and cost-effective care, including health
promotion and disease prevention services, and evaluation of the effectiveness of that care.
http://en.wikipedia.org/wiki/Public health

Public health is "the science and art of preventing disease, prolonging life and promoting health through the
organized efforts and informed choices of society, organizations, public and private, communities and
individuals"
Available From: http://www.whatispubllchealth.org/
NEW PUBLIC HEALTH

A new public health approach would therefore not only move from its present "behavioural epidemiology" and
"surveillance" mode to a more environmental and social approach, but would aim to tackle the risk patterns of
our societies with new basic assumptions.
Source; http://heapro.oxfordiournals.Org/content/4/4/265.extract [Ilona Kickbusch. Approaches to an ecological
base for public health. Health promotion. Vol 4, no.4, 265]
By the early 1990s, there was general agreement within the public health community that health promotion,
based on the Ottawa Charter principles, constituted the "new public health."13,14 Yet analysis of the health

promotion framework reveals the legacies of previous eras, thus prompting the question, "What's new about
the 'new public health'?'' In addressing this question;! demonstrate that original health promotion innovations,

and the legacies of previous eras, are "new" in the sense that the latter have been revised in the light of
advances in knowledge, increasing concerns about human rights, and emerging threats to health.
What is new about the new public health is not the originality of strategies to ensure healthy conditions, but the

manner in which health promotion discourse has adapted core doctrines of previous eras to address the public

health threats of.our era. New public health eras usually arise when the dominant public health framework

becomes obsolete as a result of changing health patterns and advances in health knowledge. Currently, public
health theorists and commentators appear to be losing .confidence in the capacity of the health promotion

paradigm to effectively address major contemporary public health threats, such as health inequalities and
terrorism. Source: Niyi Awofeso, What's new about new public health? Am J Public Health. 2004 May; 94(5):
705-709. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448321/

The New Public Health is derived from the experience of history. Organized activity to prevent disease and
promote health had to be relearned from the ancient and post-industrial revolution worlds. As the 20th century
draws to a close, we need to learn from a wider framework how to use all health modalities, including clinical
and prevention-oriented services to effectively and economically preserve, protect and promote the health of

the individual and of society. The New Public Health, as public health did in the past, faces ethical issues that
relate to health expenditures, priorities and social philosophy. Throughout the course of this book, we discuss
these issues, and try to indicate a balanced approach toward the New Public Health.
http://www.google.co.in/url?sa=t&source=web&cd=7&ved=0CHoQFiAG&url=http%3A%2F%2Fwww.elsevierdire
ct.com%2Fcompanions 0/o2F9780123708908%2Fcasestudies°/o2FNPH%2520Teaching%2520guide.doc&ei=lvabTp

yJM4L5rQe iOGmBA&usg=AFQiCNGe5gDqWWUyh-KKzGq6CXNUS6YcDQ&sig2= ZRgFTzmz3biGIHYJFFrHw
18

"The New Public Health is not so much a concept as it is a philosophy which endeavors to broaden the older
understanding of public health so that, for example, it includes the health of the individual in addition to the
health of populations, and seeks to address such contemporary health issues as are concerned with equitable

access to health services, the environment, political governance and social and economic development. It seeks
to put health in the development framework to ensure that health is protected in public policy. Above all, the
New Public Health is concerned with action. It is concerned with finding a blueprint to address many of the
burning issues of our time, but also with identifying implementable strategies in the endeavor to solve these

problems." [Ncaayiyana D, Goldstein G, Yach D. New Public Health and the WHO's Ninth General Program of Work:
A discussion Paper. Geneva: World Health Organization, 1995.]

Defining new public health (NPH):
The NPH is a comprehensive approach to protecting and promoting the health status of the individual and the

society, based on a balance of sanitary, environmental, health promotion, personal and community oriented

preventive services, coordinated with a wide range of curative, rehabilitative and long term care services.
The NPH requires an organized context of national, regional and local governmental and non-governmental
programs with the object of creating healthful social, nutritional and physical environmental conditions. The
content, quality, organization and management of component services and programs are all vital to its successful
implementation.
fl

The NPH is based on responsibility and accountability for defined populations in which financial systems promote
achievement of these targets through effective and efficient management, and cost-effective use of financial,

human and other resources. It requires continuous monitoring of epidemiological, economic and social aspects of

health status as an integral part of the process of management, evaluation and planning for improved health.
The NPH provides a framework for industrialized and developing countries, as well as countries in political-

economic transition such as those of the former Soviet system. They are at different stages of economic,
epidemiologic and socio-political development, each attempting to assure adequate health for its population with
limited resources

Additional Reading:
1.

Ahmed

FU.

Defining

public

health.

Indian

Journal

Public

Health

2011;55:241-5

Available

from:

http://www.iiph.in/text.asp?2011/55/4/241/92397 accessed on 28th December 2012.

19

Public Health competencies for health
professionals in India(Developed for Indian public Health Association (IPHA) Supported by World Health Organisation (WHO) - Country Office for India)

Several documents on public health competencies were reviewed from Indian and foreign institutions and
universities. Contact was maintained with other members working on this project, and their feedback was

considered. A potential list of core and cross-cutting competencies was prepared and dispatched for peer-review
and comments:

Core competencies:

1.

Health planning

2.

Epidemiological skills

3.

Family and community diagnosis

4.

Health management (including financial

13.

Public health biology competency

14.

Environmental health competency

Cross cutting:

1.
2.

Managing and implementing health

5.

sciences)

Monitoring and evaluation (including health
surveillance)

Health promotion (including prevention and

7.

protection)

8.

Training

Research (including biostatistics and

9.

demography)

Working with community (including

10.

community dimensions of practice)

11.

Partnership and advocacy

12.

Public health laws and ethics

Socio-cultural competency (including all social and
behavioural sciences like economics and political

programmes (including program planning)
6.

Critical analysis and systems thinking (including

problem solving)

management)

3.

Leadership

4.

Communication (including informatics)

5.

Life-long learning

6.

Equity

7.

Human resource development

8.

Policy and advocacy

9.

Governance and decentralisation

10.

Conflict resolution

Convergence and hierarchy of levels of public health competencies
An ad-hoc assessment was also made on the degree and type of competencies needed at each level of education.
This comparison was made to clarify that competencies may be shared between various types and levels of

education, but competencies may be of differing levels.

Comparative competencies and degree/level of competencies for the Indian scenario:

Competency

MD-PSM

MBBS
(PSM/CM)

(Consultant)

+
+
++

+++
+++
+++

MPH
(Practitioner)

MHA
/MSc

CORE
Health planning

Epidemiological skills
Family and community diagnosis

++
+++
20

Health management (including financial

+

+++

++

+

+++

+++

Monitoring and evaluation (including
health surveillance)

+

+++

+++

Health promotion (including prevention
and protection)

++

+++

+++

Training

+

+++

+++

Research (including biostatistics and

+

+++

++

++

+++

+++

management)
Managing and implementing health
programmes (including program planning)

demography)

Working with community (including
community dimensions of practice)

+

+++

+++

Public health laws and ethics

+

+++

+++

Public health biology competency

++

+++

+

Environmental health competency

+

+++

++

Critical analysis and systems thinking
(including problem solving)

+

+++

+++

Socio-cultural competency (including all

+

+++

++

Leadership

+

+++

+++

Communication (including informatics)

++

+++

+++

Life-long learning

+

+++

++

Equity

+

+++

+++

Human resource development

+

+++

Partnership and advocacy

CROSS-CUTTING

social and behavioural sciences like

economics and political sciences)

++

Policy and advocacy

+

+++

++

Governance and decentralisation

+

+++

+++

Conflict resolution

+

+++

+++

Key:

+: basic understanding (public health oriented general practitioner)
++: basic understanding and skill/capacity for practice (public health practitioners)

+++: advanced understanding for both practice and system-development (public health consultants)
(this applies only to MBBS, MPH and MD. Special masters programmes for example MSc Epidemiology, MSc
Health Promotion, MSc Health Services Management, MSc Health Policy and Planning etc may be specialist

enough to produce consultants for system-development in those areas)

18

Beijing Statement from the Second Global Symposium on
Health Systems Research
3 November, 2012

Beijing, China

From 31 October to 3 November, 2012, 1,775 participants from over 110 countries gathered in Beijing, China
for the Second Global Symposium on health systems research. Around the theme of inclusion and innovation

towards Universal Health Coverage (UHC), the Second Symposium reviewed state-of-the art research and
discussed strategies for strengthening the field of health systems research. Over four days comprising nearly

200 program events including keynotes, plenaries, concurrent sessions, satellites, posters, films and informal
discussions and debates, the following action points related to the inclusion and innovation themes have
emerged:
•

•

In our endeavor to achieve UHC, we must ensure the centrality of social and gender equity. UHC is not
only a health system's task but a societal goal that requires inclusion of diverse actors, different types
of knowledge and innovation across local, district, national, regional and global contexts.

Effective inclusion recognises the paramount priority of the collective development of indicators that
can be used to monitor countries' progress towards the goal of UHC, as well as being used by civil
society to hold governments accountable. Such measures must be relevant to local and national

contexts, first and foremost, and amenable to global comparisons.
•

Most urgently, local capacities for critical health systems' analysis is required for individual countries to
understand what aspects of their health systems (in terms of service delivery, financing and

governance) require change so as to make real progress to UHC with equity.

•

The social, methodological and technical innovations shared in this Symposium provide a well-spring of
knowledge and an enormous opportunity, provided they can be appropriately integrated to bring
about systemic change to accelerate progress towards UHC.

Key ideas for action that have emerged related to the objectives of the program include:
•

The cutting edge of health systems research should be advanced by supporting analysis of politics and

policy; community action interventions; fiscal innovations; equity oriented health metrics; and
Longitudinal methods to capture dynamism and long-term impact of interventions.

•

Symposium participants want more research on: social inequalities in health, including urbanisation
and ageing; social exclusion; governance; and the balance of sectors, including informal, private, and
public.

•

The development of social science methodologies, health metrics and monitoring and evaluation

systems in a balanced manner should be encouraged in order to appreciate the complexity of health
systems, policies and implementation processes and capture their historical origins, current status and
future long-term impacts.
•

Other innovations that warrant support include strengthened data surveillance systems; better
documentation of financial flows at all levels; nesting research and incorporation of knowledge uptake
in research design for improved monitoring and accountability, including by communities, in
implementation of UHC.

•

Knowledge translation should be facilitated by developing communities of practice and trust between
researchers, practitioners and policymakers; drawing from multiple sources of knowledge and

22

evidence, including real-world experiences; strengthening open-access databases; and enhancing
South-South exchange of innovations to achieve UHC.

•

Long term and public financing for public research institutions for health systems research is desired.
Interest groups and partnerships should be supported for various forms of training in health systems
research, that include communication, values, power relations and context analysis as capacities at all
levels.

We note with pride some accomplishments of key milestones committed to in Montreux, 2010
1.

The launch of the WHO Strategy on Health Policy and Systems Research represents a significant step

forward for the field. It calls for increasing the relevance and utility of Health Systems Research by

making it more demand driven. It suggests options for action by member states to embed research into

decision-making to ensure that HPSR is grounded in political realities and at the same time, the
grounding of policy processes in evidence and science.

2.

The creation of a first international society for health systems research. With more than 1400 members
and 11 newly elected board members, Health Systems Global held its first Board and Annual Geneu^

Meeting and began on its path to catalyse and convene its membership to strengthen the field

health systems research in the pursuit of more just and equitable health systems.

3.

Furthermore to meet the expectation, clearly expressed in Montreux, that HSR inform policies more
systematically, participants contributed to the first meetings of the global consultation on health in the

post-2015 development agenda as part of the United Nations Secretary General's High-Level Panel

process. Understanding how to build on the MDGs, address emerging issues, measuring new goals, and

linking these to accountability mechanisms relevant to each country requires continued contributions
by the health systems research community.

In support of the Symposium themes and recommendations, funders expressed broad support for the
establishment of a new mechanism, a Research Consortium for UHC (RC UHC), to improve the coordination of
resources to accelerate the knowledge and know-how for universal health coverage. With a committed core of

funders and a clear agenda for research, the development and operationalization of RC UHC will be finalized
and launched in 2013.

In 2014, we will gather for a Third Global Symposium on Health Systems Research to continue to evaluate
progress, share insights and recalibrate the agenda of science to accelerate universal health coverage.
Following a call for proposals, applications from South Africa and Canada, are being reviewed
M
by the Board of HS Global with a decision expected by the end of 2012.

Approved by the Executive Committee of the Second Global
Symposium on Health Systems Research

Contribution to The Beijing Statement of the Second
Global Symposium on health systems research
Best idea provided for action form the sessions in one of the six areas that are most relevant to the session.

A.

Knowledge Translation

1.

Poorest countries are taking steps for Improving access but the steps differ significantly across
countries- from introduction to national health insurance to more active role of private sector. (5)

23

Grass root level capacity to deliver basic health care so there is support for health reform(15)

2.

i. A new proposal on parallel importation rule- important to explore who should be more protected-

3.

innovations or poor people.
Proposal on material to train communities on advertisement assessment. (18)

ii.

4.

Written information needs to be combined with real world experience. (21)

5.

Tax based financing is the way.

Institutions like NHSO Thailand with good capacity are crucial. Private

Insurance contracting is increasing the administrative cost has produced mixed results in terms of UHC
or ethics.(26)

Market failures and state failures would therefore require new forms of PPP as practical and pragmatic

6.

relations. (27)
Support the ongoing enhancements to and use of one stop shops for synthesized research evidence,,

7.

such as Cochrane library for questions about public health programme and services, and health
systems evidence for questions about health systems arrangements and information strategies. (30)
Opportunities exist to strengthen the contributions of HSR

8.

Supporting HSR as a scientific endeavor.

i.

9.

ii.

Build National capacity for HSR

iii.

Embedding HSR as a core function of Health Systems. (33)

KT is not about translating research to policy. It is also about translating problems into good research

questions. (61)
10.

To establish communities of practice to link researchers, funders and policy makers on areas of core

interest. (66)

11.

i. Relationships are key (long term trust)
ii. Decision maker involvement throughout is needed. (69)

12.

Expanding population coverage is not enough-financial package also needs to be expanded. (88)

13.

More investment in strengthening capacities of decision makers to demand and use evidence. (109)

14.

More research needed to measure potentially inappropriate medication or PIMS and better policies

required for meeting the cost of MCD in LIMC's. UHC as a concept when translated into policy and
programmes tends exclude groups like elderly and health problems like NCD. (117)
15.

Researchers and policy makers need to appreciate each other's role and work together. (118)

16.

South south exchange of health systems innovation to achieve UHC works. (122)

B. State of the Art research on the health systems research
1.

Need to further develop theory and models to better understand how health systems approaches can
be fine tuned to ensure maximum impact on the diagonal. (3)

2.

Out of pocket expenses have affected poverty levels in countries, policy options needed to reduce the

negative effects of catastrophic out of pocket expenditure. (5)
3.

That the intersection of fiscal analysis and political connections is poorly understood. (8)

4.

It is important to examine the role and efficiency of community programm's on health outcomes. (12)

5.

i. Efficiency of grass roots institutions
ii. Motivate medical Professional. (15)

6.

Indicators used on the World health organization packages- they are widely used, it is important to
invest continuously on their improvement. (18)

7.

Longitudinal Methods are valuable in capturing the dynamics and complexity of health policy and

systems development. (68)

8.

Give enough time for high quality evaluation of innovations. (105)

24

9.

10.

Responsiveness and effectiveness studies are badly needed to address the problems. (115)
Health System tends to commit medication related errors in case of treating elderly. Measuring
potentially inappropriate medications or PIMS is important. PIMS index is state of the Art research to

make health system provide appropriate treatment to elderly. (117)
11.

Developing a framework to monitor and evaluate the health systems effects of performance based
financing. (120)

C.

Health systems research methodologies

1.

Evidence on Impact of Health insurance is limited but promising. We need better M&E system to
improve the evidence quickly. (7)

2.

WHO Building Blocks is only a starting point, but should not be used as research framework when
looking at health systems strengthening of interventions. (9)

3.

4.

Aligning health metrics is beneficial, doable and can/should be a scientific and inclusive process. (11)

i. Policy research focusing on capacity building, (human resource for Health)

ii. Research on urbanization and ageing. (15)
5.

Very important to Offer training on methods and on research communications. Presenters missed to

address important methods features. (18)

6.

Need to develop better mixed methods on the causes of performance shortfalls linked to health
finance and delivery. (20)

7.

Further Encourage the development of qualitative or mixed methods approaches that better describe
and evaluate policy programmes formulation and implementation process. (22)

8.
9.

More have to be studied regarding balance of public- private- people (non profit) sectors. (27)

Scale up methodologies can have an enormous impact on health systems. Different frameworks can

help identify where the particular contributions have the most potential impact. (62)
10.

Be critical and Challenge the assumptions behind research methods. (74)

11.

Use of training in research applications and skills. (90)

12.

Methodology of measuring medical expenditure for NCD's at OPD level; and measurement of
improvement due to OPD medical expenditures. (117)

13.

Importance of increased focus on social value judgments again as priority affairs framework for

14.

multicriteria analysis tool. (119)
Robust and Comparable measures of UHC are paramount to informing and monitoring progress

fl

towards UHC it must be measurable at country level as well as globally. Practitioners are encouraged to
contribute to papers to this website www.wewanttohearfromyou.org . (109)

D.

Innovations in Health Systems Research

1.

Monitoring effective coverage holding systems accountable (6)

2.

Grass root level institutions providing essential health package- basic health services for alii Social

governance. (15)
3.

No Sound innovations on research but nice to see more and more people involved into research and

implementing controlled experiences. (18)
4.

We need more examples of how systems thinking can be applied in research and practice in LMIC's.
((56)

5.

To develop a community of practice that links researchers, practitioners and policy makers conducting

social research analysis. (70)

25

6.

Using Innovative approaches to strengthen data survey systems in presence can improve health

system. (86)

7.

8.

Improving service delivery performance by assessing performance- A must!. (115)
Using PIMS Index to ensure appropriate medication thereby brining down morbidity and motivating
due to high risk medication. (117)

E. Neglected priorities or population groups in health systems research
1.

Critical to emphasize health promotion and prevention in UHC. (1)

2.

Targeting is challenging but not doing so is even worse. (4)

3.

Single MDG for health -UHC, rather than specific ones as health needs are so diverse. (10)

4.

Accelerate UHC+ Essential drugs+ Grass Roots/ Model for UHC with PHC reforms (CHINA). (14)

5.

Increased reimbursement rates for vulnerable populations. (15)

6.

Important inequalities in service rise are wide spread and deserve explicit attention. (17)

7.

This panel addressed groups generally neglected- women, poor people. It is why it is important to
empower these representations on research methods. (18)

8.

Not enough with going to universal health coverage without taking equity into account and prioritizing

it in the pathway of UHC. (32)

9.
10.

Case studies and Cross analysis of using tanahashi for district level reduction of health inequities. (59)

New journal on infectious disease of poverty that covers health systems and other research areas- a
multi disciplinary approach. (91)

11.

More efforts and attention have been exerted to the disadvantaged groups however wastes are also an
outstanding issue, worsening inefficiencies. (112)

12.
13.

Demand Side strategy Assessments. (115)

Training in applied state of the art longitudinal methods for generating valid evidence as impacts of

changes in health systems. (116)
14.

Elderly as a group is neglected in the health systems of low and middle income similarly NCD's are out
of health systems of these countries. (117)

F. Financing and capacity building for health systems research
1.
2.

Universal Insurance systems through increased budget! (15)
Health finance Diaries are an innovative tool for more accurately capturing small frequent outpatient

expenditures. (16)

3.
4.

Financing Should Include capacity building on research. (18)

That HSPR capacity building while being of national policy relevant through joint partnerships between
South and South, north and north, University and Ministry of health for PhD and other forms of
training. (55)

5.

ii. Workshops (at national Level + marginal) of scenario building, applied learning for district level

managers on using tanahashi for identifying barriers to UHC. (59)
6.

Communication, values, power relations, qualitative methods and context analysis to be included as
themes/ capacities in capacity building initiatives for health research and all levels. (100)

7.

Meeting the financial burden of Burden of NCD is a challenge which needs multiple options to financing
the management of NCD's. (117)

8.

This session focused on financing challenges - seeing 7 countries in their path towards universal health

coverage. (131)

26

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27

Towards a Community Oriented
Public Health System Development in
Karnataka

by
Mission Group on Public Health

December, 2012

Karnataka Jnana Aayoga

(Karnataka Knowledge Commission)
Government of Karnataka
www.jnanaayoga.in

28

FOREWORD
The Mission Group on Public Health of the Karnataka Jnana Ayoga (Karnataka
Knowledge Commission) was entrusted the task of making a situation analysis of public
health challenges and systems in Karnataka and suggest appropriate recommendations
for action. The Mission Group undertook the task by evolving a Public Health Charter.
The Charter envisioned Public Health Policy which encompass many aspects which
impact on the well being of people of Karnataka. The Charter also recognizes that 'Public
Health' is not just a set of medical interventions at community level but has a larger
connotation of action that addresses the mental, environmental, nutritional, social and
cultural determinants of health. The Charter also focused on capacity building,
governance, inter-sectoral action, pluralism and integration, communitization and
alertness to emerging health challenges.

For arriving at such a strong and viable Public Health Policy within the framework of the
Charter, the Mission Group held several consultative meetings with experts across all
disciplines and sectors in health through a stakeholder's consultation that included.
Primary health care workers, urban and rural health NGOs, civil society organizations
working on rational drug policy, violence against women, child and maternal
malnutrition and public health experts and consultants who have participated in indepth deliberations and gave their suggestions. These deliberations resulted in some
key initiatives and a consensus outlined in this report. These key initiatives included free
and universal access to medicines; development of urban primary health policy;
promoting medical pluralism in public health; strengthening public health human
resource development and addressing the emerging challenge of chronic diseases
through a community oriented approach.
The major concern of the Group was the increasing challenge of multi-sectoral action
and convergence of the State's efforts to provide food, water, sanitation and initiatives
for development of women and children so that public health gets a real boost in the
State. The development of a strong and responsive public health system is thus an
urgent policy imperative if Karnataka has to move towards the emerging goal of
Universal Health Coverage within the vision of Health for All. We hope the Charter and
suggested action thrusts will facilitate the journey of the State towards these goals.
Dr. Ravi Narayan

Chairman, MGPH

Smt. Sita Lakshmi Chinnappa

Co-Chairman, MGPH

29

MISSION GROUP ON PUBLIC HEALTH
Chairman
Dr. Ravi Narayan
Community Health Advisor, Society for Community Health Awareness, Research and
Action

Co-Chairman
Smt. Sita Lakshmi Chinnappa
ICMR-Nationa Informatics Centre (NIC)
Members
Principal Secretary
Department of Health and Family Welfare Services, GoK

Dr. Darshan Shankar
Vice Chairman, Institute of Ayurveda and Integrative Medicine
Dr. R. Balasubramaniam
Founder, Swami Vivekananda Youth Movement
Dr. G. Gururaj
Professor and Head, Department of Epidemiology, NIMHANS
Dr. Gopal Dabade
Chairperson, Jana Arogya Andolana-Karnataka (JAA-K)
Dr. Ruth Manorama
President, National Alliance of Women
Director, Department of AYUSH, GoK

Dr. Kishore Kumar
Research Officer, National Ayurveda Dietetics Research Institute (NADRI)
Convenor
Ms. Jayashri, Research Associate, KJA

30

TABLE OF CONTENTS
No.

