Move to weaken picture warnings on tobacco packets in India causes outcry

BMJ 2007; 335 doi: (Published 23 August 2007) Cite this as: BMJ 2007;335:366
  1. Ganapati Mudur
  1. New Delhi

    Public health experts throughout India have decried a government plan to water down picture warnings on packets of tobacco products, calling it a serious setback to efforts to control tobacco.

    A tobacco control law was passed by the Indian parliament in 2003 that mandates printing a picture of a skull and crossbones on all packets of tobacco products, but it is not yet enforced. The Indian cabinet has announced that the government will amend the law to make this picture “optional.”

    This decision has triggered an outcry among doctors and consumer activists who have long been urging stricter measures for tobacco control. “The government appears to have buckled under pressure from the tobacco lobby,” said Bejon Misra, chief executive officer of Voice, a non-government consumer organisation in New Delhi.

    The Advocacy Forum for Tobacco Control—a consortium of seven public health organisations—last week urged the Indian parliament to consider the harm that would result from any weakening of the regulations and to implement “effective picture warnings without further delay or dilution.”

    National health surveys show that India has about 250 million users of tobacco, with 16% smoking cigarettes. The rest smoke bidis—a type of unfiltered cigarette—or use other forms of tobacco, including chewable tobacco.

    A report released by the Indian health ministry two years ago cautioned that the total and indirect annual costs of the three major tobacco related diseases in India—coronary heart disease, cancer, and chronic obstructive pulmonary disease—would exceed 300bn rupees (£4bn; €5bn; $7bn).

    Public health experts blame the tobacco industry for trying to delay the implementation of the law, which was supposed to come into force from February 2007. Sections of the industry have expressed concern to the government that pictures of skulls and bones would have a big effect on use of tobacco and lead to massive unemployment in the tobacco sector.

    “The rights of Indian citizens to be adequately informed about the harmful effects of tobacco must prevail over attempts by the tobacco industry to cripple any tobacco control measure,” said Srinath Reddy, president of the Public Health Foundation of India.

    “Strong pictorial health warnings on tobacco packages are particularly necessary in India, where consumers have low levels of literacy,” said Dr Reddy.

    Doctors point out that the picture of a skull and crossbones was selected by the health ministry after studies showed that it was most effective to convey the risks of tobacco to people who can neither read nor write.

    “Virtually everybody recognises this picture as a sign of danger,” said Prakash Gupta, director of the Healis Sekhsaria Institute of Public Health, in Bombay, an epidemiologist whose studies had established a link between tobacco and oral cancer in India.

    Tobacco control in India has long been hampered by a lack of consensus within the government. Senior health ministry officials have said they would welcome early enforcement of the law, but concede that other government departments still need to be convinced.

    “The evidence suggests that picture warnings lead to only a gradual decline. Scenarios of abrupt and widespread unemployment in the tobacco sector are totally unrealistic,” Dr Gupta said.

    Australia, Brazil, Canada, Chile, the European Union, Jordan, and Singapore are among nations or jurisdictions that have implemented or finalised picture warnings on tobacco packets.

    View Abstract

    Sign in

    Log in through your institution

    Free trial

    Register for a free trial to to receive unlimited access to all content on for 14 days.
    Sign up for a free trial