Abstract
In India, there has been no attempt to measure the implementation of World Health Organization’s Framework Convention on Tobacco Control Article 5.3, which provides guidelines to address tobacco industry interference (TII). This study draws on a desk review conducted to assess the frequency and severity of TII and the Government’s response, reported between January and December 2017. This study highlights that the Government of India does not allow tobacco industry to participate in policy development. However, the industry interferes by collaborating with the Government’s allied organisations. The tobacco industry has diversified as food industry in India, and directly or indirectly supports various government programmes, by investing through their Corporate Social Responsibility schemes. In addition, there are limited legislative measures to allow transparency in adoption of Article 5.3 guidelines across the country. Hence, the findings of this study underscore an exigent need to adopt and implement Article 5.3 at national level in India.
Keywords: WHO FCTC, Article 5.3, tobacco industry interference, tobacco control, India
Introduction
In order to address the preventable epidemic of tobacco use, the World Health Organization (WHO) introduced the first global public health treaty - the Framework Convention on Tobacco Control (FCTC) during the World Health Assembly in 2003. The FCTC, which is now adopted by 181 countries across the globe, provides evidence-based guidelines to the Member States for initiating and accelerating tobacco control efforts.1 In order to counteract tobacco industry interference (TII), for effective implementation of various tobacco control policies, Article 5.3 of the FCTC specifies “protection of public health policies from the commercial and other vested interests of the tobacco industry”.1 During the third session of the Conference of Parties in 2008, all the Member States unanimously adopted Article 5.3 guidelines.
The purpose of Article 5.3 is to restrict, or where applicable, maintain transparent interaction between the Government and the tobacco industry.2 Despite eleven years of adoption of Article 5.3, its effective implementation is still suboptimal, especially in Low and Middle-Income countries (LMICs).3,4,5 In an extensive analysis of Article 5.3 implementation among 155 FCTC Parties, using Party reports and other documentary data, it was found that only 16% of Article 5.3 guideline recommendations had been implemented across the globe.6 Weak regulatory environments, interference in policy processes and close relationships or even formal partnerships between Governments and industry actors, all present challenges to effective implementation of Article 5.3.7
In India, evidence highlights that there is a fundamental and irreconcilable conflict between the tobacco industry’s interest and public health policies.8 The tobacco industry has been a major roadblock, subverting the implementation of tobacco control policies in the country. For example, the tobacco industry lobbied to dilute and delay the decision on implementation of 85% pictorial health warnings (PHWs) in India.9 In addition, the tobacco industry protested against the seventh Conference of Parties (COP 7) held in Delhi in 2016. During COP 7 industry front groups protested against their exclusion from COP and labelled it as “undemocratic”.10
Prior to becoming one of the earliest signatories to WHO FCTC, the Government of India enacted the Cigarettes and Other Tobacco Products Act (COTPA) in 2003, which aims to implement effective tobacco control laws in the country. In addition, a few states in India, issued Article 5.3 notifications in their jurisdictions since 2016.10 These notifications consist of a set of guidelines to facilitate implementation of Article 5.3. However, there has been no attempt so far to evaluate the implementation of Article 5.3. This study was conducted with an aim to assess the frequency and severity of tobacco industry interferences (TIIs), in order to evaluate the implementation of Article 5.3 in India.
Methodology
To assess the implementation of Article 5.3 in India, a review of the literature was undertaken. This was done to complete the first India Tobacco Industry Interference Index (India TII Index). The methodology of this study was based on the Southeast Asia Tobacco Control Alliance Tobacco Industry Inference Index (SEATCA TII Index).11 To conduct this study, frequency (the number of TIIs) and severity (the intensity of TIIs) of TII and the Government’s response to TIIs were reviewed The search was restricted to collate data for the year 2017 (Janurary 2017 to December 2017) as the intent was to develop Asia TII Index 2018, where the results across 14 countries in Asia undertaking this review were compared.