Title

1

Introduction

2

A State Public Health Charter

3

Free Universal Access to Medicines in Karnataka

4

Towards evolving an Urban Primary Health Policy

5

Promoting Integrated, Community based management of
Chronic Illness

6

Promoting a Plural Public Health System through a
Convergence Mission with AYUSH

7

Strengthening State Public Health Capacity and HRD in the
State

8

The Way Forward including Recommendations

9

References

10

Appendices

11

Photo Gallery

Pg.No.

A STATE PUBLIC HEALTH CHARTER
he Karnataka State Task Force on Health and Family Welfare considered the
following definition by the Association of Epidemiologists as the frame work for
public health system development.

T

"Public Health is one of the efforts organised by society to protect, promote and
restore people's health. It is the combination of services, skills and beliefs that are
directed to the maintenance and improvement of the health of all people through
collective or social actions. The programs, services and institutions involved emphasize
the prevention of disease and the health needs of the population on the whole. Public
Health activities change with changing technology and social values, but the goals
remain the same; to reduce the amount of disease, premature death and discomfort of
diseases in the population"

The Task Force also emphasized the following principles when considering Public Health
System development in the State. These included:

State's primary responsibility for Health and Health Care
Recognizing the political economy of public health system development and the
challenge of access and universality
3. The challenge of Inter-sectoral action including safe water supply, sanitation and
nutrition
4. The Primary Health Care approach to infectious disease and non-communicable
disease control
5. The focus on Equity and Social Justice in health and health care
6. The convergence of AYUSH, LHTs and the Public Health System
1.
2.

The Mission Group on Public Health endorsed the above definition and principles and
held many deliberations to evolve the following Public Health Charter:

The Public Health Charter for Karnataka
Building on the historic Public Health consciousness in the State which has been
neglected and distorted in recent years, the State has to evolve policies and programs
based on recommendations of the taskforce to cover the following challenges and
system development issues outlined in this Public Health Charter.

32

Through the Public Health Charter, the Karnataka State will continue to develop a
comprehensive, integrated Public Health System that will be committed to the following
values: Equity, Quality and Integrity emphasized by the earlier Taskforce and
Communitization, Pluralism, Gender Sensitivity and Accountability added by the
current Mission Group.

The existing system will be further strengthened by initiatives in the following six
dimensions:
1.

Public Health - Capacity building
• The State will evolve and establish a Public Health Cadre to strengthen the
capacity of the health system particularly focusing on the district and beyond.
• The state will develop a HRD unit in Health Department which will rationalize
the functions, salaries, promotions and transfers and also focus on capacity
development and continuing education of all cadres.
• The State will promote a School of Public Health to strengthen public health
capacity and skills at all levels from district level health administrators to ANM's
and ASHA's. This will enhance the development of evidence based policies,
strengthen institutional capacities and human resources, promote health
promotion, public health regulations and research towards the goal for Health
for All.

2.

Public Health - Governance

• The State will evolve mechanisms of Accountability and Transparency in all its
public health programs and campaigns.
• The State will enhance governance and supervision of peripheral Public Health
care systems with a special focus on decentralization and partnership with
Panchayat Raj Institutions.
• The State will promote community participation in all its programs and also
enhance the role of community in monitoring and providing feedback through
the Communitization process now evolved by the National Rural Health
Mission.

33

• To enhance outreach and access, within the public health system the State in
partnership with NGOs and private sector will promote values of equity, social
justice and strengthen the government's role towards 'Health for All' without
compromising the constitutional mandate and taking care to prevent market
distortions of such partnerships.
3.

Public Health - Inter-sectoral action
• Nutrition: The State will tackle the increasing malnutrition challenges using
inter-sectoral and multi-disciplinary approaches that address the problem from
grass root level upwards by strengthening the public distribution systems and
food security, food and agricultural policy, anganwadi and school feeding
programs, individual and community nutrition education and health promotion
campaigns.

• Safe water supply: The State will promoting safe water supply and mechanisms
to apply standards for water quality at all levels using appropriate technology to
enhance access and purification of water, while preventing commercialization
and commodification of water.
• Sanitation Campaigns:
> The State will support the recently announced Total Sanitation Abhiyan and
enhance promotion of sanitation with the focus on schools, meeting halls,
bus stands and public places even as individual house and communities are
encouraged to adapt sanitation systems.
> While promoting sanitation, the State will also take steps to:
■ Abolish manual scavenging in State
■ Strengthen measures to enhance the Health of Pourakarmikas
4.

Public Health-Response to some current health system challenges
• The State will enhance the access to Free Medicines for Primary Health Care
throughout the State by adopting an essential medicines list, rationalizing
logistics of medicine warehousing and distribution mechanisms, promoting
rational medicine prescribing and policy initiatives and tacking some of the
obstacles to universalizing access to medicines.

34

• The State will evolve an urban primary health charter that will focus on multi­
sectoral services integrated through a primary health care approach focusing on
women and children's health, violence against women. The Charter should
include access to basic health services, mental health and other emerging urban
health challenges.
• The State will adopt the newly announced national program for noncommunicable diseases and enhance the primary health care approach to
chronic diseases with focus on management and re-orientation of personnel,
providing support and upgrading services, improving HMIS, building new
partnerships and strengthening operational research.
• The State will enhance healthy life style promotion as part of the youth
oriented policies of the State while simultaneously linking it to health
promotion and education against substance abuse.
5.

Public Health - Promoting pluralism and Integration
• The State will evolve Accreditation and Certification System for local Health
Practitioners and Knowledgeable Women involving Universities such as IGNOU
to support Traditional /Community Knowledge Systems.
• The State will promote Public Health Orientation and Training for all AYUSH
Health Personnel starting with government sector and later offering it to
private registered medical practitioners as well as including community
supported LH practitioners on voluntary basis.

• The State will strengthen Swasthya Vritta Programme presently being
experimented in five districts and enlarge this program to cover the whole State
gradually. It will also draw upon the health promoting traditions of other system
as well.

• The State will strengthen Yoga awareness and skills through Health Promotion
in School and college curriculum.

The State will strengthen community health and knowledge practices related
to food and dietary practices using traditional knowledge and practices for
promoting healthy nutritional status.
• The State will strengthen documentation of clinical outcomes in AYUSH sector
including LHTs at all levels by introducing a standardized system.

6.

Public health - Strengthening HMIS and Knowledge translation
• The State will further strengthen the Health Information system by providing
universal access to available information to all categories of users by removing
the present imbalance between providers and users.
• The State will adopt and enhance e-governance within public health system at
all levels.

• The State in collaboration of the Health Department and the evolving State GIS
platform will enhance the development of an effective health GIS.

In conclusion, through the adoption of this six point, Public Health Charter, committed
to the above values, the State will enhance the capacity of the Public Health System to
handle the emerging heath problems and challenges; enhance the commitment to
human resource development; enhance accountability, decentralised government,
communitization and strengthen the ability of the existing system to deal with the new
emerging challenges.

36

THE WAY FORWARD - Recommendations of MGPH-KJA
ll over the country Public Health had been neglected, and underfunded post
independence after an initial two decades of Policy support. Karnataka State
was no exception. Since 2000 AD a revival of Public Health capacity building and
system development has emerged in the country as a significant policy initiative. The
first Annual Report to the People on Health by the Ministry of Health and Family
Welfare, GOI presented to the Parliament on September 2010 for public discussion and
debate clearly outlines the urgent need and challenge for a new public health policy by
stating the following:

A

"A new Public Health Policy needs to be drafted which
will reconfigure the health system to make it more
efficient and equitable,,,,,,,. Such a policy must be
evolved through wide ranging consultations in which
the voice of multiple segments of society are heard,
unlike in the past where policies have been influenced
mainly by recommendations of expert groups or
international organisations. The new initiatives in
health must be uniform and influenced by vigorous
public debate. The consensus of national goals,
emerging from such a process is likely to gain greater
acceptance and ownership by professional bodies, civil
society organisations, the private sector and
community representatives,,,,,,,,. It is for this
generation to make the choice to which road to travel".

The National Rural Health Mission, the National and State Health Systems Resource
Centres, the new chain of Public Health Institutes and courses and the recent dialogue
initiated by the planning commission on Universal Health Coverage are signs of this
Public Health Policy and disciplinary revival.
The tasks of public health system development in all States including Karnataka needs
a multidisciplinary and multisectoral policy responce that focuses on an emerging
paradigm shift constituted by the following:
> Moving beyond a narrow biomedical and techno-managerial view to a more
intersectoral, and Community Health oriented view of public health

37

> To base Public Health development on Community empowerment and system
development particularly at district level and below
> To be practitioner oriented with close interaction and engagement with the
public health system rather than an elitist, consultant orientation

Karnataka has the multi-disciplinary and multi sectoral-institutional and human
resources to make a difference. The formation of a Mission Group on Public Health by
the State Knowledge Commission building on the earlier State Task Force on Health and
Family Welfare is a sign of this commitment. A strong public health system is the way
forward. This system as it gets evolved and operationalized must address the following
system challenges outlined by a recent WHO document:

Development of evidence based public health
policies
• Development of institutional capabilities for closing the
gap between knowledge and practice
• Development of appropriate human resource at all levels
• Health promotion, healthy lifestyles with involvement of
civil society
• Strengthening of public health regulation and health
financing
• Community health based public health research
• Ability to solve complex societal problem through
multidisciplinary research"
Source: WHO-SEARO
As a beginning to this public health strengthening process the Mission Group on Public
Health makes the following key and additional action recommendations, details of
which are outlined earlier on this report

38

KEY RECOMMENDATIONS:
1. UNIVERSAL ACCESS TO FREE MEDICINES:

The Karnataka State should provide universal access to free
medicines in Karnataka by initiating the following six policy
supported steps:
i.

The Karanataka Government needs to scale up public funding on drugs from the
current 6-7 % to atleast 15% of overall Government expenditure on health care.

ii.

Reconfigure medicine procurement and supply chain system through a centralized
procurement and decentralized distribution model

iii.

All procurement of medicines should be based on essential medicine list updated
every two to three years and a set of standard treatment guidelines in all public
health facilities.

iv.

Improve the functioning of the State Medicine Regulatory System by substantial
investment in infrastructure and adequate skilled workforce.

v.

Strengthen State level Capacity Building efforts including management, accounting
and logistic capacities

vi.

Build strong monitoring and evaluation system which monitores the procurement
process to ensure that only generic medicines are procured and there is strict
adherence to ethical promotion of medicines balanced by independent and
continuous prescription audit in the public health facilities.

2. URBAN PRIMARY HEALTH POLICY MISSION:

The state should form an urban primary health policy mission group
to evolve a public health charter which will focus on multisectoral
services through a primary health care approach reaching the urban
poor and marginalised specifically

39

The Urban Primary Health Policy and services will include: Access to basic services;
Women's heath including violence against women; Child health; Mental Health and
substance abuse; Services for marginalised including people with disabilities, aged,
street children and migrants; and Intersectoral convergence

3 . AYUSH AND PUBLIC HEALTH - INTEGRATIVE MISSION

The state should evolve a integrative AYUSH and public health
mission, jointly hosted by AYUSH and Health Department, that will
develop a plural public health system with strong ayush convergence
and involvement
This integrative commission will focus on six broad themes:

I)

ii)

Creation of institutional mechanisms in the department of AYUSH to work on
planning, implementation, statistics and research
Training and utilization of AYUSH man power in primary health care and public
health care.

iii)

Inclusion of Public Health Curriculum in AYUSH institutions and AYUSH
Curriculum in non AYUSH institutions at the Health University level

iv)

Strengthening of primary health care by recognition of traditional healers and
home remedies through state and university accreditation mechanisms including
IGNOU

v)

Involvement of AYUSH in Health care especially child, adolescent, reproductive
and geriatric care as well as in NCD’s and nutrition.

vi)

Strengthening research capacity in AYUSH institutions and increasing integrated
and collaborative research between AYUSH, Allopaths and modern scientists.

4.

PUBLIC HEALTH CAPACITY STRENGTHENING

The state will strengthen public health capacity by evolving a state

public health cadre policy, a HRD unit in the health department and a
multidisciplinary state school of public health as three steps towards
increasing skill, capacity and competence at all levels.

40

The public health oriented HRD capacity building process will include the following six
steps
i.

Development of a multidisciplinary state school of Public Health that will provide
a range of short courses and training programmes focussing on competency
based skill development and research.

ii.

Development of a state public health cadre that will ultimately be multisectoral
and include health professionals from medicine, nursing, dentistry, AYUSH,
Pharmacy, and Social Sciences who have requisite public health qualifications.

iii.

Development of an HRD unit in the health department that will strengthen and
supervise all aspects of human resource development in the large team of health
professionals from medical officers to ANM's deployed in the health services all
over the state.

iv.

Development of a training strategy to strengthen public health skills and
capacities at all levels of the public health and primary health care system

v.

To strengthen convergence between department s of Health and Family Welfare,
Women and Child Development, Medical Education, Public Works Department,
Education and Rural Development and others.

vi.

Strengthening Public Health consciousness in other disciplines including social
work, law, management, engineering, agriculture, environment, journalism and
others.

PROMOTING INTEGRATED , COMMUNITY BASED MANAGEMENT OF
CHRONIC ILLNESS.

5.

Building on the existing provisions of the latest national program- National Program
for Prevention and Control of Cancer, Diabetes, CVD and Stroke and through the
setting up of a multidisciplinary state Technical Resource Group(TRG), the state will
promote a major public health initiative focussing on the emerging non
communicable disease / chronic illness epidemic.
The TRG will initiate action on the following :

41

i.

Reorientation of health personnels from physicians to ASHA's on chronic care
principles including supportive care, psychological, social and economical aspects
and counselling.

ii.

Providing support and upgradation through health promotion focusing on
empowerment, prevention, culturally sensitive interventions and appropriate
home based care.

iii.

Strengthening Health Management Information Systems integrating AYUSH and
process indicator aspects

iv.

Partnership with local health care providers at community level and with ngo and
private sector.

v.

Operational research to identify the gaps in policy and implementation

vi.

Evolving accreditation criteria for all levels and involving insurance schemes, and
community as well as promoting inter-departmental collaboration.

42

Public health information Source
Websites
Achutha Menon Centre for Health Science Studies- AMCHSS

■B-SXM
i .7 1 < -•’
ly. -.. J
j

AMCHSS is a centre of excellence for public health training by the Ministry of Health and Family Welfare
government of India. The centre focuses on research in the areas of non-communicable diseases, gender
and health, health policy and management. AMCHSS conducts a Master of Public Health (MPH) program,
Diploma in Public Health and Phd Programme.

http://www.sctimst.ac.in

Accessed on 6th December 2012.

All India Drug Action Network-AIDAN
AIDAN is an independent network of several non government organizations working to increase access and improve the
rational use of essential medicines. It works to promote Essential medicine Concept, for better controls on drug

promotion and the provision of balanced, independent Information for prescribers and consumers.

http://aidanindia.wordpress.com/

Accessed on 6th December 2012.

Gommunityhealth.in
Communityhealth.in is a collaborative project which aims to create a comprehensive, online resource

on community health and the Health For All movement in India.
ummunityheslth in

http://www.communityhealth.in

Accessed on 3rd December 2012.

Catholic Health Association of India
Catholic Health Association of India is charitable, voluntary,

non-profit Catholic Christian

organization working with a commitment for Health For All. It promotes community health as a

process of enabling the people to be collectively responsible to attain and maintain their health and
demand health as a right while ensuring availability of health care of reasonable quality at

reasonable cost.
http://chai-india.org

Accessed on 4th December 2012.

Christian Medical Association of India-CMAI
CMAI is the non-profit registered organization and a health arm of national council of churches in India.

They undertake programmes in training, research, community service, policy advocacy, information
dissemination and others.

http://www.cmai.org

Accessed on 6th December 2012.

Health Systems Research India- initiative-HSRII
_

HSRII is a network of public health professionals and works towards collating and assimilating health
knowledge to strengthen health system development. HSRII engages experts in the field of public health,
epidemiology and social science, law etc, who would help towards managing or initiating challenging tasks
■■ _■that would benefit population at large. They intend to put together a team of young and experienced

43

people drawn from diverse background with hands on working knowledge in health.
http://groups.google.co.in/group/hsri-india
http://hsriindia.blogspot.in/

Accessed on 3rd December 2012.

Indian Association of preventive and Social Medicine- IAPSM
IAPSM provides a forum for the regular exchange of views & information on education, research, and
programs of Community Medicine and is dedicated to the promotion of public health. It works towards

improving teaching standards of Preventive and Social Medicine at all levels. They also publish a peer
reviewed quarterly journal.

http://www.iapsm.org

Accessed on 6th December 2012.

Indian Clinical epidemiology Network - IndiaClen.
Indiaclen is a network of Academic Health Care researchers across 135 Medical colleges/lnstitutions^r
India including IPEN. It is dedicated to improving the health by promoting clinical practice based on the b4V

evidence of effectiveness and the efficient use of resources.
Accessed on 4th December 2012.

http://indiaclen.org

Indian Institute of Health Management and Research -IIHMR
1IHMR is dedicated to the improvement in standards of health through better management of health care and

related programs. It works extensively on capacity building of health professionals to effectively manage
health services at the national, global level and to disseminate latest knowledge and management technology
in India and other developing countries.

Accessed on 6th December 2012.

http://www.iihmr.org

Institute of Public Health -IPH
The Institute of Public Health, Bangalore is a public health research and training

institute based in Bangalore, India. IPH is a value based, community-oriented
public health institute, involved in the entire gamut of public health activitiestraining, research, consultancy and advocacy. The institute is also involved in IP^|
formed a consortium of five organisations, [Institute of Public Health, Bangalore
(IPH); Centre for Global Health Research, Bangalore (CGHR); Centre for Leadership and Management in Public Services
(C-LAMPS); Institute of Health Management and Research (IHMR), Bangalore; Karuna Trust (KT); and Karnataka Health

Promotion trust (KHPT)] called Swasthya Karnataka (SK) which aims to improve the management capacity at a district

and sub district level.
http://www.iphindia.org

Accessed on 3rd December 2012.

Indian Public Health Association-IPHA
IPHA works towards promotion and advancement of public health and allied sciences in India. They hold
annual convention and periodic meetings or conferences. They publish a Scientific Journal, specially
adapted to the needs of the administrators, programme managers and research workers in the field of
public health in India.

http://www.iphaonline.org

Accessed on 6th December 2012.

44

Jan Swasthya Abhiyan- JSA
The Jan Swasthya Abhiyan is the Indian circle of the People's Health Movement, a worldwide movement to establish
health and equitable development as top priorities through comprehensive primary health care and action on the social
determinants of health. JSA is a coalition of networks and organisations as well of individuals who have endorsed the

Indian People's Health Charter.

http://www.phm-india.org

Medico Friend Circle-mfc
Medico Friend Circle is a nation-wide platform of secular, pluralist, and pro-people, pro-poor health
practitioners, scientists and social activists interested in the health problems of the people of India.

http://www.mfcindia.org

Accessed on 6th December 2012.

Public Health in India
A group of 1000 + members on face book. It is a platform for discussions in Public Health, technical guidance, advocacy

and information.

https://www.facebook.com/groups/publichealthindia/

Accessed on 3rd December 2012.

Voluntary Health Association of India-VHAI
VHAI is a non-profit, registered society and one of the largest health and development networks promoting
health issue of human right and development. It advocates people-centered policies and support innovative

health and development programmes at the grassroots with the active participation of the people.
http://www.vhai.org

Accessed on 3rd December 2012.

Public Health Resource Network-PHRN
PHRN works through NGO networks and state health societies, to accelerate and consolidate the
potential gains from the NRHM. They run module based programme for capacity building which is more
informal, open ended participatory learning. This programme complements the official processes of
capacity building and is not a substitute for the formal training and certification of public health

management.

http://www.phrnindia.org

Accessed on 6th December 2012.

National Institute of Epidemiology-NIE
National Institute of Epidemiology conducts training programmes annually in bio-statistics, controlled
Jffll clinical trials and basic epidemiology for medical doctors, PG medical students and para-medical workers.

“““

The Institute has expertise in the areas of bio-statistics and epidemiology. The institute has strated a
school of public health which offers a range of courses.

http://www.nie.gov.in

Accessed on 6th December 2012.

45

National Institute of Mental Health and Neuro Sciences- NIMHANS
NIMHANS is a multidisciplinary Institute for patient care and academic pursuit in the frontier area of
Mental Health and Neuro Sciences. The Institute functions under the direction of Ministry of Health and
Family Welfare, Govt, of India and Ministry of Health and Family Welfare, Government of Karnataka.

NIMHANS has started Centre for Public Health, which will commence masters on public health shortly.

http://www.nimhans.kar.nic.in

Accessed on 3rd December 2012.

National Institute of health and Family Welfare-NIHFW
NIHFW is an autonomous organization, under the Ministry of Health and Family Welfare, Government of
India, and acts as an 'apex technical institute' to addresses a wide range of issues on health and family
welfare from a variety of perspectives through various departments. The Institute offers arnge of courses

like Phd, certificate courses and teaching programme.

http://www.nihfw.org

Accessed on 6th December 20:

National Health Systems Resource Centre - NHSRC
National Health Systems Resource Centre (NHSRC), is India's Technical Support unit under

the Ministry of Health & Family Welfare working across the country through the National
Rural Health Mission (NRHM).NHSRC facilitate the attainment of universal access to
equitable, affordable and quality healthcare through technical support and capacity building

for strengthening public health systems.

Accessed on 3rd December 2012.

http://nhsrcindia.org

Public Health Foundation of India- PHFI
The Public Health Foundation of India (PHFI) is a public private initiative that has collaboratively
evolved through consultations with multiple constituencies. It is an independent foundation which

adopts a broad, integrative approach to public health, tailored to Indian conditions. It has Established 5

Institutes of Public health which run Academic Programmes.
http://phfi.org

Accessed on 4th December 2012.

Society for Community Health Awareness Research and Action- SOCHARA

secham
building community health

SOCHARA is a Community health resource group who are committed to the 'Health for
AH' goal. SOCHARA works with a large network of non-government and government

institutions, health and developmental campaign groups and people's movements to
make them part of this 'Health for AH' movement. SOCHARA team provided space,

support, peer encouragement, vocational guidance and facilitation of self-study to young professionals in community
health. This was formalized into Community Health Fellowship Programme, and now as SOCHARA School of Public
Health, Equity and Action (SOPHEA). Presently SOPHEA runs the fellowship Programme in MP and Karnataka.

www.sochara.org

Accessed on 3rd December 2012.

46

Tata Institute of Social Sciences -TISS
;

•

T^e Tata Institute of Social Sciences is a post-graduate school of social work which engages continuous

\

study of Indian social issues and problems and impart education In social work to meet the emerging need.
It has Various Schools like, Education, Management and Labour Studies, Rural Development, Social Work,
Health Systems Studies, Habitat Studies, Law, Rights and Constitutional Governance, Vocational Education,

-------- _2_

Development Studies, Media and Cultural Studies.

http://www.tiss.edu

Accessed on 4th December 2012.

Journals
•

Indian Journal of Public Health-IJPH- http://www.ijph.in/
Indian Journal of Public Health is a peer-reviewed international journal published Quarterly by the Indian Public
Health Association. It is indexed by major international indexing systems and allows for free access (Open
Access) to its contents. The journal's full text is available online at www.ijph.in.

•

Indian Journal of Community medicine-IJCM- http://www.ijcm.org.in
Indian Journal of Community medicine is a peer-reviewed quarterly publication of the Indian Association of

Preventive and Social Medicine (IAPSM). It is indexed across various indexing systems and full text is available

on line.

•

Indian Journal of Medical Research-IJMR-http://www.icmr.nic.in/Publications/IJMR.html
The Indian Journal of Medical Research is one of the oldest medical

Journals

which strated as quarterly

publication in 1913 presently it is published monthly, in two volumes and 12 issues per year. The journal is
published from Indian Council of medical research.

•

Indian Journal of Medical Ethics-IJME- http://www.ijme.in
The Indian Journal of Medical Ethics (formerly Issues in Medical Ethics) is a platform for discussion on health
care ethics with special reference to the problems of developing countries like India.

•

National Medical Journal of India-NMJI- http://www.nmji.in/
The National Medical Journal of India is a premier bi-monthly health sciences journal published from India.

The archives are available online from 1998.

• The Economic and Political weekly (EPW)- www.epw.in
EPW, is the only social science journal published by the Sameeksha Trust.

The weekly publication contains

analysis of contemporary affairs side by side with academic papers in the social sciences. Access to current four

issues are available from www.epw.in.

Others
•

Health Action
Started as a in-house bulletin named Catholic Hospital -Medical Service evolved into Health Action published
under a separate society registered as Health Accessories for all (HAFA) in 1987. Health Action disseminates

information on various health topics to enable people to gain adequate knowledge of health so that they can
take care of their health as well as that of others. It promotes health, health activism and community

development and promotes alternative systems of medicine and low-cost therapies.

47

Health for the millions
Bimonthly magazine since 1975. It provides insights into innovative and fascinating grassroots interventions as

well as important policy changes, which affect the lives of millions.

Health Round Up
Health roundup is the compilation on all health - related news, views, policies and latest statistics from various
publications to the notice of the reader. It is a bi monthly update on books journals and other sources that come

to Community Health Library and Information Centre of the SOCHARA. Please write up to chlic@sochara.org to

receive the periodical.

Health Digest
Health digest is a compilation on all health - related news Community Health Library and Information Centre of

the SOCHARA. Please write up to chlic@sochara.org to receive the compilation.

Medico Friend Circle Bulletin
The MFC bulletin (first published in 1975) is the main medium of communication through which experiences,

ideas and information about MFC and its activities are shared. It carries articles which usually represent varying
points of view of our membership within the broad mfc perspective. Archives of the bulletin are available from

http://www.mfcindia.org/main/bulletins.html .

NRHM News Letter
NRHM Newsletter is a bi-monthly publication brought out by the Department of Health and Family Welfare,
MOHFW

on

the

National

Rural

Health

The

Mission.

issues

are

available

from

http://www.mohfw.nic.in/NRHM.htm, Address: 409-D, Nirman Bhavan, Department of Health and Family

Welfare, Ministry of Health and Family Welfare, New Delhi -110 011

Selected readings on health systems- Selected readings on health systems is an initiative of Indian
Hub on Health Systems at the Institute of Public Health, Bangalore. It is supported by Switching International

Health Policies & Systems (SWIHPS) network at the Institute of Tropical Medicine, Antwerp.

4

Archives are available from http://www.iphindia.org/resources/ihhs/. Write to km@iphindia.org

E Groups -discussion mails
o

Communityhealth.in-discuss:

Discussion group for communityhealth.in project members and

editors. Write to Ialit82@gmail.com to become a member of the group.

o

Disease Surveillance - Disease Surveillance e-Group is conceptualized to exchange innovative ideas,
strategies and sharing of field/personal expereinces not only in surveillance but any aspect of Public
health practice. Write to prabirkc@yahoo.com to become a member of the group

o

JAAK- This is a discussion group formed to enable group discussions among the members of the
Janaarogya

Andolana,

a

campaign for the

health

rights

of the

common

people.

Write to

chc@sochara.org to become a member of the group.

o

KPHP- This group is for professionals interested and committed for Public health infrastructure and
services in Karnataka state. Write to epigiridhar@gmail.com to become a member of the group.

48

°

MFC - Discussion groups of mfc members Membership to the group requires introduction from existing
member.-Write to sunilgitheant.org to become a member of the group.

Compilation of Health Committee and Commission Reports
MoHFW GOI, A compilation of Health Committee and Commission Reports, 1946 to 2005,

(compiled by

Nandaraj S, Khot A, Srivastava P,) Available from, http://nrhm-mls.nic.in/ui/who/GOI-who-link.htm accessed on
28-12-2012.

MFC Annual meeting on Public Health Education- December 2006
MFC
bulletin
(2007;
320-21)
on
Public
Health
Education
http://www.mfcindia.org/mfcpdfs/MFC320-321.pdf- accessed on 28th Dec 2012.

Available

from-

1.
2.

Priya, R. Public Health Education in India, Medico friend Circle Bulletin 2007; 320-21:1-3.
Narayan R, Narayan R, Public Health Education in India- Some Reflections, Medico friend Circle Bulletin

3.

2007; 320-21:4-18.
Phadke A, Few Additional issues for discussion at the MFC meet, Medico friend Circle Bulletin 2007; 320-

21:19.

Banerji D, Education of Public Health workers, Medico friend Circle Bulletin 2007; 320-21:19.20-3.

4.

Asthekar S, Mankad D, Training of primary and paramedic workers and public health, Medico friend Circle

5.

Bulletin 2007; 320-21:19.25-31.

Narayan T, Capacity building for public health, Medico friend Circle Bulletin 2007; 320-21:19.32-6.
Anonymous, Extracts from Accreditation Guidelines for Educational/Training Institutions and Programmes
in Public Health Report of the Regional Consultation, Chennai, India, 30 January-1 February 2002 (WHO

6.
7.

Project: ICP OSD 002) Medico friend Circle Bulletin 2007; 320-21:19.37-40.
Sathyamala C, Redefining public health. Medico friend Circle Bulletin 2007; 320-21:19.41-46.
Reddy KS, Sivaramakrishnan K, Unmet National Health Needs Visions of Public Health Foundation of India,

8.
9.

Medico friend Circle Bulletin 2007; 320-21:19.47-52.
10.
Quader 1, Wither Public Health, Medico friend Circle Bulletin 2007; 320-21:19.53.
11.
Shukla A, Public health foundation of India- will be public be placed at centre, Medico friend Circle Bulletin

12.

2007; 320-21: 19.47-54-55.
Nayar KR, Rao M, Public Health in Private Hands?- A Note on the Public Health Foundation of India Medico

friend Circle Bulletin 2007; 320-21:19.47-56-60.
13.
Reddy KS, Public Health needs a Boost-Not Bickering, Medico friend Circle Bulletin 2007; 320-21:19.47-6162.

PHFI conference -New Directions for Public Health Education in Low and Middle
Income Countries Processes, Proceedings and Proposed Next Steps.- August 2008.
New Directions for Public Health Education in Low and Middle Income Countries Processes, Proceedings and
Proposed Next Steps Public Health Global Network- Back ground papers 12th and 14th of August 2008,
Hyderabad
India.
Available
http://www.publichealthglobal.org/index.php?option=com_content8iview=article&id=718dtemid=89-

from-

accessed on 28th Dec 2012.

1.

Canon G, Public Health: Moving Beyond Definitional Debates to Consensus and Collective Action,
Background paper for International Conference on New Directions for Public Health Education in Low and
Middle Income Countries Processes, Proceedings and Proposed Next Steps. 12th and 14th of August 2008.
Available from - http://www.publichealthglobal.org/images/pdf/summary moving beyond.pdf. Accessed
on 28th Dec 2012.

49

Sanders D, Alexander L, Configuring Public Health Education to Respond to the Challenge of Implementing

2.

Primary Health Care in Decentralized Health Systems. Background paper for International Conference on

New Directions for Public Health Education in Low and Middle Income Countries Processes, Proceedings and
Proposed
Next
Steps.
12th
and
14th
of
August
2008.
http://www.publichealthglobal.org/images/pdf/full pg background paper 2.pdf

Available
from
Accessed on 28th Dec

2012.
Chunharas S, Problem-solving in Public Health: Improving Connectivity between Health Systems and Public

3.

Health Education. Background paper for International Conference on New Directions for Public Health

Education in Low and Middle Income Countries Processes, Proceedings and Proposed Next Steps. 12th and
14th
of
August
2008.
Available
from
http://www.publichealthglobal.org/images/pdf/full pg background paper 3.pdf Accessed on 28th Dec
2012.

Sridhar D, Governance and Resourcing of Public Health: Recognizing the Role of Multiple Stakeholders.

4.

Background paper for International Conference on New Directions for Public Health Education in Low and
Middle Income Countries Processes, Proceedings and Proposed Next Steps. 12th and 14th of August 2008.
Available from - http://www.publichealthglobal.org/images/pdf/full pg background paper 4.pdf Accessed

5.

on 28th Dec 2012.
A
Valladares LM, Integrating Public Health Education across Different Levels and Categories of Heai^r
Personnel: Balancing the Need for Team-Building with the Need for Specialization. Background paper for
International Conference on New Directions for Public Health Education in Low and Middle Income
Countries Processes, Proceedings and Proposed Next Steps. 12th and 14th of August 2008. Available from http://www.publichealthglobal.org/images/pdf/full pg background paper 5.pdf Accessed on 28th Dec
2012.

Narayan, R. Extending the Frontiers: Integrating Public Health Consciousness into other Academic

6.

Programmes. Background paper for International Conference on New Directions for Public Health Education
in Low and Middle Income Countries Processes, Proceedings and Proposed Next Steps. 12th and 14th of

August
2008.
Available
from
http://www.publichealthglobal.org/images/pdf/full pg background paper 6.pdf Accessed on 28th Dec

2012.
7.

Rao M, Evaluating New Models of Public Health Education: Indicators of Quality, Relevance and Impact on
Health Systems. Background paper for International Conference on New Directions for Public Health

Education in Low and Middle Income Countries Processes, Proceedings and Proposed Next Steps. 12th and
14th
of
August
2008.
Available
from
http://www.publichealthglobal.org/images/pdf/background paper 7.pdf Accessed on 28th Dec 2012.

Bringing Evidence into Public Health Policy- 2010-2012.
EPHP-2010.
1.

Institute of Public Health , EPHP 2010, National Conference on bringing evidence into public health policy, five
years of national rural health mission, December 10, 11 2010, Bangalore. Institute of Public Health, Institute of.

tropical Medicine. 2010.

EPHP-2012.
2.

Bhojani U, Mishra A, Prashnath NS, Soors W, Bringing Evidence into Public Health Policy (EPHP) 2012:
Strengthening health systems to achieve universal health coverage BMC Proceedings 2012;6 (Suppl 5): 28

September 2012, Available online at http://www.biomedcentral.eom/bmcproc/supplements/6/S5 Accessed on
28th December 2012.

50

ARORA & NAZAR: PROHIBITING TOBACCO ADVERTISING, PROMOTIONS & SPONSORSHIPS

plain packaging would reduce the attractiveness, appeal

1.

Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, AdairRohani H, el al. A comparative risk assessment of burden of
disease and injury attributable to 67 risk factors and risk factor
clusters in 21 regions, 1990-2010: a systematic analysis for
the Global Burden of Disease Study 2010. Lancet 2012; 380
: 2224-60.

2.

Bonita R, Magnusson R, Bovct P, Zhao D. Malta DC, Gencau
R, et al‘, Lancet NCD Action Group. Country actions to meet
UN commitments on non-communicable diseases: a stepwise
approach. Lancet 2013; 381: 575-84.

3.

World Health Organization. Tobacco Free Initiative (TFI):
Tobacco Facts; 2013. Available from: http://www.who.int/
tobacco/mpower/tobacco_facts/en/, accessed on April 1,
2013.

4.

World Health Organization. WHO Framework Convention on
Tobacco Control. Geneva: World Health Organization; 2003.

5.

World Health Organization. WHO report on the global tobacco
epidemic, 2011: warning about the dangers of tobacco.
Geneva: World Health Organization; 2011.

6.

World Health Organization. Tobacco Free Initiative (TFI):
World No Tobacco Day; 2013. Available from: http://www.
who.int/tobacco/wntd/2013/en/, accessed on April 2,2013.

7.

National Cancer Institute. The role of the media in promoting
and reducing tobacco use. Tobacco Control Monograph No.
19.
Bethesda, MD: U.S. Department of Health and Human
Services, National Institutes of Health, National Cancer
Institute; 2008.

8.

Mazumdar PD, Narendra S, John S. Tobacco advertising,
promotion and sponsorship across south and south east Asia:
challenges and opportunities. Delhi & Mumbai, India: Centre
for Media Studies & Healthbridge; 2009.

9.

World Health Organization. Guidelinesfor implementation of
Article 13 of the WHO Framework Convention on Tobacco
Control (Tobacco advertising, promotion and sponsorship);
2013. Available from: http://www.who.int/fctc/guidelines/
article_l3.pdf, accessed on April 6,2013.

and promotional value of the tobacco pack, over 60 per

cent believed plain packaging would help in reducing

experimentation and initiation of tobacco among
youth and over 80 per cent believed, it would motivate
tobacco users to quit24. Multi-disciplinary researchers

and tobacco control advocates are strongly proposing

introduction of plain packaging of tobacco products in
India to enhance effectiveness of graphic warnings in

India. A Private Members’ Bill has been introduced on
this issue in the Indian Parliament, which remains to be

discussed25.
A TAPS ban should be comprehensive as partial

bans or voluntary arrangements

do not work. A

comprehensive ban on all TAPS could achieve a
reduction in tobacco use by seven per cent5.
Counter-advertising
accompanied

through

school-

with

or

mass

media

community-based

programmes, warning about the dangers of tobacco use
has been an effective strategy in preventing tobacco use
as well as encouraging the users to quit7. Mass media
campaigns form a major strategy for tobacco control
under India’s NTCP22. Counter-advertising through

Government efforts needs to be stepped up to counter
misleading messages conveyed by the tobacco industry

through TAPS campaigns.

Conclusion
The WHO, while proposing targets for reducing
the NCD burden, has proposed a 30 per cent reduction

in tobacco use globally by 2025. The global narrative

on tobacco control

is

increasingly exploring the

concept of tobacco endgame, which envisions reducing

tobacco prevalence and availability to minimal levels.

Experts aiming at the endgame give a target for
tobacco-free world, where prevalence for tobacco
use in each country would reduce to less than five per
cent by 204026. This would require tobacco control

10. Sinha DN. Tobacco control in schools in India (India global
youth tobacco survey & global school personnel survey, 2006).
New Delhi, India: Ministry of Health and Family Welfare,
Government of India; 2006.
11.

World Health Organization. India (Ages 13-15) Global Youth
Tobacco Survey (GYTS) 2009 Fact sheet: 2013. Available
from: http://www.who.int/fctc/reporting/Annexoneindia.pdf ,
accessed on April 3,2013.

12.

International Institute for Population Sciences. Global adult
tobacco survey (GATS India 2009-2010), New Delhi. India:
Ministry of Health and Family Welfare. Government of India;
2010.

13.

Lovato C, Linn G, Stead LF, Best A. Impact of tobacco
advertising and promotion on increasing adolescent
smoking behaviours. Cochrane Database Syst Rev 2003; (4)
CD003439.

14.

Arora M, Reddy KS, Stigler MH, Perry CL. Associations
between tobacco marketing and use among urban youth in
India. Am J Health Behov 2008; 32 : 283-94.

measures be strictly enforced as per FCTC guidelines
and innovative measures beyond FCTC be introduced
in countries having political, commitment to end the

tobacco epidemic in their country.

Monika Arora1-2’1 & Gaurang P. Nazar2
'Public Health Foundation of India

(PHFf) & "Health Related Information

Dissemination Amongst Youth (HRIDAY)

New Delhi, India
'For correspondence-.
monika.arora@phfi.org

869

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Shah PB, Pednekar MS, Gupta PC, Sinha DN. The relationship
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16.

Arora M, Gupta VK, Nazar GP, Stigler MH, Perty CL, Reddy
KS. Impact of tobacco advertisements on tobacco use among
urban adolescents in India: results from a longitudinal study.
Tob Control 2012; 21: 318-24.

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Paynter J, Edwards R. The impact of tobacco promotion at
the point of sale: a systematic review. Nicotine Tob Res 2009;
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18.

Arora M. MathurN, GuptaVK, Nazar GP, Reddy KS, Sargent
JD. Tobacco use in Bollywood movies, tobacco promotional
activities and their association with tobacco use among Indian
adolescents. Tob Control 2012; 21 : 482-7.

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Tobacco Free Center. Advertising, promotion, and sponsorship:
Corporate social responsibility; 2011. Available from: http://
globaI.tobaccofreekids.org/files/pdfs/en/APS_CSR_en.pdf,
accessed on April 4,2013.

20.

World Health Organization. Guidelines for implementation of
Article 5.3 of the WHO Framework Convention on Tobacco
Control on the protection of public health policies with respect
to tobacco control from commercial and other vested interests
of the tobacco industry. Available from: http://www.who.int/
fctc/guidelines/article_5_3.pdf, accessed on April 5,2013.

21.

Chaudhry S, Chaudhry S, Chaudhry K. Point of sale tobacco
advertisements in India. Indian J Cancer 2007; 44 : 131-6.

22. National Tobacco Control Cell. Operational guidelines:
National Tobacco Control Programme. New Delhi, India:
Ministry of Health and Family Welfare, Government of.India;
2012.
23. Public Law: Cigarettes and other Tobacco Products
(Prohibition of Advertisement and Regulation of Trade and
Commerce, Production, Supply and Distribution) Act of
2003, Notification No. GSR 708 (E) The Gazette of India:
Extraordinary (September 21, 2012). New Delhi: Govt, of
India Press; 2012.

24. Australia India Institute. Report ofthe Australia India Institute
Taskforce on tobacco control: Plain packaging of tobacco
products. Melbourne (Australia): Australia India Institute;
2012.
25. Bhaumik S. Private member’s bill proposes plain packaging
of tobacco products in India. BM/2013; 346:1953.
26. Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G,
Asaria P. et al.: Lancet NCD Action Group; NCD Alliance.
Priority actions for the non-communicable disease crisis.
Lancet 2011:377: 1438-47.

Indian J Med Res 137. May 2013, pp 867-870

Editorial
Prohibiting tobacco advertising, promotions & sponsorships:
Tobacco control best buy

In the 1990s tobacco smoking and exposure to

regarded as a tobacco control ‘Best Buy’6. The theme

second hand smoke (SHS) ranked among the top three

for the World No Tobacco Day this year is ‘Ban

risk factors contributing to the global bur den of disease

Tobacco Advertising, Promotion and Sponsorship’,

along with childhood underweight and household

the objective being to encourage the Parties to impose

air pollution.

Today,

after two

decades,

tobacco

a comprehensive TAPS ban and to strengthen efforts

smoking and exposure to SHS still rank among the

to reduce tobacco industry interference in introducing

top three risk factors despite the other risk factors

and enforcing such comprehensive bans.

being replaced by high blood pressure and alcohol

Despite existing TAPS prohibition laws, tobacco

use, which are essentially risk factors contributing to

industry circumvents the laws to promote their products

non-communicable diseases (NCDs)1. Tobacco control

by employing innovative and at times, covert marketing

has been identified as a high priority, cost-effective

strategies. Indirect or surrogate tobacco advertising

intervention along with reduction of dietary salt intake

such as dark advertising, brand stretching, corporate

and treatment of people at high risk for cardiovascular

social

disease, which cam aid in achieving the global target

industiy

has

responsibility

(CSR)

activities,

promotion

through films and new media such as internet, discounts

of 25 per cent reduction in NCD related mortality by
20252.

or free-gift offers, distribution of free samples, sale

of tobacco products in the form of children’s sweets/

in

toys, etc. gained momentum with increasing pressure

through

on tobacco industry78. Guidelines for implementing

aggressive marketing campaigns. It is the only industiy

Article 13 of FCTC, describe comprehensive TAPS

that kills its 5.4 million loyal customers eveiy year3. In

ban to apply to all form of commercial communication,

2005, the WHO Framework Convention on Tobacco

recommendation or action and all forms of contribution

Control (WHO FCTC), the first treaty negotiated under

to any event, activity or individual with the aim, effect

the auspices of the WHO, came into force4. Article

or likely effect of promoting a tobacco product or
tobacco use either directly or indirectly9.

Tobacco

been

instrumental

spreading the tobacco epidemic globally

13 of FCTC suggests a comprehensive advertising
ban, within five years of entry into force of FCTC

Exposure to tobacco advertising among Indians

for each party. Currently, only 19 countries of the
world (representing 6% of the global population) are

To protect the general populace from harmful

covered by comprehensive ban on tobacco advertising,

effects of tobacco use, the Cigarettes and Other Tobacco

promotion and sponsorship (TAPS), with 101 countries

Products (Prohibition ofAdvertisement and Regulation

imposing partial bans and 74 countries having no
ban at all5. This is a matter of public health concern.

of Trade and Commerce, Production, Supply and

Comprehensive TAPS ban would lead to reduction in

Section 5 of COTPA prohibits all forms of TAPS in

initiation and continuation of tobacco use; as such a

line with Article 13 of the WHO FCTC. Despite the

policymeasurewouldhavelargepopulationlevel impact,

existence of TAPS ban in India, exposure to tobacco

thereby reducing demand for tobacco. Therefore, it is

advertising and promotion is still prevalent. Among

Distribution) Act (COTPA), 2003 was enacted in India.

This editorial is published on the occasion of World No Tobacco Day - May 31.2013.
867

868

INDIAN J MED RES, MAY 2013

Indian school-going youth aged 13-15 yr, exposure to

In India, PoS advertising by tobacco companies

pro-cigarette advertisements on billboards in the past

is rampant and most common violations in this regard

30 days increased from 71.6 in 2006 to 74.4 per cent

include oversized advertisement boards, which are

in 200910-11. Twenty eight per cent of Indian adults are

frequently backlit, placement of two boards together

exposed to cigarette advertising, and 47 and 55 per

to give the impression of one large board, placement of

cent, respectively are exposed to bidi and smokeless

multiple advertisements on one board and placement

tobacco (SLT) advertisements as per GATS (Global

of advertisement boards on shops not selling tobacco21.

Adult Tobacco Survey) 201012. COTPA allows ‘On-

India needs to step up enforcement of its TAPS ban

Pack advertising’ and ‘Point of Sale (PoS) advertising’

legislation, as indirect methods of advertising and

with some restrictions.

promotions are rampant. There is also imminent need
to amend COTPA to remove “On pack advertising”

Need for comprehensive TAPS ban
Substantial

evidence now

exists

and “PoS” advertising.
of a causal

relationship of tobacco advertising and promotion
with

increased

tobacco

use,

especially

in

Recent progress in India on restricting TAPS
The Hon’ble Supreme Court of India on January

the

youth7’13. Cross-sectional 14’15 and longitudinal studies16

3,

conducted with school-going adolescents in India

advertising of tobacco products, which was imposed

also support these findings. A review of international

by the Bombay High Court in 2006, demonstrating

studies suggests that PoS marketing and displays are

commitment ofthe Indianjudicial system towardsbetter

2013 vacated the stay on rules related to the PoS

susceptibility,

health of its citizens through effective tobacco control.

experimentation, and uptake among children, and

Following the hearing in January 2013, Ministry of

associated
with

with

increased

increased

smoking

craving among adults17.

Celebrity

endorsement of tobacco products in films is also

Health and Family Welfare (MoHFW), Government of
India (GOI), issued a letter to the Chief Secretaries and

causally associated with tobacco use among the youth

Director Generals of Police of all Indian States/UTs to

with a dose-response relationship7. A study conducted

ensure that all steps are taken to curb the violations of

with about 4000 school-going adolescents in Delhi

PoS advertising rules. Under India’s National Tobacco

concluded that students highly exposed to tobacco

Control Programme (NTCP), monitoring committees

use in Bollywood films are at more than twice the

specifically for Section 5 of COTPA at State and

risk of being ever tobacco users compared with the

district levels, as well as a national level steering

least exposed18. Comprehensive TAPS ban would

committee, have been mandated, to take cognizance of
direct/indirect advertising of tobacco products22. The

ensure that youth and adults are not misled by these

advertisements and promotions. Tobacco companies

MoHFW has continued to show its commitment to

have designed product promotion campaigns around

tobacco control by introducing comprehensive tobacco

sports and music events providing links on Facebook

control legislation and for some measures, India has

and Twitter, clearly targeting youngsters through this

been identified as a global leader. The Government of

powerful communication channel. Advertising through

India has recently introduced trendsetting rules related

these new media channels needs to be addressed under

to depiction of tobacco imagery in Indian films, a

comprehensive TAPS ban.

popular entertainment media23.

Engagement in CSR activities by tobacco industry
is

a more

recent strategy wherein,

What needs to be done?

the tobacco

The only advertising venue now allowed in India for

companies try to portray their image as being socially

the tobacco industry is ‘on-pack’ advertising. Tobacco

responsible and ethical ”. The industry on one hand funds

packs are importantmeansofadvertising for the industry

activities such as youth anti-smoking programmes,

and they employ attractive imagery such as logos, brand

reforestation campaigns and environmental camps for

names, colours, etc. on the pack for the same. Plain,

school children, and on the other hand continues the

standardized tobacco packaging as currently being

promotion and sale of tobacco products819. Article 5.3

implemented by the Australian Government, mandates

of the FCTC guidelines recommend, denormalising

prevention of promotion through on-pack advertising

and

regulating

activities

described

as

‘socially

and enhances effectiveness of graphic health warnings

responsible’ by the tobacco industry, including but not

on the pack. Results of a feasibility study for plain

limited to activities described as CSR20.

packaging of tobacco products conducted in Delhi

ARORA & NAZAR: PROHIBITING TOBACCO ADVERTISING, PROMOTIONS & SPONSORSHIPS

revealed that over 80 per cent of participants believed
plain packaging would reduce the attractiveness, appeal

869

References
1.

Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, AdairRohani H, et al. A comparative risk assessment of burden of
disease and injury attributable to 67 risk factors and risk factor
clusters in 21 regions, 1990-2010: a systematic analysis for
the Global Burden of Disease Study 2010. Lancet 2012; 380
: 2224-60.

2.

Bonita R, Magnusson R, Bovet P, Zhao D, Malta DC, Geneau
R, et al-, Lancet NCD Action Group. Country actions to meet
UN commitments on non-communicable diseases: a stepwise
approach. Lancet 2013; 381: 575-84.

3.

A TAPS ban should be comprehensive as partial
bans or voluntary arrangements do not work. A

World Health Organization. Tobacco Free Initiative (TFI):
Tobacco Facts; 2013. Available from: http://www.-who.inl/
tobacco/mpower/tobaccoJacts/en/, accessed on April 1,
2013.

4.

World Health Organization. WHO Framework Convention on
Tobacco Control. Geneva: World Health Organization; 2003.

comprehensive ban on all TAPS could achieve a
reduction in tobacco use by seven per cent5.

5.

World Health Organization. WHO report on the global tobacco
epidemic, 2011: warning about the dangers of tobacco.
Geneva: World Health Organization; 2011.

6.

World Health Organization. Tobacco Free Initiative (TFI):
World No Tobacco Day; 2013. Available from: http:/Avww.
who.int/tobaccoAvntd/2013/en/, accessed on April 2,2013.

7.

National Cancer Institute. The role of the media in promoting
and reducing tobacco use. Tobacco Control Monograph No.
19. Bethesda, MD: U.S. Department of Health and Human
Services, National Institutes of Health, National Cancer
Institute; 2008.

8.

Mazumdar PD, Narendra S, John S. Tobacco advertising,
promotion and sponsorship across south and south east Asia:
challenges and opportunities. Delhi & Mumbai, India: Centre
for Media Studies & Healthbridge; 2009.

9.

World Health Organization. Guidelines for implementation of
Article 13 of the WHO Framework Convention on Tobacco
Control (Tobacco advertising, promotion and sponsorship);
2013. Available from: http://www.who.int/fctc/guidelines/
article_l3.pdf, accessed on April 6,2013.

and promotional value of the tobacco pack, over 60 per
cent believed plain packaging would help in reducing
experimentation

and initiation

of tobacco

among

youth and over 80 per cent believed, it would motivate
tobacco users to quit24. Multi-disciplinary researchers

and tobacco control advocates are strongly proposing
introduction of plain packaging of tobacco products in
India to enhance effectiveness of graphic warnings in
India. A Private Members’ Bill has been introduced on
this issue in the Indian Parliament, which remains to be
discussed25.

Counter-advertising
through
mass
media
accompanied with school- or community-based
programmes, warning about the dangers of tobacco use

has been an effective strategy in preventing tobacco use
as well as encouraging the users to quit7. Mass media

campaigns form a major strategy for tobacco control
under India’s NTCP22. Counter-advertising through
Government efforts needs to be stepped up to counter
misleading messages conveyed by the tobacco industry
through TAPS campaigns.

Conclusion
The WHO, while proposing targets for reducing

the NCD burden, has proposed a 30 per cent reduction

in tobacco use globally by 2025. The global narrative

on tobacco control is

increasingly exploring the

concept of tobacco endgame, which envisions reducing
Experts aiming at the endgame give a target for
tobacco-free world, where prevalence for tobacco

10. Sinha DN. Tobacco control in schools in India (India global
youth tobacco survey & global school personnel survey, 2006).
New Delhi, India: Ministry of Health and Family Welfare,
Government of India; 2006.

use in each countiy would reduce to less than five per

II.

World Health Organization. India (Ages 13-15) Global Youth
Tobacco Survey (GYTS) 2009 Fact sheet: 2013. Available
from: http://www.who.int/fctc/reporting/Annexoneindia.pdf,
accessed on April 3,2013.

12.

International Institute for Population Sciences. Global adult
tobacco survey (GATS India 2009-2010), New Delhi. India:
Ministry of Health and Family Welfare, Government of India;
2010.

13.

Lovato C, Linn G, Stead LF, Best A. Impact of tobacco
advertising and promotion on increasing adolescent
smoking behaviours. Cochrane Database Syst Rev 2003: (4)
CD003439.

14.

Arora M, Reddy KS, Stigler MH, Perry CL. Associations
between tobacco marketing and use among urban youth in
India. Am J Health Behav 2008; 32 : 283-94.

tobacco prevalence and availability to minimal levels.

cent by 204026. This would require tobacco control

measures be strictly enforced as per FCTC guidelines
and innovative measures beyond FCTC be introduced
in countries having political commitment to end the
tobacco epidemic in their country.

Monika Arora1’2'- & Gaurang P. Nazar2
’Public Health Foundation of India
(PHFI) & ^Health Related Information
Dissemination Amongst Youth (HRIDAY)

New Delhi, India
'For correspondence'.

monika.arora@phfi.org

870

15.

INDIAN J MED RES, MAY 2013

Shah PB, Pednekar MS, Gupta PC, Sinha DN. Die relationship
between tobacco advertisements and smoking status of youth
in India. Asian Pac J Cancer Prev 2008; 9: 637-42.

16.

Arora M, Gupta VK, Nazar GP, Stigler MH, Perry CL, Reddy
KS. Impact of tobacco advertisements on tobacco use among
urban adolescents in India: results from a longitudinal study.
Tab Control 2012; 2/ : 318-24.

17.

Paynter J, Edwards R. The impact of tobacco promotion at
the point of sale: a systematic review. Nicotine Tob Res 2009;
11:25-35.

18.

Arora M. MathurN, Gupta VK, Nazar GP. Reddy KS, Sargent
JD. Tobacco use in Bollywood movies, tobacco promotional
activities and their association with tobacco use among Indian
adolescents. Tob Control 2012; 21 :482-7.

19.

Tobacco Free Center. Advertising, promotion, and sponsorship:
Corporate social responsibility; 2011. Available from: http://
global.tobaccofreekids.org/files/pdfs/en/APS_CSR_en.pdf,
accessed on April 4,2013.

20.

World Health Organization. Guidelines for implementation of
Article 5.3 of the WHO Framework Convention on Tobacco
Control on the protection of public health policies with respect
to tobacco control from commercial and other Vested interests
of the tobacco industry. Available from: http://yvww.who.int/
fctc/guidelines/article_5_3.pdf, accessed on April 5,2013.

21.

Chaudhry S, Chaudhry S, Chaudhry K. Point of sale tobacco
advertisements in India. Indian J Cancer 2007; 44 : 131-6.

22. National Tobacco Control Cell. Operational guidelines:
National Tobacco Control Programme. New Delhi, India:
Ministry of Health and Family Welfare. Government ofjndia;
2012.
23. Public Law: Cigarettes and other Tobacco Products
(Prohibition of Advertisement and Regulation of Trade and
Commerce, Production, Supply and Distribution) Act of
2003, Notification No. GSR 708 (E) Dre Gazette of India:
Extraordinary (September 21, 2012). New Delhi: Govt, of
India Press; 2012.
24. Australia India Institute. Report ofthe Australia India Institute
Taskforce on tobacco control: Plain packaging of tobacco
products. Melbourne (Australia): Australia India Institute;
2012.

25. Bhaumik S. Private member’s bill proposes plain packaging
of tobacco products in India. IIM/2013; 346:1953.
26. Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G,
Asaria P, et al.: Lancet NCD Action Group; NCD Alliance.
Priority actions for tire non-communicable disease crisis.
Lancet 2011; 377: 1438-47.

Why ban tobacco advertising, promotion and sponsorship (TAPS)?
Experts say tobacco advertising and promo­
tion increase consumption. In 2009 a com­
prehensive review of tobacco-related research
was released by The National Cancer Institute
(US). The monograph was compiled by 23 au­
thors, 63 expert reviewers and took five years
to produce. The two main scientific conclu­
sions were:
1. There is a causal relationship between
tobacco advertising and promotion and
increased tobacco use.
2. Comprehensive bans reduce tobacco
consumption but partial bans only lead to
greater expenditure in 'non banned’ areas,
resulting in no net reduction of tobacco
use.
The report also found that generally tobacco
advertising and promotion exhibits three main
themes:
» Providing satisfaction (taste, freshness)
» Reducing fears about the dangers of to­
bacco use (mildness)
» Creating associations between tobacco
and desirable characteristics (social suc­
cess, sexual attraction, thinness etc).

It is clear that in countries
with weak regulation,
marketing reaches a very
high proportion of people. For
example according to the 2011
National Adult Tobacco Survey
of Cambodia, 80 percent of
respondents had seen tobacco
advertising in the past months.
Advertising, promotion and sponsorship nor­
malise tobacco, making it seem like any other
consumer product. This increases its social
acceptability and hampers efforts to educate
people about the hazards of tobacco use.

The tobacco industry maintains that the role
of advertising and promotion is solely to en­
courage smokers to switch brands. However,
another impact is to increase the desirability
of smoking by associating it with character­
istics such as independence, glamour and
machismo’.
In countries where partial bans prohibit direct
advertising and promotion of tobacco prod­
ucts in traditional media, tobacco companies
frequently employ indirect marketing tactics to
circumvent the restrictions. Tactics include:
» sport and music event sponsorship
» pack designs and displays
» branded merchandise
» product placement
» so-called corporate social responsibility
activities
» new media technology campaigns.
What is TAPS?
"Tobacco advertising, promotion and
sponsorship applies to all forms of
■ commerciat-cOmmUnication. ir..e'c-6m- 4'
mendation or action and allWSjms
■
■ of contribution to .any event, activity . .
. or individual with.the aim,’■'‘effect, or.
■-likely effect of promoting a tobacco'
I product or tobaccq/.use.'either directly
j or indirectly." (Guideline’s- for . i.rriplementation of. Article 13 of the FCTC)
i In some countries the tobacco in: dustry still use’s pr’nt and broadcast ■
- media, ,.bil|.bo.ards.4el.e.G.tr,onic mail and
i. direct mail ana the internet to market
;■ its products. .
'
'■ Point qif;.'scfi^\pfdmotion‘jSjparticyldriy
’ ' powerful, .'and ’is.'.al'owed iniiptacticdlly
I ^SSrY'i’Co.u.ntry in the world:
1 Bates C. Rowell A. Tobacco explained: the truth about the
tobacco industry...in its own words. London: Action on Smok­
ing and Health, 2004. www.who.int/tobacco/media/en/TbbaccoExp1ained.pdf

EI.'SCRCE BAHS OH TOBACCO ADVERTISING, PROMOTION AMD SPONSORSHIP. 2010

E3 Ban on aS forms of direct and indirect advertising
Ban on national television, radio and print media as well as on some but not all other forms of direct and indirect advertising
Ban on national television, radio and print media only
I _ .71 Complete absence of ban, or ban that does not cover national television, radio and print media
I
; Paa not reported

£

Da'a not available

Advertising, promotion and
sponsorship bans work

*Dlrect advertising bans include: national television and
radio; local magazines and newspapers; billboards and
outdoor advertising; point of sale. Indirect advertising
bans: free distribution of tobacco products in the mail
or through oilier means; promotional discounts; non­
tobacco goods and services identified with tobacco
brand names (brand extension); brand names of non­
tobacco products used for tobacco products; appear­
ance of tobacco products in television and/or films;
sponsored events. Map source: WHO Report on the
Global Tobacco Epidemic, 2011. Appendix X.

Comprehensive bans can be achieved by fol­
Comprehensive bans on direct and indirect
lowing the international best practice stan­
advertising, promotion and sponsorship pro­
tect people - particularly youth - from industry dards outlined in the Guidelines for implemen­
tation
of Article 13 of the WHO Framework
marketing tactics and can substantially reduce
Convention on Tobacco Control (WHO FCTC).
tobacco consumption.
A
comprehensive
ban on all advertising and
Comprehensive bans significantly reduce the
promotion reduces tobacco consumption
industry’s ability to market to young people
by about 7 percent, independent of other
who have not started using tobacco and to
interventions. Some countries have seen
adult tobacco users who want to quit.
consumption drop by as much as 16 percent
following an ad ban.
The. WHO Framework Convention' oh Tobacco Control (FCTC) states:

Article 13 .
... o comprehensive ban on advertising, promotion and sponsorship would
reduce the consumption of tobacco products.
Each Party shall ... undertake a comprehensive ban of all tobacco
advertising, promotion and sponsorship.

ph
Indian J Med Res 137. May 2013, pp 867-870

Editorial
Prohibiting tobacco advertising, promotions & sponsorships:
Tobacco control best buy

In the 1990s tobacco smoking and exposure to
second hand smoke (SHS) ranked among the top three

regarded as a tobacco control ‘Best Buy’6. The theme
for the World No Tobacco Day this year is ‘Ban

risk factors contributing to the global burden of disease

Tobacco Advertising, Promotion and Sponsorship',

along with childhood underweight and household

the objective being to encourage the Parties to impose

air pollution.

after two

decades,

tobacco

a comprehensive TAPS ban and to strengthen efforts

smoking and exposure to SHS still rank among the

to reduce tobacco industry interference in introducing

top three risk factors despite the other risk factors

and enforcing such comprehensive bans.

Today,

being replaced by high blood pressure and alcohol

Despite existing TAPS prohibition laws, tobacco
industry circumvents the laws to promote their products

use. which are essentially risk factors contributing to

non-communicable diseases (NCDs)1. Tobacco control
has been identified as a high priority, cost-effective

by employing innovative and at times, covert marketing

strategies. Indirect or surrogate tobacco advertising

intervention along with reduction of dietary salt intake

such as dark advertising, brand stretching, corporate

and treatment of people at high risk for cardiovascular

social

disease, which can aid in achieving the global target
of 25 per cent reduction in NCD related mortality by
20252.

responsibility

(CSR)

activities,

promotion

through films and new media such as internet, discounts

or free-gift offers, distribution of free samples, sale
of tobacco products in the form of children’s sweets/

Tobacco industiy has been instrumental in
spreading the tobacco epidemic globally through

toys, etc. gained momentum with increasing pressure
on tobacco industry7-8. Guidelines for implementing

aggressive marketing campaigns. It is the only industry
that kills its 5.4 million loyal customers every year3. In

Article 13 of FCTC, describe comprehensive TAPS
ban to apply to all form of commercial communication,

2005, the WHO Framework Convention on Tobacco

recommendation or action and all forms of contribution

Control (WHO FCTC), the first treaty negotiated under

the auspices of the WHO, came into force4. Article

to any event, activity or individual with the aim, effect
or likely effect of promoting a tobacco product or

13 of FCTC suggests a comprehensive advertising

tobacco use either directly or indirectly’.

ban, within five years of entry into force of FCTC
for each party. Currently, only 19 countries of the

Exposure to tobacco advertising among Indians

world (representing 6% of the global population) are

To protect the general populace from harmful

covered by comprehensive ban on tobacco advertising,
promotion and sponsorship (TAPS), with 101 countries

effects of tobacco use, the Cigarettes and Other Tobacco
Products (Prohibition ofAdvertisement and Regulation

imposing partial bans and 74 countries having no
ban at all3. This is a matter of public health concern.

of Trade and Commerce, Production, Supply and

Comprehensive TAPS ban would lead to reduction in
initiation and continuation of tobacco use; as such a

Section 5 of COTPA prohibits all forms of TAPS in

policy measurewouldhavelargepopulation level impact,

existence of TAPS ban in India, exposure to tobacco

thereby reducing demand for tobacco. Therefore, it is

advertising and promotion is still prevalent. Among

Distribution) Act (COTPA), 2003 was enacted in India.
line with Article 13 of the WHO FCTC. Despite the

This editorial is published on the occasion of World No Tobacco Day - May 31, 2013.

867

868

INDIAN J MED RES, MAY 2013

Indian school-going youth aged 13-15 yr, exposure to
pro-cigarette advertisements on billboards in the past
30 days increased from 71.6 in 2006 to 74.4 per cent

In India, PoS advertising by tobacco companies
is rampant and most common violations in this regard

include oversized advertisement boards, which are

in 20091011. Twenty eight per cent of Indian adults are

frequently backlit, placement of two boards together

exposed to cigarette advertising, and 47 and 55 per

to give the impression of one large board, placement of

cent, respectively are exposed to bidi and smokeless

multiple advertisements on one board and placement
of advertisement boards on shops not selling tobacco21.

tobacco (SLT) advertisements as per GATS (Global
Adult Tobacco Survey) 201012. COTPA allows ‘On-

India needs to step up enforcement of its TAPS ban

Pack advertising’ and ‘Point of Sale (PoS) advertising’

legislation, as indirect methods of advertising and

with some restrictions.

promotions are rampant. There is also imminent need
to amend COTPA to remove “On pack advertising”

Need for comprehensive TAPS ban
Substantial

evidence now

exists

and “PoS” advertising.

of a

causal

relationship of tobacco advertising and promotion

with

increased

tobacco

use,

especially

in

the

Recent progress in India on restricting TAPS
The Hon’ble Supreme Court of India on January

youth7'13. Cross-sectional14-15 and longitudinal studies16

3, 2013 vacated the stay on rules related to the PoS

conducted with school-going adolescents in India

advertising of tobacco products, which was imposed

also support these findings. A review of international

by the Bombay High Court in 2006, demonstrating

studies suggests that PoS marketing and displays are

commitment ofthe Indian judicial system towards better

associated

with

increased

smoking

susceptibility,

experimentation, and uptake among children, and
with

increased

craving among adults17.

Celebrity

endorsement of tobacco products in films is also

health of its citizens through effective tobacco control.

Following the hearing in January 2013. Ministry of
Health and Family Welfare (MoHFW), Government of
India (GOI), issued a letter to the Chief Secretaries and

causally associated with tobacco use among the youth

Director Generals of Police of all Indian States/UTs to

with a dose-response relationship7. A study conducted

ensure that all steps are taken to curb the violations of

with about 4000 school-going adolescents in Delhi

PoS advertising rules. Under India’s National Tobacco

concluded that students highly exposed to tobacco
use in Bollywood films are at more than twice the

Control Programme (NTCP), monitoring committees
specifically for Section 5 of COTPA at State and

risk of being ever tobacco users compared with the

district levels, as well as a national level steering

least exposed18. Comprehensive TAPS ban would

committee, have been mandated, to take cognizance of

ensure that youth and adults are not misled by these

direct/indirect advertising of tobacco products22. The

advertisements and promotions. Tobacco companies

MoHFW has continued to show its commitment to

have designed product promotion campaigns around

tobacco control by introducing comprehensive tobacco

sports and music events providing links on Facebook

control legislation and for some measures, India has

and Twitter, clearly targeting youngsters through this

been identified as a global leader. The Government of

powerful communication channel. Advertising through

India has recently introduced trendsetting rules related

these new media channels needs to be addressed under

to depiction of tobacco imagery in Indian films, a

comprehensive TAPS ban.

popular entertainment media23.

Engagement in CSR activities by tobacco industry

is

a

more recent strategy

wherein,

the

What needs to be done?

tobacco

The only advertising venue now allowed in India for

companies try to portray their image as being socially

the tobacco industry is ‘on-pack’ advertising. Tobacco

responsible and ethical1

The industry on one hand funds

packs are important means ofadvertising for the industry

activities such as youth anti-smoking programmes,

and they employ attractive imagery such as logos, brand

reforestation campaigns and environmental camps for

names, colours, etc. on the pack for the same. Plain,

school children, and on the other hand continues the

standardized tobacco packaging as currently being

promotion and sale of tobacco products8-19. Article 5.3

implemented by the Australian Government, mandates

of the FCTC guidelines recommend, denormalising

prevention of promotion through on-pack advertising

‘socially

and enhances effectiveness of graphic health warnings

responsible’ by the tobacco industry, including but not

on the pack. Results of a feasibility study for plain

limited to activities described as CSR20.

packaging of tobacco products conducted in Delhi

and

regulating

activities

described

as

ARORA & NAZAR: PROHIBITING TOBACCO ADVERTISING, PROMOTIONS & SPONSORSHIPS
revealed that over 80 per cent of participants believed

plain packaging would reduce the attractiveness, appeal

I.

Lim SS, Vos T, Flaxman AD, Danaei G. Shibuya K, AdairRohani H, et al. A comparative risk assessment of burden of
disease and injury attributable to 67 risk factors and risk factor
clusters in 21 regions, 1990-2010: a systematic analysis for
the Global Burden of Disease Study 2010. Lancet 2012; 380
: 2224-60.

2.

Bonita R, Magnusson R, Bovet P. Zhao D. Malta DC, Geneau
R, et al\ Lancet NCD Action Group. Country actions to meet
UN commitments on non-communicable diseases: a stepwise
approach. Lancet 2013; 381 : 575-84.

3.

World Health Organization. Tobacco Free Initiative (TFI):
Tobacco Facts: 2013. Available from: http://www.Who.int/
tobacco/mpower/tobaccoJacts/en/, accessed on April 1,
2013.

and promotional value of the tobacco pack, over 60 per

cent believed plain packaging would help in reducing
experimentation and initiation of tobacco among

youth and over 80 per cent believed, it would motivate
tobacco users to quit24. Multi-disciplinary researchers
and tobacco control advocates are strongly proposing
introduction of plain packaging of tobacco products in

India to enhance effectiveness of graphic warnings in
India. A Private Members’ Bill has been introduced on
this issue in the Indian Parliament, which remains to be

discussed25.
A TAPS ban should be comprehensive as partial

bans or voluntary arrangements

do not work. A

comprehensive ban on all TAPS could achieve a
reduction in tobacco use by seven per cent5.
Counter-advertising
accompanied

through

school-

with

or

mass

4.

World Health Organization. WHO Framework Convention on
Tobacco Control. Geneva: World Health Organization; 2003.

5.

World Health Organization. WHO report on the global tobacco
epidemic. 2011: warning about the dangers of tobacco.
Geneva: World Health Organization: 2011.

6.

World Health Organization. Tobacco Free Initiative (TFI):
World No Tobacco Day; 2013. Available from: http://www.
who.int/tobacco/wntd/20 13/en/, accessed on April 2,2013.

7.

National Cancer Institute. The role of the media in promoting
and reducing tobacco use. Tobacco Control Monograph No.
19.
Bethesda, MD: U.S. Department of Health and Human
Services. National Institutes of Health, National Cancer
Institute: 2008.

8.

Mazumdar PD, Narendra S, John S. Tobacco advertising,
promotion and sponsorship across south and south east Asia:
challenges and opportunities. Delhi & Mumbai, India: Centre
for Media Studies & Heallhbridge: 2009.

9.

World Health Organization. Guidelines for implementation of
Article 13 of the WHO Framework Convention on Tobacco
Control (Tobacco advertising, promotion and sponsorship);
2013. Available from: http://www-who.int/fctc/guidelines/
article_13.pdf, accessed on April 6, 2013.

media

community-based

programmes, warning about the dangers of tobacco use

has been an effective strategy in preventing tobacco use
as well as encouraging the users to quit7. Mass media
campaigns form a major strategy for tobacco control
under India’s NTCP22. Counter-advertising through

Government efforts needs to be stepped up to counter
misleading messages conveyed by the tobacco industry

through TAPS campaigns.

Conclusion
The WHO, while proposing targets for reducing
the NCD burden, has proposed a 30 per cent reduction

in tobacco use globally by 2025. The global narrative
on tobacco control

is increasingly exploring the

concept of tobacco endgame, which envisions reducing
tobacco prevalence and availability to minimal levels.
Experts aiming at the endgame give a target for
tobacco-free world, where prevalence for tobacco
use in each country would reduce to less than five per
cent by 204026. This would require tobacco control

10. Sinha DN. Tobacco control in schools in India (India global
youth tobacco survey & global schoolpersonnel survey, 2006).
New Delhi, India: Ministry of Health and Family Welfare,
Government of India; 2006.

11.

World Health Organization. India (Ages 13-15) Global Youth
Tobacco Survey (GYTS) 2009 Fact sheet: 2013. Available
from: http://www. who. int/fctc/reporting/A nnexoneindia.pdf
accessed on April 3,2013.

12.

International Institute for Population Sciences. Global adult
tobacco survey (GATS India 2009-2010), New Delhi, India:
Ministry of Health and Family Welfare. Government of India;
2010.

13.

Lovato C. Linn G. Stead LF, Best A. Impact of tobacco
advertising and promotion on increasing adolescent
smoking behaviours. Cochrane Database Syst Rev 2003: (4)
CD003439.

14.

Arora M. Reddy KS. Stigler MH, Perry CL. Associations
between tobacco marketing and use among urban youth in
India. Am J Health Behav 2008; 32 : 283-94.

measures be strictly enforced as per FCTC guidelines
and innovative measures beyond FCTC be introduced

in countries having political commitment to end the
tobacco epidemic in their country.

Monika Arora'" ' & Gaurang P. Nazar2
'Public Health Foundation of India

(PHF1) & "Health Related Information
Dissemination Amongst Youth (HRIDAY)
New Delhi, India
'For correspondence:
monika.arora@phfi.org

869

References

INDIAN J MED RES, MAY 2013

15.

Shah PB, Pednckar MS. Gupta PC. Sinha DN. The relationship
between tobacco advertisements and smoking status of youth
in India. Asian Pac J Cancer Prev 2008; 9: 637-42.

16.

Arora M. Gupta VK, Nazar GP, Stigler MH, Peny CL, Reddy
KS. Impact of tobacco advertisements on tobacco use among
urban adolescents in India: results from a longitudinal study.
Tob Control 2012; 21: 318-24.

17.

Paynter J. Edwards R. The impact of tobacco promotion at
the point of sale: a systematic review. Nicotine Tob Res 2009;
11:25-35.

18.

Arora M, Mathur N, Gupta VK. Nazar GP. Reddy KS, Sargent
ID. Tobacco use in Bollywood movies, tobacco promotional
activities and their association with tobacco use among Indian
adolescents. Tob Control 2012; 21: 482-7.

19.

Tobacco Free Center. Advertising, promotion, and sponsorship:
Corporate social responsibility; 2011. Available from: http://
global, tobaccofreekids. org/files/pdfs/en/A PS_CSR_en.pdf
accessed on April 4,2013.

20.

World Health Organization. Guidelines for implementation of
Article 5.3 of the WHO Framework Convention on Tobacco
Control on the protection of public health policies with respect
to tobacco control from commercial and other vested interests
of the tobacco industry. Available from: http://www.who.inb'
fctc/guidelines/article _5_3.pdf accessed on April 5,2013.

21.

Chaudhry S, Chaudhry' S. Chaudhry K. Point of sale tobacco
advertisements in India. Indian J Cancer 2007; 44: 131-6.

22. National Tobacco Control Cell. Operational guidelines:
National Tobacco Control Programme. New Delhi. India:
Ministry ofHealth and Family Welfare. Government of.India;
2012.
23. Public Law: Cigarettes and other Tobacco Products
(Prohibition of Advertisement and Regulation of Trade and
Commerce, Production, Supply and Distribution) Act of
2003. Notification No. GSR 708 (E) The Gazette of India:
Extraordinary (September 21, 2012). New Delhi: Govt, of
India Press; 2012.
24. Australia India Institute. Report ofthe Australia India Institute
Taskforce on tobacco control: Plain packaging of tobacco
products. Melbourne (Australia): Australia India Institute:
2012.

25. Bhaumik S. Private member’s bill proposes plain packaging
oftobacco products in India. &VX/2013; 346 :1953.
26. Beaglehole R, Bonita R. Horton R, Adams C. Alleyne G,
Asaria P. et al.: Lancet NCD Action Group; NCD Alliance.
Priority actions for the non-communicable disease crisis.
Lancet 2011:377: 1438-47.

Invitation
A State Level Consultation
Ban On

“Tobacco Advertising,
Promotion And Sponsorship”
on Friday Sth July, 2013

Timing : 9.00 AM onwards

To,

Rajiv Gandhi University
of Health Sciences,
Jayanagar, 4th ‘T’ Block,
Bangalore, - 560 041.
Karnataka

SOCHARA
#359, 1st Main, 1st Block
Koramangala,
Bangalore-560 041
Karnataka

fill

ft<Hx£<rS

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buildiiij community health

SOCHARA
&
Rajiv Gandhi University of Health Sciences,
Karnataka
Consultation on

(

otion and Sponsorship’

Ban on ‘‘Tobacco Advertisi

sedation with State Anti-Tobacco Cell, Karnataka.

At
Dhanvanthri Hail, Rajiv Gandhi
University of Health Sciences,
Jayanagar, 4th ‘T’ Block, Bangalore-560 041.
on

Friday 5th July, 2013

Timing : 9.00 AM onwards

Inauguration J)
Shri U.T. Khader
Hon’ble Minister for Health and Family Welfare,
Government of Karnataka.

Presided by )

Dr. K.S. Sriprakash
Hon’ble Vice-Chancellor, Rajiv Gandhi University of
Health Sciences, Bangalore.

( Chief Guest )

Dr. Sharanaprakash Rudrappa Patil
Hon’ble Minister for Medical Education & Pro-Chancellor,
Rajiv Gandhi University of Health Sciences, Karnataka

I

Shri M. Madan Gopal, i.a.s.
Principal Secretary to Government.

Health and Family Welfare Department, Karnataka

Shri '■ >. Patil, i.a.s.
Commissioner

epartment, Karnataka

> Raji.a.s.
Secretary to Government,
Department of Medical Education, Karnataka

Dr. B.N. Dhanya Kumar
Director
Health and Family Welfare Services, Karnataka

^Resource Person^

Dr. Thelma Narayan,
Director - SOCHARA. Bangalore

Panel Discussion on:
Ban on

“TOBACCO ADVERTISEMENT PROMOTION AND SPONSORSHIP”
With the experts from Health, Education, Law, Police, Agriculture and Media,

Moderated by: Ms. Nupur Basu, Former NDTV Journalist

Program Details (9.00 AM onwards) )
Registration 9.00 AM to 9.30 AM

• Welcome Address
• Inaugural Address
• Presidential Address
• Tea Break
• Lunch

• Inauguration
• Address by the Dignitaries
• Vote of Thanks
• Panel Discussion
• Action plan-way forward

Dr. Prem Kumar

Dr. Thelma Narayan

Registrar, RGUHS

Director - SOCHARA

.

pH' >-0
V

Society for Conunuidty Health Awareness Research and Action

'

State level consultation on ban on ‘Tobacco Advertising Promotion and Sponsorship’ (TAPS)
Minute to minute Program

Date: S’" July, 2013
Venue: Dhaiivanihri Hall, Rajiv Gandhi University of Health Sciences

Press Release
The global tobacco epidemic kills nearly six million people each year, of which more than
600 000 are non-smokers dying from breathing second-hand smoke. Unless we act, the
epidemic will kill more than eight million people every year by 2030. More than 80% of
these preventable deaths will be among people living in |ow- and middle-income countries.
The ultimate goal of any tobacco control initiative is to contribute to protect present and
future generations not only from these devastating health consequences, but also against the
social, environmental and economic scourges of tobacco use and exposure to tobacco smoke.

SOCHARA has been actively involved in tobacco free initiatives since 1998. It played an
active role in tobacco control measures taken at local, national and international levels. Over
the years SOCHARA has been addressing the demand and supply side issues through various
programs and campaigns. SOCHARA is one of the founding members of the network
‘Consortium for tobacco free Karnataka’ (CFTFK) founded in the year 2001.

The theme of the World No Tobacco Day (WNTD) - 2013 is ‘Ban tobacco advertising,
promotion and sponsorship’ this issue is covered under section-5 of COTPA Act-2003 as
‘Tobacco Advertisement, Promotion and Sponsorship’ (TAPS). Recently SOCHARA
participated at a national consultation on TAPS for 13 states including Karnataka organized
by HRIDAY, MoHFW and WHO country office in Delhi. One of the recommendations of the
national consultation was to organize state level consultations with various government
departmental officers who are responsible for implementing COTPA to sensitize and
strengthen their role, with active participation of civil society organizations.

Karnataka State Anti Tobacco Cell, Rajiv Gandhi University of Health Sciences (RGUHS)
and SOCHARA are jointly organizing a state level consultation on ban on
Tobacco Advertisement, Promotion and Sponsorship ’ (TAPS), on Friday 5th July
2013 Dhanvanthri Hall, RGUGHS, 4th T Block, Jayanagar, Bangalore-560 041 from 9 AM to 4
PM.
A comprehensive ban of all tobacco advertising, promotion and sponsorship is required under
the WHO Framework Convention for Tobacco Control (WHO FCTC) for all Parties to this
treaty within five years of the entry into force of the Convention for that Party. Evidence

shows that comprehensive advertising bans lead to reductions in the numbers ofpeople
starting and continuing smofemg. Statistics show that banning tobacco advertising and
sponsorship is one of the most cost-effective ways to reduce tobacco demand and thus a
tobacco control “best buy”.
Mr. SJ Chonder,Trg& Research Associate, SOCHARA

Atote9448034l52

Dr. K. S. Nagesh, Director Public Health, RGUHS

FRAMEWORK CONVENTION

^SJALLIANCE
Z J yr
lCCO DAY 2013
Why ban tobacco advertising, promotion and sponsorship (TAPS)?
Experts say tobacco advertising and promo­
tion increase consumption. In 2009 a com­
prehensive review of tobacco-related research
was released by The National Cancer Institute
(US). The monograph was compiled by 23 au­
thors, 63 expert reviewers and took five years
to produce. The two main scientific conclu­
sions were:
1. There is a causal relationship between
tobacco advertising and promotion and
increased tobacco use.
2. Comprehensive bans reduce tobacco
consumption but partial bans only lead to
greater expenditure in ‘non banned’ areas,
resulting in no net reduction of tobacco
use.
The report also found that generally tobacco
advertising and promotion exhibits three main
themes:
» Providing satisfaction (taste, freshness)
» Reducing fears about the dangers of to­
bacco use (mildness)
» Creating associations between tobacco
and desirable characteristics (social suc­
cess, sexual attraction, thinness etc).

It is clear that in countries
with weak regulation,
marketing reaches a very
high proportion of people. For
example according to the 2011
National Adult Tobacco Survey
of Cambodia, 80 percent of
respondents had seen tobacco
advertising in the past months.
Advertising, promotion and sponsorship nor­
malise tobacco, making it seem like any other
consumer product. This increases its social
acceptability and hampers efforts to educate
people about the hazards of tobacco use.

The tobacco industry maintains that the role
of advertising and promotion is solely to en­
courage smokers to switch brands. However,
another impact is to increase the desirability
of smoking by associating it with character­
istics such as independence, glamour and
machismo1.
In countries where partial bans prohibit direct
advertising and promotion of tobacco prod­
ucts in traditional media, tobacco companies
frequently employ indirect marketing tactics to
circumvent the restrictions. Tactics include:
» sport and music event sponsorship
» pack designs and displays
» branded merchandise
» product placement
» so-called corporate social responsibility
activities
» new media technology campaigns.
What is TAPS?
"Tobacco advertising, promotion and
sponsorship applies to all forms of
commercial communication, recom­
mendation or action and all forms
of contribution to any event, activity
or individual with the aim, effect, or
likely effect of promoting a tobacco
product or tobacco use either directly
or indirectly." (Guidelines for imple­
mentation of Article 13 of the FCTC)
In some countries the tobacco in­
dustry still uses print and broadcast
media, billboards, electronic mail and
direct mail and the internet to market
its products.
Point of sale promotion is particularly
powerful, and is allowed in practically
every country in the world.
1 Bates C. Rowell A. Tobacco explained: the truth about the
tobacco industry ..in its own words. London: Action on Smok­
ing and Health. 2004. www.who.int/tobacco/media/en/TobaccoExplained.pdf

ENFORCE BANS ON TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP. 2010

[
I B?> on all forms of direct and indirect advertising
t -I Ban on national television, radio and print media as well as on some but not all other forms of direct and Indirect advertising
£223 Ban on national television, radio and print media only
;
| Complete absence ol ban, or ban that does not cover national television, radio and print media
. J Data not reported
;___ I Data not available

Advertising, promotion and
sponsorship bans work

Comprehensive bans on direct and indirect
advertising, promotion and sponsorship pro­
tect people - particularly youth - from industry
marketing tactics and can substantially reduce
tobacco consumption.
Comprehensive bans significantly reduce the
industry’s ability to market to young people
who have not started using tobacco and to
adult tobacco users who want to quit.

*Direct advertising bans include: national television and
radio; local magazines and newspapers; billboards and
outdoor advertising; point of sale. Indirect advertising
bans- free distribution of tobacco products in the mail
or through other means; promotional discounts; non­
tobacco goods and services identified with tobacco
brand names (brand extension); brand names of non­
tobacco products used for tobacco products; appear­
ance of tobacco products in television and/or films;
sponsored events. Map source: WHO Report on the
Global Tobacco Epidemic. 2011. Appendix X.

Comprehensive bans can be achieved by fol­
lowing the international best practice stan­
dards outlined in the Guidelines for implemen­
tation of Article 13 of the WHO Framework
Convention on Tobacco Control (WHO FCTC).
A comprehensive ban on all advertising and
promotion reduces tobacco consumption
by about 7 percent, independent of other
interventions. Some countries have seen
consumption drop by as much as 16 percent
following an ad ban.

The WHO Framework Convention on Tobacco Control (FCTC) states:

Article 13
... a comprehensive ban on advertising, promotion and sponsorship would
reduce the consumption of tobacco products.
Each Party shall ... undertake a comprehensive ban of all tobacco
advertising, promotion and sponsorship.

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Published by
Consortium For Tobacco Free Karnataka
For further Information contact CFTFK at sochara@chc.org
Pamphlet Courtesy: Cardiological Society of India Bangalore Chapter, Ifcmat•'

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Are you being manipulated?

BAN TOBACCO ADVERTISING,
PROMOTION AND SPONSORSHIP
WORLD NO HI U1V
H

....

/ .fea World Health
e ganization

Publishers: Society for Community Health Awareness Research
and Action (SOCHARA) and State Anti Tobacco Cell ( SATC)
Opinions and views expressed in this booklet are those or
the authors themselves and not of the publishers or editors.

Editors:
Mr. S J Chandedr& Dr. Prem Mony
Cover page design and printing by:
Comfort prints : 97311 31270

From the Editors' Desk
Tobacco use is the single most preventable cause of death globally. Every
year, May 31” is observed as World No Tobacco Day (WNTD), to
highlight the health burden associated with tobacco use and advocating
for effective policies to reduce tobacco use. A comprehensive ban of all
tobacco advertising, promotion and sponsorship is required under the
World Health Organization's Framework Convention on Tobacco Control
(FCTC). Yet, only 19 countries, representing 6% of the world's
population, have comprehensive national bans. India's Cigarettes and
Other Tobacco Products Act (COTPA) 2003, under section 5, clearly
Mticulates the following:
W ® Both direct & indirect advertisement of tobacco products
prohibited in all forms of audio, visual and print media
e Total ban on sponsoring of any sport and cultural events by
cigarette and other tobacco product companies
° No trade mark or brand name of cigarettes or any tobacco product
to be promoted in exchange for sponsorship, gift, prize or
scholarship
® No person, under contract or otherwise, to promote or agree to
promote any tobacco product.
While the laws are in place, enforcement leaves a lot to be desired in India.
On a scale of 1 to 10 (1 being least compliant and 10 being most
compliant) for compliance with the provisions, India scored 4 out of 10
according to a recent survey in 2009. It's appropriate that the theme for
WNTD 2013 is: ban tobacco advertising, promotion and sponsorship
(TAPS).

The ban on direct advertising of tobacco products is implemented
^ectively in urban pockets of the country. Nevertheless, direct
advertising, particularly of smokeless tobacco products like gutkha and
pan masala, feature in newspapers, public transport, kites, calendars, and
at the tobacco vendors. The ban on indirect advertisements of tobacco
products has suffered serious setback due to legal challenges and poor
enforcement. Indirect advertising of tobacco products is rampant in all
forms of media and feature regularly in newspapers, television, public
transport, billboards, magazines, and in market places. In India, cigarette
companies engage heavily in using surrogate advertising and brand
stretching - the proverbial “wolf in sheep's clothing”. Tobacco
companies, through their surrogate products, sponsor events such as
fashion shows, music, sports events, and braveiy awards which are in turn
promoted through the mass media.

To mark the WNTD 2013 activities in Karnataka, partners in health from
across different organizations in Bangalore, have come together to
improve public awareness on tobacco control in general, and banning
TAPS, specifically, through this informative booklet. Mr Madan Gopal, I
A S, Secretary-Health, Govt of Karnataka, in the foreword to this booklet,
provides a crisp note on tobacco-attnbutable ill-health and appeals for
tobacco control for a healthy India. Mr V,B.Patil, I A S ,the Health
Commissioner, Govt of Karnataka, highlights the opportunity provided
by WNTD to wean youth away from initiation of tobacco use. Dr
Prashantha Kumari, Secretary to the State Anti-Tobacco Cell, shines a
light on the close link between tobacco and poverty that is very contextual
for our nation.
Drs Hebbar and Bhojani, present a state-of-the-art situational analysis <0
TAPS presently in India and are upbeat about the potential opportunities
for avoiding manipulation by the tobacco industry in the future. Dr
Pradyumna, provides a scholarly account of the harmful effects of
'second-hand smoking' or 'passive smoking'. Dr Vishal Rao, draws from
his clinical experience as a cancer specialist to draw our attention at a
personal level to the major problem at hand - that of prevention by
tackling tobacco as the root cause, rather than trying to treat the myriad
health problems that arise from tobacco use. Dr Vanishree, offers a simple
do-it-yourself (DIY) guide on conducting an examination of the mouth
for those who are or who may have someone close being a smoker or
tobacco chewer, in the belief that early detection and treatment improve
quality of life and longevity. Mr. Chander, in his inimitable style, provides
an historical account of the Consortium for Tobacco-Free Karnataka
(CFTFK), a network of about a dozen organizations from Bangalore
working on tobacco control. Lastly, Drs Murthy and Chand, give an
insight into the development of tobacco addiction and also offer useful
tips on how to quit tobacco use including tips on handling withdrawal.

Somewhere in between are interesting first-person accounts of 'tt^j
discomfiture of a passive smoker' and a 'positively inspiring story of
active smoker who successfully quit smoking'... Evidence of the energy
of school and college students....Positive role of famous personalities
like sportspersons and filmstars...motivating individuals and inspiring
organizations.. .collaboration of governments and NGOs stories from
India and China. ...plain language and medical jargon.. ..sad stories and
hope forthe future! All in all, a smorgasbord of information'
Here's to a tobacco-free future!

n MuS J 9^nder’ SOCHARA-SOPHEA, Bangalore
Dr Prem Mony, MD, St John's Medical College, Bangalore

31st May 2013

M. Madan Gopal, i.a.s.,

Principal Secretary to Government
Department ofHealth & Family Welfare
Government ofKarnataka
Department of Health & Family Welfare Services
Vikasa Soudha, Bangalore-560001

Foreword
Karnataka being the seventh largest State in India geographically
has achieved great endeavours in the field of health, family welfare,
maternal and child health and communicable diseases. However, noncommunicable diseases have been a great challenge to mankind owing to
its burden on human life. In this context, tobacco control plays a pivotal
role in improving people's health and quality of life.

Tobacco kills around 10 lakh people in India every year. This is
more than the combined deaths due to HIV/AIDS, malaria and
tuberculosis. To combat the public health challenge posed by tobacco,
there is an urgent need to have a strong and effective tobacco control
measures in the State ofKarnataka.
•
The World Health Organization's initiative of celebrating World
No Tobacco Day on 3 Is' of May every year is a step taken to promote a
tobacco- free world and educate people especially youths on the ill effects
of tobacco consumption. This booklet released on World No Tobacco Day
conveys a message to the people of Karnataka on the ill effects of tobacco
consumption and various control measures available to combat tobacco
related diseases. In this regard, I appeal all the readers to pledge to live a
tobacco-free life and thereby build a stronger and healthier nation.

(Madan Gopal. M)

V. B. Patil, >.A.s,

Commissioner
Department of Health & Family Welfare
Government of Karnataka

A
"

Directorate of Health & Family Welfare Services
Anand Rao Circle, Bangalore- 560009

Message
Every year, on 3 Is1 May, World Health Organization and partners
everywhere mark World No Tobacco Day, highlighting the risks
associated with tobacco use and advocating for effective policies to
reduce tobacco consumption. Tobacco use is the single most preventable
cause of death globally and is currently responsible for killing one in 10
adults worldwide. More than 80% of these preventable deaths will be
among people living in low and middle income Countries.
The ultimate goal of World No Tobacco Day is to contribute to
protect present and future generations not only from these devastating
health consequences, but also against the social, environmental and
economic scourges of tobacco use and exposure to tobacco smoke.

The theme for World No Tobacco Day 2013 is “Ban on Tobacco
Evidence shows that
Comprehensive advertising bans lead to reductions in the numbers of
people starting and continuing smoking. Banning tobacco advertising and
sponsorship is one of the most cost-effective ways to reduce tobacco
demand.

Advertising, Promotion and Sponsorship”.

This year's World No Tobacco Day celebration is a great
opportunity to create awareness among various sections of the community
on the need to ban tobacco advertising, promotion and sponsorship in
order to prevent youths from being attracted to tobacco consumption. I
wish all success to the Directorate of Health and Family Welfare Services
to celebrate World No Tobacco Day 2013.
(V. B. Patil)

Content
Page No
1. Ban on TAPS! Past, present and future.

1-3

2. Hardly a personal thing — impacts of
tobacco on “others”

4-6

Tobacco and Poverty - A vicious circle

7-8

4.

Tobacco or Health- a change in perceptive for
Indian health care

9-11

5.

Effects of tobacco on oral health and
importance of self Examination

12-17

6.

The story of a network working towards a
tobacco free Karnataka

18-21

7.

Why and How I Quit Tobacco

22-25

Ban on TAPS! Past, present and future.
Dr. Pragati B Hebbar, Dr. Upendra Bhojani

Institute of Public Health Bangalore.

According to a World Health Organization (WHO) report on the global
tobacco epidemic, 2011 - only 6% of the world's population was fully
protected from exposure to the tobacco industry advertising, promotion
and sponsorship tactics in 2010 which shows that much needs to be done
on this front. The WHO marks 31st of May each year as the 'World No
Tobacco Day'. This year aptly the theme of celebration proposed by Wl|J)
is 'Ban on Tobacco Advertising Promotion and Sponsorship' (TAPS).
Evidence suggests that comprehensive advertising bans lead to reductions
in the numbers of people initiating and continuing smoking. The article 13
of Framework Convention on Tobacco Control (FCTC) obligates its
Parties to implement, within five years, a comprehensive ban on tobacco
advertisement, promotion and sponsorship including cross-border
advertising. Very few countries have lived up to implementing strict ban
on TAPS within five years of agreeing to Framework Convention on
Tobacco Control. India was one of the first few countries to sign (10
September 2003) and ratify (5 February 2004) the WHO Framework
Convention for Tobacco Control, hence it is all the more important to
strictly implement a ban on TAPS.

The Indian Act termed Cigarette and Other Tobacco Products Apd.
(COTPA) 2003 prescribes for a complete ban on all forms of tobacco
advertisements, promotions and sponsorships. However, in and on pack
advertisements and point of sale (POS) advertisements are still permitted with some restrictions. According to COTPAboard specifications for POS
advertisements, it should not exceed 60x45cm and should bear a health
warning covering 20x 15cm area and saying “Tobacco Causes Cancer” or
“Tobacco Kills”, no brand pack shot, brand name of tobacco product or
other promotional messages are allowed to be displayed.

1

Some ofthe Common violations ofTAPS are as follows

ADVERTISING:
Indirect/ surrogate advertisements, (brand stretching/brand sharing)
Eg: Use of similar imagery, logos etc. for tobacco products (gutka) and
non-tobacco products (pan masala)
Point of sale (POS) advertisements - Commonly entire kiosks/small
shops are seen bearing famous tobacco company brand names and logos.
Direct advertisements - The enforcement ofban on direct advertisements
is also occasionally violated by pasting advertisements on private vehicles
.^d autos etc.
PROMOTION and SPONSORSHIP:

A conflict of interest exists here as Indian Tobacco Board a Government of
India body has a mission of "To strive for the overall development of
tobacco growers and the Indian Tobacco Industry" which is in contrast
with the article 13 ofFCTC regarding promotion of tobacco-.
Some examples for sponsorship include

°

•
®

Red and White Bravery awards, now renamed as Godfrey Phillips
Bravery awards as part of company 'CSR initiatives' wherein
often Government officials hand over the awards.
ITC Milky Magic Contest in Tamil Nadu targeting 4th to 9th std
children. Award distribution by famous sports celebrities.
Four Square Cigarette singing competition in Tamil Nadu, which
was later banned.

Issues relating to ban on TAPS in the State:

^Global Tobacco Networking Forum in Bangalore was sponsored by
Indian Tobacco Board a Government of India body. The Karnataka High
Court ruled in favour of Institute of Public Health (IPH) by ordering the
Tobacco Board to stop its sponsorship of GTNF 2010 and banned all
government officials from attending the conference. IPH also developed
and presented a code of conduct (Public Policies and the Tobacco Industry
- Upendra Bhojani, Vidya Venkataraman, Bheemaray Manganawar,
Economic and Political Weekly Vol - XLVI No. 28, July 09,2011) to the
Karnataka High Court focusing on primarily bringing about transparency
in the interactions of Government officials with tobacco industry
members. The other aspects that the code of conduct touches upon is
regarding partnerships or contribution ofgovernment officials in

2

tobacco industry events, declaration of any affiliations with tobacco
industry, denormalizing the so called 'Corporate Social Responsibility'
CSR activities of tobacco industry and avoiding preferential treatment to
the tobacco industry. The state is yet to accept and implement this code of
conduct and hence advocacy efforts are on for the same.
The way forward:

The other sections of COTPA such as section 4 addressing prohibition of
smoking in public places and section 6 addressing limiting access of
tobacco to minors subdivided into section 6a and 6b have received^
substantial attention. IPH has closely worked in the past and continues tir
do so with the Home department for strict implementation of COTPA
section 4. Through sustained advocacy efforts the COTPA violations of
section 4,5,6a, 6b and 7 has been included into the monthly crime record
(MCR) by the home department. The education department has also
started an online reporting system where section 6b violations are
reported.

Somehow section 5 of COTPA pertaining to TAPS has not received the
similar attention as the other sections. Through this World No Tobacco
Day awareness needs to be spread among the civil society as well as the
media regarding what is allowed and what is not allowed as per the
national and international laws and Acts with regard to tobacco
advertising promotion and sponsorships. Advertising is a very powerfill
tool to attract the youth to take up tobacco habits. If children initiate such
harmful habits at younger age the addiction is much stronger and quittinAil
becomes all the more difficult. Still a lot needs to be done to make the state
and the nation tobacco free but with sustained efforts of the consortium in
this direction a tobacco free future is something that we all can surely hope
for.

3

Hardly a personal thing - impacts of tobacco on “others”
Dr Adithya Pradyumna,

Research and Training Assistant, SOCHARA, Bangalore
(adithya@sochara. org)

If you're not a smoker, you may remember many instances that made you
uncomfortable around people smoking. I do. For instance, that one time
when a cute German exchange student inadvertently blew some smoke in
my direction and I almost fell back in repulsion, surprising her in the
process.
discomfort may be overtly expressed by vigorously shaking your hands to
Woo the smoke away or by covering your nose and throwing a dirty stare
at the smoker, but “discomfort” is only the superficial aspect. There is a
health impact of environmental tobacco smoke (ETS), commonly known
as passive smoking, which is rarely acknowledged. ETS contributes to the
negative health externalities of tobacco consumption - that is, the smoke
generated by cigarette/beedi consumption also impacts other persons
besides the consumer. There are also indirect health impacts of tobacco
consumption arising from the massive environmental impact of growing
and processing tobacco, which will be discussed later.

Several studies have been conducted over the years to estimate the health
effects ofpassive inhalation of ETS at homes and workplaces. These show
that ETS increases the risks among non-smokers for the same health
conditions that smokers are prone to, but at relatively lower levels. The
health problems include the increased risk of lung cancer (by up to 30%),
heart disease (up to 30%), stroke (up to 82%), chronic respiratory
symptoms and low birth weight. These become significant because of the
size of the exposed population which includes vulnerable groups such as
^ildren and pregnant women. Non smoking women exposed chronically
WETS showed a 15% increase in dying of heart disease compared to non
smoking women not exposed to ETS . In the UK it was seen that 40-60%
of children were exposed to ETS, making them vulnerable to exacerbation
of asthma (9% of cases), middle ear disease and lower respiratory
infections (25% of cases), among other things . These stats wouldn't be
very different in India as the prevalence of smoking is 30% among adults.
There is a need for persistent efforts to stop exposure to ETS, especially
for children.

And this is not all. What is perhaps the greater impact is the indirect one,
affecting people far removed from ETS. Globalisation has led to the shift
of tobacco industry (cultivation and processing) to developing countries,

4

which have made cigarettes available at relatively low costs. These
relatively low costs are made possible through the subsidies provided by
tobacco workers (by loss of health), by the local communities (loss of
forest resources), and by people worldwide (who are impacted by climate
change due to deforestation). Tobacco cultivation and processing is
associated with deforestation and soil degradation. There is pressure to
expand into forest lands, and the demand for wood for the tobacco curing
process is also on the rise. Forest fires are not the only way cigarettes
destroy forests after all! And as tobacco is a plantation crop, a heavy dose
of chemicals is used to maintain it, leading to soil degradation toqujjj
Workers do not regularly use safety equipment while handling chemicals
(during cultivation) or tobacco (during processing) leading to harmful
exposure. In several instances, children are involved in rolling beedis
which impacts the physical and mental health of this vulnerable group in
many ways. These are just some examples.
While these health impacts are not immediately apparent, they very much
exist and it is something that smokers should acknowledge. It is the
demand for tobacco that drives these impacts. And it is important that non
smokers too are aware of these effects they face, which should hopeftilly
encourage them to advocate for their health and environment through
demand reduction and better regulation of tobacco production and
consumption for a smoke-free world tomorrow.

References
1. Health and Safety Authority, Office of Tobacco Control. Report on^

the health effects of environmental tobacco smoke (ETS) in the
workplace [Internet], Ireland: HSA; 2002 Dec. Available from:
http://www.medicine.tcd.ie/public_health_primary_care/assets/
pdf/reports/ETS_Report.pdf
2.

Id

H

Kaur S, Cohen A, Dolor R, Coffman CJ, Bastian LA. The Impact of
Environmental Tobacco Smoke on Women's Risk of Dying from
Heart Disease: A Meta-Analysis. Journal of Women's Health. 2004
Oct; 13(8):888—97.

5

3.

Rushton L. Health impact of environmental tobacco smoke in the
home. Reviews on environmental health. 19(3-4):291-309.

4.

Chilmonczyk B, Salmun L, Megathlin K, Neveux L. Association
between Exposure to Environmental Tobacco Smoke and
Exacerbations of Asthma in Children. New England Journal of
Medicine. 1993;328:1665-9.

Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco Use in
India: Prevalence and Predictors of Smoking and Chewing in a
National Cross Sectional Household Survey. Tob Control. 2003 Dec
W I;12(4):e4-e4.

5.

6.

Lecours N, Almeida GEG, Abdallah JM, Novotny TE.
Environmental Health Impacts of Tobacco Farming: A Review of
the Literature. Tob Control. 2012 Mar 1 ;21 (2): 191-6.

7.

WHO Framework Convention on Tobacco Control. Study group on
economically sustainable alternatives to tobacco growing (in
relation to Articles 17 and 18 of the Convention) [Internet], Geneva:
W H O ; 2 0 0 8
Sep. Available fro.m:
http://apps.who.int/gb/fctc/PDF/cop3ZFCTC_COP3_ll-en.pdf

*

6

Tobacco and Poverty- A vicious circle
Dr A.S. Prashantha Kumari

Member Secretary,
State Anti Tobacco Cell- Karnataka

Tobacco and poverty create a vicious circle. Studies have shown that in the
poorest households in many low-income countries, spending on tobacco
products often represent more than 10% of total household expenditure.
As a result, these families have less expendable income for necessities

such as food, education and health care. Thus, in addition to its direct
health effects, tobacco leads to malnutrition, increased health-care costs

and premature death. Viewed from this perspective, tobacco may also
contribute to a higher illiteracy rate, since money is spent on tobacco
instead of education. Some street children and other homeless people in
India spend more on tobacco than on food, education or savings.
Tobacco and poverty is a vicious circle, through which tobacco

exacerbates poverty and poverty is also associated with higher prevalence
of tobacco use. Studies from different parts of the world have shown that
smoking and other forms of tobacco use are much higher among the poor.

If a person spends Rs 10 per day for purchasing tobacco products, they are
losing Rs 300 per month and Rs 3650 per year. If saved, this lost money
could bring them wealth of Rs 80,000 in 10 years and Rs 3 lakhs in 20

years.

7

If one uses tobacco, treatment of tobacco-related diseases may cost them
lakhs of rupees. One can eat nutritious food and educate their child by
saving the money spent on tobacco products. They can even buy a dream
vehicle and house with that money. On an average, the wealth loss due to a
monthly expenditure of Rs 100 for tobacco products over 10,20,30 and 45
years could be Rs 26,000, Rs 97,000, Rs 2.78 lakh, and Rs 10 lakh
respectively.(Sourec.STEPSTobaccoC(,nlrolProgran])
In many countries, workers spend a significant portion of their salaries on
tobacco. The following table shows the amount of time that workers in
selected countries would have to work in order to pay for a pack of
Marlboro or local brand cigarettes and the equivalent amount of time that
jjt would take to buy bread or rice instead.
Required work time to buy cigarette pack Vs bread or rice
(selected countries)
Country
Brazil
Canada

Marlboro
22 min
21 min

Local brand
18 min
17 min

Bread (Ike)
52 min
10 min

Rice (1 ke)
13 min
11 min

Chile
Giina
Hunaarv
India
Kerrva
Mexico

38 min
62 min
71 min
102 min
158 min
49 min
56 min
40 min

33 min
56 min
54 min
77 min
92 min
40 min

19 min
103 min
25 min
34 min
64 min
49 min

25 min
47 min
42 min
79 min
109 min
25 min

40 min
40 min

21 min
6 min

23 min
8 min

Poland
United Kinedom

Source: Guindon GE et al. Special Communication. Trends and affordability of cigarette
prices: ample room for tax increases and related health gains. Tobacco Control, 2002,

As per the table mentioned above, a cigarette smoker in India has to work
rfbr nearly 77 minutes a day to buy just a local brand of cigarette pack
which is much higher work time when compared to other Countries
except for Kenya. At the same time, the money earned during this work
time can be diverted to purchase a kilogram of rice which can feed the
smoker's entire fami ly for a day.
India is a developing country and most of its citizens do not have
adequate resources to spend on tobacco products on a daily basis and to
further spend on related costs such as sickness absenteeism and health
expenditure incurred due to tobacco related diseases. One of the most
effective ways to prevent our people from being poverty stricken is to
enable them stay away from the dreadful habit of tobacco consumption.

8

Tobacco or health - A change in perspectives
for Indian health care
Dr. Vishal Rao,
Senior Consultant Oncologist-Head and Neck Surgeon, BGS Global Hospital
and Cancer Institute, Department of Head and Neck Surgical Oncology
Over the decades much has been heard and spoken on tobacco and its
ill effects time and again. Now let me put across my perspectives on
this problem as a head and neck cancer surgeon.
The question a lot ofreaders may wonder is - Why is this doc so concerned
about tobacco issues? Well, a doctor may save more lives by indulging
tobacco controlfor several hours than by treating the diseases caused by
tobaccofor a lifetime!

Although most of us are quite aware of the perils of tobacco consumption,
today in India we have close to 300 million tobacco consumers. Every
year more than 30-40 lakh people in India fall prey to diseases of the heart,
lung or cancer owing to this deadly habit. Is this number not large enough
for us as citizens to wake up and ask ourselves and government to take
necessary steps to curb this?

The health care system in India is largely governed by the private sector
(80%) which means a person who reaches out to embrace these habits,
eventually ends up spending from his own pocket to treat the illnesses
caused by this substance abuse. This further leads to increase in the
financial burden to him and his family. Let's stop here and look into what
costs does the common man bear as a price of his addiction.

Although tobacco affects every cell of the body, the 3 main illness causey
by tobacco consumption are heart diseases, lung disorders and cancer
Rath and chaudhry way back in 1999 through an ICMR study showed that
the average cost incurred to treat these disease were rupees 3,50,000,
29,000 and 23,300 respectively. This is a serious concern for the citizens
of this country where 80% of our population resides in villages and 75% of
our population has a PPP (purchase power parity) of less than 2$ per day.
How do we expect this common man to bear with the increasing costs of
health care and why should he pay this price?
Well the government says the economy needs tobacco! Revenue from
taxation, exports and employment (agriculture, advertisement, vendors)

9

are important for fiscal gains. The government on an average earns 9000
crores from taxes and exports on tobacco, but the expenditure on health
diseases caused by tobacco is of the order of 30,000 crores (taking only 3
main diseases into consideration!). This comprises l/4tb of India's
expenditure on health.

As a doctor, we often observe, that it is not only the patient who undergoes
the treatment but also his entire family which bears the brunt both
emotionally and financially. Furthermore, lots of these patients do not
have accessible health care in the villages and hence need to move to town
or cities with better facilities. Annually, India registers 1 lakh new cases of
cancer and tobacco consumption is implicated in almost 50% of these
^Ancers in general and 95% of head and neck cancers. Cancers of the head
and neck include areas of the body such as mouth, throat, voice box or
food pipe which take care of vital functions such as speech, swallowing,
breathing and also maintain cosmesis. Hence cancer afflicting these areas
kills the very life force of existence. As a cancer surgeon, dealing with
these cases on a daily basis, involves surgically removing a patients jaw,
tongue, throat or voice box, which may not be gratifying, more so when
the thought crosses your mind that these cancers were caused voluntarily.
The fact remains that these mutilating surgeries could have been avoided.
Despite advances in technology science has not been able to significantly
improve the cure rates or add years to life, in these cancers caused by
tobacco. Yes, this is true! Some may ponder, why so, even after man has
scientifically advanced in this jet age? Well, expecting any technological
advancement to improve outcomes is like letting a man consume poison
and then looking for a new antidote. Isn't this imprudent? Precisely, that is
we have been witnessing all these years. “Trying to find a new antidote Rather than quitting the poison!”

^ave always practiced a simple principle in medicine, “Treat the cause
and not only the effect”. Thats right!! For instance, if any one of you is
diagnosed with fever, would treatment with paracetamol only suffice?
Naturally NO. Fever is the effect, the cause of which may be malaria,
typhoid, dengue, H1N1 etc. Hence it is mandatory to treat the cause too.
Similarly, treatment for these cancers, whatever is the modality; surgery,
chemotherapy or radiotherapy, aim at treating the effect- CANCER after
the cause has played its role. That is why the scientific world has moved
from - trying to improve survival to improving quality of life for these
patients. However, what could yield more gratifying results is
“preventing cancers”.

10

Similarly why not look at the lakhs of heart diseases, lung disorders or
several such diseases caused by tobacco and develop the same preventive
outlook. Rather than treat these diseases by medications, surgery or other
treatments, let us say no to tobacco and embrace life!
One of my patients a 30 year old gentleman, working in a software
company was diagnosed with tongue cancer owing to tobacco
consumption. The diagnosis of cancer came in as a shock to his family and
his wife whom he was married to for a year. The patient was diagnosed at
such an advance that despite chemotherapy and radiotherapy the tumour
spread could not be controlled. Towards the end, the tumor has spread to
the neck and started to show in his skin over the neck. All we could do \\ )
helplessly watch the young man go into the jaws of death. He bled to death
in the hospital room on one fateful day. I still recall his words to me Doctor, I got cancer because I consumed tobacco, but I quit the habit a year
back after I was married. What wrong did I do to deserve this? He left
behind him a devastated family and a young widow. This was the story of
one of the million bread winners.

Here is a good old Chinese story that I came across in an article called
'Reconnecting with peace' by Marguerite Theophil in the times of Ideas
which may be relevant:

Long ago, there lived a man with three sons, who all became doctors, but
only the youngest son became famous throughout the land. Patients from
far and wide, considered to be beyond hope, would go to him and be cured.

Someone asked their father, "All three of your sons are doctors, yet
how come only the youngest has become so famous?"
He replied, "This son of mine can cure people even at the point of
death, so naturally, everyone knows him. But, my middle son can detect
and cure sickness before it grows too serious, so there are only few who
know him. And my eldest son takes such good care of people's health
that they rarely get sick at all, so he remains unknown.
My youngest son’s name may be better known than the other two, but I
believe the skill of my other two children is equal to if n not far ’
greater than his."

11

Effects of tobacco on oral health and
importance of self examination
Dr. Vanishree,
Prof & Head, Dept of Public Health Dentistry, Bangalore Institute of Dental Sciences

Introduction:

Tobacco is derived from the species of the plant of genus Nicotina. Use of

tobacco has been a part of Indian cultural system. Tobacco leaves are
Objected to different types of curing and are processed into various forms

of smoked and smokeless tobacco like bidi, cigarettes, zarda, mawa,
gutka, mishri, khaini, gudakhu etc. In certain areas of Andhra Pradesh,
Vishakapatnam etc reverse smoking is practiced where in the lit end of the

cigarette is placed within the mouth. This is more detrimental to oral
health. Other than this tobacco is also used along with hookah especially

in areas where there is mughal influence.

Epidemiology:
It has been reported that the consumption of tobacco has reached the

proportions of an epidemic. WHO reports suggest that tobacco kills nearly
6 million people each year, of whom more than 5 million are from direct
tobacco use and more than 600 000 are nonsmokers exposed to second-

£nd smoke. Approximately one person dies every six seconds due to
tobacco and this accounts for one in 10 adult deaths. In men, oral cancer is
the eighth most common cancer type globally. Tobacco smoke is known to

contain more than 43 cancer producing agents. Nevertheless smokeless

tobacco like snuff and chewable tobacco also contains high amounts of
cancer producing agents. In the present days the use of smokeless tobacco

has increased as compared to use of smoked form of tobacco. Tobacco use
in the past decades was observed only in males, however in the recent

12

Effects on Oral Health
Tobacco use promotes the development of gum diseases where in there is
loss of supporting bone due to which teeth may become mobile and be lost
at earlier age resulting in disturbance of the masticatory function of the
mouth. Smoker is 5-20 times at higher risk of developing gum disease as
compared to a non smoker. Gum disease in later stages results in exposure
of root which in turn may increase risk of root decay. Nicotine present in
tobacco weakens the defense system of the person thus increasing the risk
of bacterial infections from microorganisms in plaque (deposit on tooth).
Halitosis (foul smell in the mouth) is another problem faced due to use of
tobacco. Both smoked and smokeless form of tobacco are the agents
responsible for the development of cancers of the mouth and pharyrj a
Tobacco use also causes a delay in healing of wounds like extraction
socket, surgical wounds in the mouth etc mainly as it affects the salivary
and serum immunoglobulin and also because of reduced oxygenation to
tissues in case ofsmokers.
Smoking of cigarettes can result in failure of treatments like dental
implants mainly due to inflammation in the area surrounding the implants.
Smoking during pregnancy increases the risk of development of cleft lip
and cleft palate. Long term smoking can result in a condition known as
smokers palate where there are changes in the skin of palate, which
appears diffuse white having red dots present on elevated nodules in the
lesion. Another condition commonly seen in tobacco and betel nut users is
the occurrence of stiffness in the oral mucosa (skin of the mouth) resulting
in reduced opening. This condition is accompanied by burning sensation
in the mouth. There can also be reduction in the movements of tongue. In
addition tobacco use may result in development of white patches in the
oral cavity called leukoplakia which is a precancerous lesion (lesion
preceding the development). The lesion may be smooth, fissured or
nodular. The white lesions may at times be interspersed with red lesiO
and the condition is known as erythroplakia which carries more risk of
turning into oral cancer. The risk of mouth cancer is still higher when the
person uses alcohol along with smoked form of tobacco. Smoking leads
to mouth cancer mainly due to carcinogens (cancer causing agents)
present in cigarette, drying of the mucosa by the high intra-oral
temperature, pH change, alteration in immune response, or altered
resistance to fungal or viral infections.

13

Pipe smoking has been associated with wear of tooth (loss of the surface
layer of the tooth). Smokers melanosis can be seen in smokers which
results in pigmentation of the skin of the mouth due to increase in
production of melanin. Smoking also results in black/brown
discolouration of teeth, restorations and dentures. There can be alteration
in the taste sensation. Smokers are also more prone for fungal infection
known as candidiasis which presents as white scrapable patch in the
mouth.
IMPORTANCE OF SELF-EXAMINATION:

ousands of Indians are diagnosed every year with life threatening oral
icer. On a positive note, when detected early, this disease has an
estimated 80 per cent survival rate. Learning to recognize abnormal
conditions in your mouth and performing routine self-examinations are
important detection measures and could even save your life. It's important
to learn to recognize the normal healthy condition of your own mouth so
that you can detect abnormal conditions and report anything unusual to a
dental professional or a medical specialist.

•

MONTHLY SELF-EXAMINATION ROUTINE

Perform oral cancer self-examination if any of the following symptoms
are present:

1.

Difficulty in chewing or swallowing.

2.

A chronic sore throat or hoarse voice that does not heal.

3.

Red patches in the mouth or on the tongue.

4.

White patches in the mouth or tongue.

£ 5.

A lump or overgrowth of tissue anywhere in the mouth.

Supplies needed: flashlight, small mirror (optional), piece of gauze, wall

mirror
Look at yourself in the mirror - both sides of your face and neck

should look the same. Press along the sides and front of the neck and feel

for any tenderness or lumps. Do the same on your face. Normally, your
face and neck are symmetrical so notice any bumps or swelling.

14

Pull your upper lip up and look for any sores and color changes on your
lips and gums. Repeat this on your lower lip.

Use your fingers to pull out your cheeks and look for any color changes
such as red, white, or dark patches. Put your index finger on the inside
and your thumb on the outside of your cheeks to feel for any lumps.
Repeat on other cheek.

15

Tilt your head back and open your mouth wide to see is there are any lumps
or color changes.

Grab your tongue with cotton gauze and examine for any swellings
or color changes. Look at the top, back and each side ofyour tongue

16

Touch the roof of your mouth with your tongue and look at the underside

of your tongue and the floor ofyour mouth.

See if there are any color changes or lumps. Use one finger inside your

mouth and one finger on the outside corresponding to the same place and
feel for any unusual bumps, swelling, or tenderness.

17

The story of a network working towards a
tobacco free Karnataka
S J Chander, SOCHARA- SOPHEA

The World Health Organization (WHO) has organized World No Tobacco
Day' since 1989, with various themes eveiy year. The preparatory process
for developing a Framework Convention on Tobacco Control (FCTC)
commenced in 1995, and in 1999 the WHO began negotiations with the
member countries. The FCTC was adopted by the World Health Assembly
in 2003 and came to force in 2005. This led to greater awareness
generation on ill effects of tobacco among various sections of the society,
^rticularly among the health care professionals.

In Karnataka various community health organizations; institutions
including medical, dental and other health science colleges; and
professional associations worked on tobacco control in diverse ways.
SOCH ARA was involved with the WHO efforts since the late 1990s. This
linkage moved us beyond health education alone to understanding the
entire 'Tobacco Cycle' from cultivation to consumption. Since 1999
collective efforts were made by a few health institutions in Bangalore for
awareness raising events in different parts of the city and the state around
World No Tobacco Day. The Karnataka Task Force on Health and Family
Welfare deliberated on the issue in 2000-1 and held discussions with
several government departments including that of Agriculture. The
women's health empowerment program working in parts of 11 districts of
the state through partner NGOs and self help groups with the Community
Health Cell (CHC) as the state nodal organisation included a section on
tobacco in 2001-2. Creative posters were developed by students from
Karnataka Chitrakala Parishad in collaboration with the Community
;alth Cell and donors. These were used extensively for exhibitions and
ks with students. Public rallies were conducted. Participating
institutions reviewed and reflected about their work and the annual
campaigns and this led to the birth of the Consortium for Tobacco Free
Karnataka (CFTFK). In view of the alarming ill effects of tobacco; the
following institutions expressed the need to form a network and carry out
action to address the various issues related to demand and supply of
tobacco: Society for Community Health Awareness Research and Action
(SOCHARA), Bangalore Institute of Oncology (BIO) National Institute
of Mental Health and Neuro Sciences (NIMHANS) and the Indian
Medical Association-Kamataka Chapter. Later on many more institutions
have joined the CFTFK.

«

18

Advocacy issues addressed
While the negotiation process for FCTC was being carried out by the
WHO, the Karnataka government initiated the process for THE
KARNATAKA PROHIBITION OF SMOKING AND PROTECTION
OF HEALTH OF.NON-SMOKERS ACT, 2001 which was notified in
2003. CFTFK wrote to the health minister for framing rules for
implementation of the Act. In the same year Government of India
announced 'THE CIGARETTES AND OTHER TOBACCO
PRODUCTS (prohibition of advertisement and regulation of trade and
commerce, production, supply and distribution) Act 2003' (COTTT)
following which CFTFK wrote to the union health minister urging herto
ban all forms of advertisement of tobacco products especially those
targeting children. A memorandum was also submitted to all the
Members of Parliament in Karnataka to support the safe passage of the
above Act in Rajya Sabha. CFTFK facilitated the process of 'Students
Action Against Tobacco' by college students in Bangalore to appeal to the
minister for education to take action to protect them from aggressive
marketing strategies of tobacco companies. In the year 2004 CFTFK
mobilized over 10000 signatures and submitted a memorandum to the
Governor ofKarnataka for urging the state government to implement both
the Acts mentioned above. In the year 2006 CFTFK organized a panel
discussion with senior officers from police, law and health department,
focusing on lapses in implementing the COTPA Act. Justice Malimath
was the chief guest for this event.

Awareness campaigns
Bangalore city witnessed for the first time tobacco awareness banners and
wall posters in some of the prime localities during the 2001 campaign.
Theses banners carried messages such as 'Tobacco Kills- Don't be duped'
and 'Tobacco Contains over 4000 poisonous substances'. The public
awareness rallies always included celebrities from the film industry and
sports.Some of the movie stars who supported the campaign are: Late Shri
, Vishnuvardha and his actress wife Smt. Bharathi, comedian Shri,
Shivram, Mrs. Jayanthi and Mr. Narendra Babu. Sports stars who
•pported the campaign are: swimmer Ms. Nisha Millet, Ms.Ashwini
Nachappa, and Cricketer Rahul Dravid.

The year 2002 focused more on mobilization of students' body across the
city. St Joseph, Christ and Baldwin PU colleges played a key role in
organizing public rallies and awareness programs within the colleges. The
campaign in 2003 was supported by the network of organizations working
with street children. Rag pickers Development Education Society (REDS)
played the lead role. The children gathered on M G Road and appealed to
the leading film actors who were promoting tobacco advertisement to
abstain from it.
The 2004 campaign was unique as CFTFK organized many public
awareness programs preceding the WNTD program. First time people at
the railway stations and bus stations in Bangalore and Mysore witnessed
public awareness program on tobacco. A special program was street
children in the city were organized through a magic show and puppet

20

Untouched agenda
The efforts by the government to implement various provisions in COTPA
seem reasonably good in terms of displaying the key messages of the Act

such as: ban of smoking in public places and ban on sale of tobacco
products to minors and within 100 meters from educational institutions.
Violators have been penalized in a few places, though not all of them.
Despite all these efforts it appears that the consumption of tobacco

products in India does not indicate a declining trend. This is evident for the
information furnished in websites of tobacco companies which reports^

increase in both production and sales. It has been observed that the
COTPA does not fully comply with FCTC recommendations. One of the

key measures recommended by FCTC for supply reduction is to shift
tobacco cultivation to other economically viable crops in a phased

manner. The work of the Center for Multidisciplinary Development
Research (CMDR) in Dharwad and other institutions across the globe

shows that there exists the possibility of tobacco farmers shifting to

alternate crops or finding alternate livelihood options. It is evident that no
efforts are taken to implement this measure and there is a need for

advocacy towards it. Tobacco consumption has gained wide social

acceptance for many years now. While the information on harmful effects
of tobacco is reaching the public, it is important that we further engage
society through social mobilization to reject tobacco and to put pressrtj
on the regulatory systems for effective implementation of COTPA.
W

I would like to close with the words ofDr. CM Francis, founder

president ofSOCHARA 'if tobacco is allowed to grow, there will be

pressure to sell it hence, reduction in tobacco cultivation is an
important step towards changing the trends in both demand and supply
oftobacco'.

21

Why and How I Quit Tobacco
Dr. Prabhat Chand and Prof. PratimaMuthy
Tobacco Cessation Clinic, Centre for Addiction Medicine,
NIMHANS, Bangalore
“I used to workfor a big company and used to travelfrequently. The work
stress was very high. With work stress and travel, my smoking increased
rapidly. It became three packets per day and continued till till I was45
years old. One evening while watching television, I had sudden chest pain
and breathlessness. The pain was very much and I could not breathe. I did
not know what happened after that. When I woke, I was in hospital with so
*uany tubes, needles around me. The doctor told me Ihad a massive heart
Attack. I could not believe him as I am neithera hypertensive (BP) nor
diabetic nor obese and I have been physically fit. Then the doctor asked
me “do you smoke? ”. He also advised me to quit smoking completely or
else the chance ofanother attack would bevery high. I stoppedfrom that
day onwards. I stayed in hospitalfor a bypass operation (open heart) as
there were seven blocks in my heart vessel. Now I am 84 year and healthy.
I wish I had not started smoking or that someone had advised to stop
smoking.Stilllfeelproud that I could kick the habit. ” (A True story)

Tobacco is the most addictive substance known to mankind. Its use, either
as smoking or in the smokeless form, is common among both men and
women. In view of its chemical nature, its regular use leads to nicotine
addiction. When a person gets addicted, there is a constant urge to smoke
or chew and feeling of uneasiness, restlessness in the person upon
stopping use. Some people use tobacco in certain situations like after
coffee/lunch/dinner, while driving, when tense or angry etc. Use of
tobacco provides a sense of short-lived relaxation. The use increases over
time and person develops physical problems.
fkhat will happen if I continue

using tobacco?
It is an irony that tobacco related
advertisement is popular every
where whereas its harmful effects
are not. People may know that
tobacco use is harmful but are
often ignorant about the range of
health hazards.Tobacco use can
involve all the systems of the body
and can cause serious harm.

22

What benefit will I get if I quit tobacco?
A person often thinks, “I don't have any physical problem or illness...
what is the benefit I will get from quitting tobacco. In fact, using tobacco
improves my mood and is helping me to work better”. It is important that
quitting tobacco at any point of time is beneficial In fact, the best benefit is
probably got by such a person who has not developed any tobacco related
problems and can prevent such problems in the future. It is also better to
quit before addiction develops, as the struggle to quit is much more once
addiction develops. The benefits of quitting occurs not just in physicalhealth but also in psychological health i.e. there is a feel good factor thatthe person has been able to overcome tobacco use. At the same time,
immediate family members and friends are also saved from the dangerous
effects ofpassive smoking.

By quitting smoking

By quitting chewing

By 1 day
BP and heart rate become
normal.
Carbon monoxide (toxin)
reduces.
Chance of heart attack reduces
By 3 months
Breathlessness decreases
Fertility improves
By 5 to 15 years
Risks of lung cancer, coronary
artery disease and stroke reduce
to levels of that of a nonsmoker.

Dental staining and mouth
ulcer comes down
Opening of mouth
becomes normal
There is no further tooth
decay
Risk for pre-cancerous
lesions like leukoplakia or
erythroplakia reduces

23

How do I quit tobacco?
There are various ways in which a person can quit tobacco. These
approaches are used regularly and found to be useful.
1. Understanding that nicotine is addictive.

2. Fixing a Quit date: Fix a date from when you want to quit
completely. It can be from the present day itself. Do not fix a date
which is too far. Once you quit there are chances of nicotine
withdrawal symptoms like irritability, restlessness, sleep
disturbance etc. These are normal in nicotine withdrawal and very
ft
mild. These will go way in a few days. These withdrawal
symptoms will be more intense in the first two to three days and
gradually come down. At this time there will be an increased urge
to use tobacco. One can fight these urges with simple techniques
that are described below.
3.

Handling the urge (craving): It is important to understand that
the urge for tobacco will remain for the next 3-6 months and
perhaps even longer. In the first three months it will be most
intense. Each time the urge for tobacco appears, you need to
learn the technique to handle it. Also remember that the intensity
will come down with time as one remains tobacco free.

Techniques to help withdrawal and urges after you stop tobacco
Remind yourself that withdrawal will last only a few days. The symptomswill appearlike
a mild fl u and disappear by themselves.
Take each day at a time.
When the urge comes, remember it will stay only for a few minutes and then go away.

For many, keeping something in the mouth, like a clove, cardamom, fennel seeds or
chewing gum is very helpful when there is craving.
Keep the hands busy - wash vessels, wash clothes, water the plants, squeeze a ball
Eat a healthy diet; Get enough exercise and Learn to relax.
Avoid situations that cause temptation, (i.e. tobacco userfriends)
Remind yourself the benefits that you have got or will get by quitting tobacco

24

Medications
•

Nicotine

•

i.e. nicotine gums
Others : varenicline, bupropion,
clonidine. nortrvotiline etc.

replacement

therapy

1. Medication As mentioned before, nicotine use is very addictive.
Use of medication facilitates the quitting process and in staying
away from tobacco. The medications normally help people who
are heavy tobacco users or need tobacco the moment they get up,
or ifthey find it difficult to handle craving (urges).
’
These medications need to be taken under advice of a doctor. The
role ofmedications is to assist in the quitting process. They are not
a substitute for your effort to quit. Studies show that the chance of
successful quitting increases upto 5-6 times with medications.
Your decision to quit, the lifestyle changes that you make to avoid
tobacco use (avoiding alcohol, eating well, exercising, learning
other ways of relaxation and stress reduction) are important in
quitting and medications would further help you in your decision
ifyou are addicted and your craving is strong.

Conclusion
Tobacco use normally starts as a temporary pleasure that
becomes a costly and risky pastime when it ends up in
addiction or with serious medical problems. The best
success with quitting is when it occurs early. However, eveil

addicted smokers CAN quit, with sustained effort. As in the
person mentioned at the beginning of the article, every quitter
should be proud of kicking the habit either by self or with help as
well as encourage others to quit.

Please contact Tobacco Cessation Clinic (TCC), Centre for Addiction
Medicine, N1MHANS in case you want any help in quitting tobacco.
Phone number: 080 26995547 (OPD: Monday, Thursday, Saturday)
email: tccbangalore@gmail.com
25

Prohibition on Tobacco Advertising, Promotion
and Sponsorship in India:
A Resource Kit

A Resource Kit developed by Health Related Information Dissemination Amongst Youth (HR1DAY) with support from Ministry of
Health and Family Welfare, Government of India (MoHFW, Gol) and World Health Organization (WHO) Country Office for India.

Tobacco Advertising Promotion and Sponsorship (TAPS)
Tobacco manufacturers are some of the best marketers in the world and
increasingly aggressive at circumventing prohibitions on advertising,
promotion and sponsorship that are designed to curb tobacco use (World
Health Organization, Report on The Global Tobacco Epidemic, 2008).

I

DI. .

Initiatives in India

• Tobacco industry uses means such as television, print, radio, internet.
Point of Sale (PoS) displays, product placement in films, brand
stretching, and sponsorship of sports, cultural, fashion and music events.

• The pack in which tobacco products are sold itself is a strong vehicle for
advertising.
Cross-sectional and longitudinal studies conducted with school-going
adolescents in India establish a causal relationship of TAPS with
increased tobacco use.

A study conducted with about 4000 school-going adolescents in Delhi
concluded that students highly exposed to tobacco use in Bollywood
films are at more than twice the risk of being ever tobacco users
compared with the least exposed.

jiteiasi ssfti© as

• This association suggests the need to strengthen policy and programme
based interventions in India to reduce the influence of such exposure.

Tools to curb TAPS
WHO Framework Convention on Tobacco Control

“tobacco advertising and promotion" means any form of commercial communication,
recommendation or action with the aim, effect or likely effect of promoting a tobacco product or tobacco use either
directly or indirectly;
^J^ticle 1 (g) - "tobacco sponsorship" means any form of contribution to any event, activity or individual with the
^raim, effect or likely effect of promotinga tobacco product or tobacco use either directly or indirectly;
Article 1 (c) -

The Cigarettes and Other Tobacco Products (Prohibition of Advertising and Regulation of Trade and
Commerce, Production, Supply and Distribution) Act, 2003 (COTPA)
Section 3 (a) - "advertising" includes any visible representation by the way of notice, circular, label, wrapper or

other document and also includes any announcement made orally or by any means of producing light, sound,
smoke or gas;
Section 5 (1) - "Indirectadvertisement"means:

•

the use of a name or brand of tobacco products for marketing, promoting or advertising other goods,
services and events;

•

the marketing of tobacco products with the aid of a brand name or trademark which is known as, or in use
as, a name orbrand for other goods and service;

•

the use of particular colours and layout and/or presentation those are associated with particular tobacco
products; and

•

the use of tobacco products and smoking situations when advertising other goods and services.

COTPA Section 5
The I ndian law prescribes for a complete ban on all forms of TAPS with ban on the display of tobacco products at the
PoS. However, in-and-on pack advertisements and PoS advertisements are still permitted - with some restrictions.
PoS rules under COTPA

•

An advertisement board should not exceed 60 cms x 45 cms with a 20cms x 15cms health warning on the top
edge.

•

Each such board shall contain in an Indian language as applicable, one of the following warnings Q) Tobacco
causes cancer, or Qi) Tobacco Kills.

•

The health warning must be prominent, legible and to be in black colour with a white background.

•

The board should only list the type of tobacco products available and shops cannot display any kind of tobacco
products and no brand pack shot, brand name of the tobacco product or other promotional message and
picture shall be displayed on the board.

•

The display board should not be backlit or illuminated.

Penalties for violation

•

First conviction: up to 2 years jail or up to Rs. 1,000 fine or both.

•

Subsequentconviction:upto5yearsjailanduptoRs.5,000fine.

•

Infringement of the law may lead to forfeiting of advertisements and advertising material.

Cable Television Network (Regulation) Act, 1995
An amendment to the Cable Television Network Rules 1994 was notified by the Ministry of Information and
Broadcasting on February 27, 2009 which allowed the indirect advertising of prohibited products like cigarette,
tobacco, liquor etc. with some restrictions. The letter by Director, Information and Broadcasting dated June 17,
2010 categorically directs all TV channels including news and current affairs channels to stop airing any
advertisement of a product on their channel that uses a brand name or logo which is also used for cigarettes,
tobacco products, wine, alcohol, liquor or other intoxicants and strictly follow the provisions of Rule 7 (2) (viii) (A)
of Cable television rules, 1994.

The Broadcasting Services Regulation Bill, 2007
The Broadcasting Services Regulation Bill, 2007, Ministry of Information and Broadcasting, Government of India
has provisions of a 'Content Code' and revoking of licenses of broadcasters, which would regulate inter alia, the
broadcasting and advertisement of tobacco and other addictive products.

Broadcasting ContentComplaints Council (BCCC)
BCCCs (a thirteen member body under Indian Broadcasting Foundation) Self Regulatory Content Guidelines for
Non News & Current Affairs TV Channels has prohibition on smoking and tobacco as one of the principles and a
complaint can be made against its violations.

The Advertising Standards Council of India
The Advertising Standards Council of India's Voluntary Code of 1998 envisaged prohibiting of advertisements
targeting underage consumers, as well as suggestions that using tobacco products is safe, healthy or popular.

Current Situation in India
Print, Electronic and Outdoor Advertisements

• With a ban on direct advertisement of tobacco products in place since 2004, tobacco companies have used
indirect and surrogate means to advertise their products on print, electronic and outdoor media.

• Tobacco companies have ubiquitously used television, radio, newspapers, billboards, hoardings, rain shelters
and transport vehicles for advertising and promotion of their products.

Large outdoor hoarding of
surrogate products

Advertising of surrogate
products on transport facilities

Advertising in leading
newspapers

Advertising of
cigarette brands
on carry bags

PoS and Product Display

• Tobacco companies in India provide lucrative incentives to retailers of their products for placing tobacco ads
and other items promoting tobacco usage.
• Companies supply vendors with promotional materials, including LCD television, giant posters and refurbish
their stores to make them more attractive and turn the stores into tobacco advertisements.

Advertisements of Surrogate products

• Tobacco companies use their non-tobacco products having similar
names, packaging, logos and labeling to indirectly advertise their
tobacco products.
• These advertisements are present everywhere in Indian media and
instances of such advertisements have increased after a majority of
Indian states/union territories have banned Gutkha and other
smokeless tobacco products under Regulation 2.3.4 ofthe Food Safety
and Standards (Prohibition and Restrictions on Sales) Regulations,
2011.

Surrogate products resembling
tobacco products

Brand Stretching

Sponsorship

• The tobacco industry uses its brand
names, logos, or visual brand identities on
non-tobacco products including clothing
and accessories to attract new consumers.

• TobacctTcompanies in India
have associated with popular
'sports and fashion events to
promote their products.

• This strategy turns customers into
advertisementmediums.

Range of body care products and clothing carrying
the same name as cigarette brands

Tobacco companies
sponsoring fashion events

Tobacco companies advertising
products during cricket matches

Tobacco companies associating
with popular Grand Prix events

Competitions/Contests

• Tobacco companies flout Section 5 ofCOTPA by promoting tobacco
product use through competitions targeted towards
children/youth or providing financial benefits to tobacco users.

Contest schemes from tobacco companies

Packaging as Advertisement

• Tobacco packages have always been an important part of the tobacco
industry's marketingstrategy.
• Tobacco product package design is used to reinforce brand imagery, to
minimize perceptions of risk, and to contribute to the tobacco user's
identity.

Cigarette packs during crit

• Tobacco companies also use limited editions pack in conjunction with
sports, festival/events.

Kiddie packs of cigarette

International Best Practice: Australia adopts plain packaging of tobacco produc
The GovemmentofAustralia took a momentous step forward by implementing plain packaging oft
from December 1, 2012. With this, Australia has become the first country in the world to have
packaging of tobacco products. Plain packaging restricts tobacco industry logos, brand imagery, colours an
promotional text appearing on packages, thus eliminating the "badge value’’ of all forms of tobacco product
packaging. Brand and product names are allowed only in a standard colour, position, font style and size in a pre­
defined area on the package. To enhance effectiveness of graphic warnings in India, researchers and tobacco control
advocates are strongly proposing introduction of plain packaging of tobacco products. A Private Members’ Bill has
been introduced on this issue in the Indian Parliament, which remains to be discussed.

plain'll

Corporate Social Responsibility (CSR)

• CSR is a strategy by which tobacco companies manipulate the public's attitude towards their reputation and
send the message that they are looking out for the public's best interest.
• Tobacco companies have often engaged in such activities in order to promote their products while portraying a
'positive self image’.

Tobacco industry
sponsored bravery awards

Tobacco industry's CSR initiatives
targeted towards farmers

Tobacco industry's
CSR initiatives

Product Placement and Tobacco use Imagery
in Films

• A number of actors from the Indian film
industry have being found smoking/using
tobacco in their films and films scenes
displaying tobacco brand packages and
logos for surreptitious promotion of
products has also been observed.
Tobacco Imagery in Indian Movies

Protectyouthfromui

= -nimes

India is one of the first corn
television programmes, kl

iacco imagery in films and
' ” “ J - ne into force from

October 2,2012. These rules
•

Minimum30secondshealthspoi

•

Minimum 20 seconds audio visu:

•

Non-compliance may lead to s

•

No films to be certified without b

Indian youth monitor, score a

i Bollywood films!

In a unique ongoing monitoring c
youth from Delhi to monitor depiction
reviewed so far. 15 have received aTht
haven't complied with the rules regulatingdepiction c

has engaged school and college going
;ed Bollywood films. Out of the 27 films
pl, which means 56 percentofthefilms

Challenges in dealing with TAPS
• Almost all smokeless tobacco products have their identical non-tobacco brand extensions which are
extensively advertised as surrogates for the tobacco products.
• In-and-on pack advertising gives much room to the tobacco industry to make its product visible in eveiy
corner of the country
• Despite of Hon'ble Supreme Court’s new ruling tobacco industry is using several posters, boards and LCD
screens within the kiosks to advertise at PoS.
• Tobacco companies make use of the loophole in the Trade Marks Act, 1999 which allows tobacco companies to
register the same trademark for non-tobacco products. This allows the tobacco companies to advertise their
non-tobacco products thus, resulting in indirect advertisement /promotion of tobacco products which is in
gross violation to Section 5 of COTPA.

• Tobacco industry activities in the name of CSR are targeted to promote brand loyalty and create a positive
image of the Industry.

• Excessive advertisement on internet and social networking sites e.g. Facebook, Twitter etc.
• Print, electronic and outdoor media see tobacco industry as their leading customers, hence contribute to
increase in surrogate and indirect advertisements.
• When compared to other provisions of the law, there is a general lack of awareness among enforcement officers
and the public on the extent of the advertising bans. This further leads to lack of action.
• Besides, steps should be taken to prohibit cross-border advertisements as recommended under FCTC. The
bordering regions of the country experience free-flow of tobacco advertisements through both print an J
electronic media.
I
• The tobacco industry has ample financial resources to support development of advertising, promotion and
sponsorship strategies and to challenge any bans in absence of proper enforcement.

Delhi Metro Rail Corporation (DMRC) urged to take offsurrogate advertisements of tobacco products
Raising concern over display of tobacco product advertisements in Delhi Metro, HRIDAY urged the Delhi Metro Rail Corporateas
(DMRC), to remove all such advertisements from, metros, metro stations and metro feeder buses. Replying to this DMRC officials satel
that "The Delhi Metro Rail Corporation follows theguidelinessetby the Directorate ofAudio Visual Publicity, Ministry ofInformational
Broadcasting, regarding the display of advertisements in its premises. Surrogate advertisements are allowed only if the requests a
accompanied by an NOCfrom the Ministry ofInformation and Broadcasting, GovernmentofIndia."

Existing enforcement mechanisms
Role of enforcement officers
PoS

• Ensure complete ban on TAPS and implementation of
Section 5 ofCOTPA within their jurisdiction.
• Conduct frequent raids and surprise checks to prevent
TAPS including cross-border TAPS.
• Enter and search any premises if she/he suspects the
existence of any material advertising tobacco
products.
• Seize and confiscate such materials as per the
provisions of Criminal Procedure Code,

• All materials so seized are forfeited to the government.
• Complain to the Steering Committee - all and any
instance of tobacco advertisement.

Films and Television

•

Ensure complete enforcement of
October 2, 2012 regulations oiA^
depiction of tobacco imagery in films
and television programmes.

• Monitor violations of the rules in films
and television programmes and bring
them in notice of the Steering
Committee.
Tobacco product packaging

•

Ensure that the tobacco products sold
in their jurisdiction depict the notified
pictorial health warnings, as per the
size prescribed in the law.

• Monitor violations of in-and-on pack
advertisements and bring
... :n
notice of the Steering Committee

;
'

Following categories of enforcement officers are authorized by the Government of India to implement the
provisions of Sections 5 and 7 of COTPA:
S.No.______________ Designation

Department

1

All officers of the level of Superintendent and above
ofthe Customs and Central Excise

All Premises registered under
Departmentof Revenue

2

All officers of the rank of Inspectors and above of
Sales Tax/Health/Transport

Departmentof Revenue/
Health/Transportofthe State

3

Junior Labour Commissioner and above

Labour Department

4

Joint Director

Office of the Commissioner of Industries/Small Scale
Industries

5

Sub-Inspector and above of Police/State Food and
Drug Administration or any other officer holding the
equivalent, rank of Sub-Inspector of Police

Department of Food and Drugs and Department of
Home Affairs.

Committees to enforce ban on TAPS
.4 'tate and District level Steering Committees have been constituted to guide monitor and ensure enforcement of ban on
'he Committees are empowered to take cognizance of TAPS violations under COTPA and look into specific instances of
• ,.ation of Section-5 of COTPA and take suo-moto action. The Steering Committee consists of representativesfrom 3 Departments of
'-•vernment of India. In addition representatives from Press information.Council of India, Press Information Bureau, Advertising
andards Council of India (ASCI) &. from Civil Society Organizations are members of this Committee.

Proposed Recommendations to strengthen enforcement of TAPS ban in India
1.

Regular meetings of the National, State and District level Steering Committees for Section 5.

2.

Formation of raiding teams atstate and districtlevel for law enforcement.

3.

Effective Government-NGO partnership for enforcement ofTAPS ban.

4.

Coordinated action among all concerned departments and ministries for meeting FCTC and COTPA mandates at
all levels.

5.

Strengthening COTPA and other related laws to encompass uncovered or under-covered areas, such as: CSR,
advertising on internet and social platforms, in-and-on pack advertisements.

6.

Advertisement materials to be handled carefully during search and seizure to ensure that relevant evidence
remains intact (conviction for contravention as under COTPA Sections 22 and 23).

7.

Active engagement of multi-sectoral partners such as: Central Board of Film Certification, Broadcast Content
Complaints Council, under Indian Broadcasting Foundation, Advertising Standards Council of India, Ministry of
Information and Broadcasting, Ministry of Health and Family Welfare, Ministry of Commerce and Industry,
Ministry of Transport and Ministry of Finance.

8.

Propose amendment in the Trade Marks Act to curb the use of tobacco products brands/trade marks for any
other non-tobacco goods or services.

9.

Specific violations of the advertising and programmme code of the Ministry of Information and Broadcasting
(on TV and printmedia), mustbe reported to the Ministry of Information and Broadcasting. Likewise, violations
by cable TV operators should be reported to the District Magistrates.

National Tobacco Control Helpline (1800-110-456) should be effectively utilized for reporting violations of
TAPS ban.
11.
Prohibition on in-and-on pack advertising and strengthening existing pictorial health warnings through
strategies such as Plain Packaging of tobacco products should be considered.
10.

12,

13

Mobilization of civil society, media and general public to report violations to the concerned authorities and
highlight the issue atvarious platforms.
Greater consumer awareness about tobacco industry tactics that counteract public health campaigns.

Global Best Practices on Prohibition of TAPS
• United Kingdom restricts internet advertising and promotion of all tobacco products.

• Sri Lanka completely prohibits Corporate Social Responsibility activities by tobacco industries.
• Myanmar banned tobacco advertisement on Satellite TV.
• Brazil and Thailand prohibit display and promotion of tobacco products at PoS.
• Nepal's tobacco control law imposed a total ban on TAPS in any form.
• Australia has implemented plain packaging of tobacco products to counter on-pack advertisements.
• Countries with the highest level of achievement against TAPS: Chad, Colombia, Djibouti, Eritrea, Iran, Jordan,
Kenya, Kuwait, Madagascar, Montenegro, Myanmar, Niger, Norway, Panama, Qatar, Sudan, Syrian Arab
Republic, Thailand and United Arab Emirates.

References
Advertising Standards Council of India, Voluntary Code, 1998.
Arora M, Gupta VK, Nazar GP, Stigler MH, Perry CL, Reddy. KS. Impact of tobacco advertisements on tobacco use among urban
adolescents in India: results from a longitudinal study. Tob Control 2012;21:318-24.
Arora M, Mathur N, Gupta VK, Nazar GP, Reddy KS, Sargent. JD. Tobacco use in Bollywood movies, tobacco promotional activities ant^^
their association with tobacco use among Indian adolescents. Tob Control 2012; 21:482-7.

Arora M, Reddy KS, Stigler MH, Perry CL. Associations between tobacco marketing and use among urban youth in India. Am J Health
Behav 2008; 32:283-94.

Broadcasting Content Complaints Council, Self Regulatory Guidelines, 2011, Indian Broadcasting Foundation.

Ministry of Health and Family Welfare. The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of
Trade and Commerce, Production, Supply and Distribution) Act, 2003 and Related Rules & Regulations. New Delhi: Government of
India Press, 2003.
Ministry of Information and Broadcasting, Broadcasting Services Regulation Bill, 2007, New Delhi: Government of India.
Ministry of Information and Broadcasting, The Cable Television Networks (Regulation) Act, 1995, New Delhi: Government of India.
World Health Organization. Guidelines for implementation of Article 13 of the WHO Framework Convention on Tobacco Control
(Tobacco advertising, promotion and sponsorship); 2013. Available from: http://www.who.int/fctc/guidelines/article_13.pdf,
accessed on May 22,2013.

%

L. HRIOAY
HEALTH
Rf LATT.0AMONGST
KRJRMATItM
DEiSEMMATlON
DISSEMINATION
YOUTH

T-7, Green Park Extension, New Delhi -110 016, India Tel.: 91-11-4103 1191, 26163362
Fax: 91-11-2616 3361 Email: lnfo@hriday-shan.org Website: www.hriday-shan.org

Examining the Impact of the
Gutka Bans in Selected States in India
Karnataka- Summary Findings

According to the Global Adult Tobacco Survey India (2009-10), 28 per cent of adults (15 years

and above) in Karnataka used tobacco. About 12 per cent of adults were smokers and 19 per
cent used smokeless tobacco. Of the latter, 6 per cent were current users of gutka.

A study was jointly undertaken by the Johns Hopkins University Bloomberg School of Public Health's Institute of
Global Tobacco Control (JHSPH-IGTC) and the World Health Organization Country Office for India, in collaboration with

JHSPH Center for Communication Programs (JHSPH-CCP) and Centre for Communication and Change-lndia (CCC-I) to
understand the impact of state laws that ban the sale and distribution of gutka.
Surveys were conducted with 1,001 current and former gutka users and 458 tobacco product retailers to gain insight

into the effect of the bans on consumer use and product availability in seven states (Assam, Bihar, Gujarat, Karnataka,

Madhya Pradesh, Maharashtra, and Odisha) and the National Capital Territory. Observations of 453 retail
environments and 54 in-depth interviews with government officials, enforcement officials and citizens working with

civil society groups were conducted to the same end.

In Karnataka, surveys were conducted in the districts of
Bengaluru and Mangaluru with current and former gutka users
and tobacco product retailers to determine the impact and

effectiveness of gutka ban. In addition, observation of 60

retail environments and in-depth interviews with government
officials, enforcement officials and citizens working with civil
society

groups

were

conducted

to

find

out

different

stakeholders' reaction to the ban.

The study is supported by JHSPH-IGTC and WHO Country Officefor India and conducted in collaboration with JHSPH-CCP and CCC-I

Summary Findings
■

Support for gutka ban is very high (94%) across the studied jurisdictions

■

Almost universal agreement (99%) that gutka ban is good for the health of India's youth

■

Product ban did impact use. None of the respondents use pre-packaged gutka since the ban

■

Post-ban, manufacturers have started selling twin packs (pan masala and tobacco separately). All the respondents
reported purchasing ingredients separately and combining/mixing them for consumption

■
■

A large percentage of dual users (64%) reduced the use of smokeless tobacco products after the ban

Eighty five per cent of respondents agreed that the government should ban the manufacturing sale and

distribution of other forms of smokeless tobacco
■

Interest in quitting is high with approximately half of the respondents (45%) reported attempting to stop using

gutka in the last year. Approximately seventy three per cent of respondents agree that the gutka ban will help
people to quit

■

Of the respondents that quit since the ban, a substantial proportion in Karnataka (92%) reported that they quit
because "gutka was not available"

■
■

There was virtually no retail outlet where pre-packaged gutka was on display
A very small percentage (8%) of tobacco product retailers interviewed reported that they had been approached

post-ban by a supplier to continue selling pre-packaged gutka
■

A very small percentage (7%) of outlets observed displayed a board declaring that "sale of tobacco products to

minors is prohibited"

■

Twenty two per cent of the retail outlets observed were located within 100 yards of an educational institute

Recommendations
The study Impact and Effectiveness of ban on Gutka yielded significant insights. These are presented as
recommendations here:

■

Policy measures need to be adopted to curb the sale and purchase of all other smokeless tobacco products
including products that can be bought separately and mixed to be consumed as gutka or a product similar to gutka

(by whatever name it be called).
■

Enforcement mechanisms need to be strengthened to ensure complete compliance of the ban.

■

Provision for tobacco cessation services to be scaled up to cater to the unmet need for tobacco cessation.

■

Smokeless tobacco products are freely available at a very low price near educational institutions leading to easy
access of these products by youth. The boards declaring that "sale of tobacco products to minors is prohibited"

were not displayed at all outlets as per the law. This calls for a stronger monitoring of tobacco control laws.

The study is supported by JHSPH-IGTC and WHO Country Officefor India and conducted in collaboration with JHSPH-CCP and CCC-I

Examining the Impact of the Gutka
Bans in Selected States in India
Karnataka

Examining the Impact of the Gutka Bans in Selected States in India
Karnataka - Abstract of Findings

Tobacco use patterns in Karnataka

According to the Global Adult Tobacco Survey (GATS) India report-2009-10, current
smokeless tobacco users comprise 19 per cent of the total adult population of
Karnataka. About 23 per cent of males and 16 per cent of females above 15 years of
age, fall in the current user category.

Twenty eight per cent of adults (15 years and above) in Karnataka used tobacco.
About 12 per cent of adults were smokers and 19 per cent used smokeless tobacco. Of
the latter, 6 per cent were current users of gutka (GATS).
The total percentage of daily adult users of smokeless tobacco comprises 17 per cent
of the total adult population. Almost 20 per cent of males and 14 per cent of females
above 15 years of age, fall in the daily current user category.

he Karnataka state government imposed a ban on gutka, joining the group of
25 States and five Union Territories that had already banned it.*1 With this,
Karnataka became the 26th State to ban gutka in May, 2013.

T

Methodology
In Karnataka surveys were conducted in the districts of Bengaluru and Mangaluru
with current users2*
4, dual users3 and former gutka users
*
1 and tobacco product
retailers to determine the impact and effectiveness of Gutka ban. In addition,
observation of 60 retail environments and in-depth interviews with government
officials, enforcement officials and citizens working with civil society groups were
conducted to find out different stakeholders’ reaction to the ban.

The Hindu - www.thehindu.com
1 Current users were defined as those gutka consumers who have used gutka or something similar-to-gutka by mixing tobacco at least once in last one month,
and have not used any other tobacco product in the last one month
’ Dual users were defined as those gutka consumers who have used gutka or something similar-to-gutka by mixing tobacco at least once in the past month, and
have also used any other tobacco product (smoked and/or smokeless) at least once in the past month
4 Quitters were those gutka consumers who have used gutka in the past but have not used something similar-to-gutka even once in the past month, and have
stopped using gutka since the ban of gutka

Study findings
Age at initiation:- Twenty to twenty three per cent had initiated gutka consumption
when they were below 20 years of age (20% of current users, 22% dual users and
23% of quitters).
Status of gutka use: - All consumers of gutka had switched over to something similar
- to- gutka because it was not available after the ban.

Comparison of usage before and after the ban: - A large percentage of dual users
reduced the use of smokeless tobacco products and cigarettes respectively (64% and
62%).

Opinion on the state enforced ban: - There was almost universal (94%) support for
the ban even by those who were currently consuming tobacco products in any form.
When asked about the reasons for the ban, almost 51 per cent of the current users, 58
per cent of the dual users and 37 per cent of quitters reported that they were not
aware of the reasons for the ban.

Extension of ban to other smokeless tobacco products: - Eighty five per cent of the
respondents were in favor of the ban being extended to all other smokeless tobacco
products.
Effect on health of children: - All the respondents reported that the ban on gutka was
good for the health of children

Quitting behavior: - People feel that gutka ban will definitely help in quitting
consumption of gutka or a similar product. However, only 45 per cent of the
respondents have made serious efforts to quit gutka or similar product.
Information regarding prohibition of sale of tobacco products to minors: - Section
6 (a) of Tobacco Control Act, 2003 states that the sale of tobacco products to persons
under the age of 18 is prohibited. Further, the shop should display a board declaring
that "sale of tobacco products to minors is prohibited". Out of 60 outlets, only 4
outlets had such messages displayed.

Information regarding prohibition of sale of tobacco products to minors: - Section
6 (a) of Tobacco Control Act, 2003 states that the seller should not sell tobacco to a
minor. In Karnataka, minors were observed purchasing gutka/tobacco products from
. 4 outlets.

Location of outlets in the proximity of educational institutions: - Section 6 (b) of
Tobacco Control Act, 2003, states that the sale of the tobacco products is prohibited
within a radius of 100 yards of any educational institution. Observation shows that
out of 60 outlets, 13 were located within 100 yards of any school or college.
Display of gutka packets for sale: - None of the outlets observed was found displaying
pre-packaged gutka packets.

Observation of vendors: - None of the vendors was found consuming gutka.

Manufacture’s, supplier’s and retailer’s response: - The retailers were asked about
the manufacturers’ and distributors’ response to the gutka ban. They were also asked
whether retailers still stock it

•
•
•

•
•

Nearly 66 per cent of the retailers said that gutka was not being manufactured
About 58 per cent said that gutka was not available with the retailers.
Nearly one-fourth (26%) of retailers mentioned that consumers have
approached them to buy gutka.
Only 8 per cent of the retailers were approached by suppliers to store gutka
About 37 per cent of the retailers were approached to store something similarto-gutka products.

Monitoring of gutka availability: - The retailers were asked several questions on
their response to the ban

•
•
•

Nearly 90 per cent of the retailers have started selling gutka ingredients
separately post the ban.
About 85 per cent of the retailers sell smokeless tobacco products and 92 per
cent sell smoked tobacco products
Ninety eight percent retailers were in the favor of the ban.

Recommendations
The study Impact and Effectiveness of ban on Gutka yielded significant insights.
These are presented as recommendations here:
•

•
•
•

Policy measures need to be adopted to curb the sale and purchase of all other
smokeless tobacco products including products that can be bought separately
and mixed to be consumed as gutka or a product similar to gutka (by whatever
name it be called).
Enforcement mechanisms need to be strengthened to ensure complete
compliance of the ban.
Provision for tobacco cessation services to be scaled up to cater to the unmet
need for tobacco cessation.
Smokeless tobacco products are freely available at a veiy low price near
educational institutions leading to easy access of these products by youth. The
boards declaring that “sale of tobacco products to minors is prohibited” were
not displayed at all outlets as per the law. This calls for a stronger monitoring
of tobacco control laws.

Examining the Impact of the Gutka Bans in
Selected States in India

A study was conducted by the Johns Hopkins University Bloomberg School of
Public Health and the World Health Organization Country Office for India to

understand the impact of state laws that ban the sale and distribution of gutka.
Surveys were conducted with 1,001 current and former gutka users and 458
tobacco product retailers to gain insight into the effect of the bans on consumer

use and product availability in seven states (Assam, Bihar, Gujarat, Karnataka,

Madhya Pradesh, Maharashtra, and Orissa) and the National Capital Territory.

Observations of 450 retail environments and 54 in-depth interviews with
government officials, enforcement officials and citizens working with civil society

groups were also conducted to the same end.

Summary Findings:
•

Support for gutka bans is very high (92%) across the studied jurisdictions
Almost universal agreement (99%) that gutka bans are good for the health of India's youth

Product bans did impact use. Of the respondents who continue to use pre-packaged gutka, half (49%) reported
they consume less since the bans

Ninety per cent of respondents agreed that the government should ban the manufacturing, sale and
distribution of other forms of smokeless tobacco

Post-bans, most gutka users report purchasing ingredients separately and combining/mixing their own gutka.
However, 15 per cent of respondents continue to purchase pre-packaged gutka

Interest in quitting is high-approximately half of respondents reported attempting to stop using gutka in the

last year. Approximately 80 per cent of respondents agree that the gutka bans will help people to quit
Of the respondents that quit since the bans, a substantial proportion in each state (from 41-88%) reported that

they"quit using gutka because of the ban"

The cost of pre-packaged gutka increased following the bans
There was virtually no retail outlet where pre-packaged gutka was on display

More than one-quarter of tobacco product retailers interviewed reported that they had been approached
post-ban by a supplier to continue selling pre-packaged gutka

Limitations:
•

Sample is not nationally representative

•

Sample only includes adults

•

Responses are self-reported and are not corroborated with any biological measures to confirm gutka or tobacco use

The study was supported by WHO Country Office for India and JHSPH-IGTC in collaboration with JHSPH-CCP and CCC-I

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www.stoptobacco.in / www.satc.karnataka.in

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