To conduct this study, a pre-defined broad search strategy, using keywords including “tobacco company”, “tobacco industry” “Article 5.3 FCTC”, and “Government agencies” with synonyms, was employed. The search was conducted to gather and review the incidence of TIIs and the Government’s response. The incidence of TII was defined as an act or action by the tobacco industry to submerge the tobacco control laws with respect to public health policies in India. These incidences were searched in several Indian newspaper dailies available online and websites (imcluding Indian Government websites and major Indian tobacco industry websites). Other grey literature was also searched on WHO website and CTFK.. The search was restricted to include incidence in Hindi and English. The incidences in Hindi were translated by the authors into English. Two reviewers independently searched for evidence and discussed them before scoring. Evidence of TIIs collated through these incidences were reviewed against seven key themes: 1) Level of Industry Participation, 2) Corporate Social Responsibility (CSR) Activities, 3) Benefits to the Tobacco Industry, 4) Forms of Unnecessary Interactions, 5) Transparency, 6) Conflict of Interest and 7) Preventive Measures. These seven themes contained a total of twenty indicators (Table 1), which were scored for each incidence of TII.
As per the SEATCA TII Index scoring guidelines, each incidence of TII was scored based on its frequency, severity and the Government’s response. A base score of “3” was given for any incidence of interference. This number was then adjusted based on the severity of the interference and the Government response. 1 point (+1) was added for aggravating circumstances, i.e., for the actions that were undertaken to promote or support tobacco industry; and 1 point (-1) was subtracted for any mitigating circumstance, i.e., for the actions that were undertaken to reduce or lessen the effect of TII (See Supplementary file 1). Therefore, a higher score indicated poor implementation of Article 5.3 measures and a lower score denoted better implementation of Article 5.3. Each incident could attain a maximum score of 5 and a minimum score of 0. The severity and frequency of each incidence of TII under the seven themes was scored and averaged.
In order to maintain the scientific integrity of this study, the authors followed the guidelines provided by SEATCA. Regular communication was maintained with the SEATCA to score each indicator accurately. Scoring was reviewed and verified by four technical experts, who are civil society representatives and tobacco control experts working on Conflict of Interest and Article 5.3 issues in India.
Results
Approximately 180 articles (which included newspaper briefs, industry reports, minutes of meetings etc.) were found as a result of the search. Of these 180 articles, 45 articles were relevant, which were then analysed to assess the frequency and severity of TIIs in India. The findings of the first India TII Index study conducted for the year 2017 are presented under seven key themes, as elucidated earlier. In total, the India TII Index was scored at 72 out of a maximum score possible (100). This is illustrated in Table 1.
Results are presented under each of the seven themes:
1. Level of industry participation in policy development
The first theme of the India TII Index, “Industry Participation in Policy Development” obtained a total score of 6 out of the maximum possible score of 20. (Table 1)
While the Government of India does not allow the tobacco industry to participate in policy development, the tobacco industry, through varied allied organisations, impedes the development and implementation of public health policies related to tobacco control. On one hand, the Ministry of Health and Family Welfare (MoHFW) has a mandate to strengthen tobacco control policies, the Ministry of Commerce and Industry has an objective to promote tobacco crop.12 Tobacco industry front group highlights that “Various government agencies in India, such as Indian Tobacco Board, under the Ministry of Commerce and Industry, and Central Tobacco Research Institute under the Ministry of Agriculture and Farmers Welfare, are inseparable from the tobacco growers and trade due to interlinked objectives and organisational mandate”.13 Consequently, as per the scoring guidelines, an average score of 1 was given to this incident (incident a) (3 base score – 2 Ministry of Commerce and Industry = 1).
In another incident (incident b), the tobacco industry tried to lobby against the implementation of taxes on tobacco leaves and bidi products during the introduction of Goods and Services Tax (GST),14 the Government went ahead and imposed 28% GST on all tobacco products. However, the decision to impose additional cess (a form of tax which is levied on certain goods and services including tobacco under Section 8 of the GST Act, 2017), on bidi was postponed in 2017.15 Therefore, as per SEATCA scoring guidelines, a score of 4 was given for this incident (3 base score + 1 pleas from lobbying tobacco industry bodies accepted = 4).
Based on these incidents (incident a; and incident b), an average score of 3 (1 [score of incident a] + 4 [score of incident b] = 2.5), of the maximum possible score of 5, was given to Indicator 1. Similar scoring guidelines were followed for the next indicators, which were then averaged to derive a final score for the entire theme.
No incidences were found in the public domain where the government accepts, supports or endorses policies or legislation drafted by or in collaboration with the tobacco industry. Thus, a score of 0 (good implementation of Article 5.3) was given to the corresponding Indicator 2.
Nevertheless, the media reported several occasions where the tobacco industry sent repeated representations to the MoHFW and other ministries, and Parliamentary Committees, asking to withdraw the large mandatory PHWs.16 It was found that the tobacco industry has diversified as a food industry and regularly attend meetings of an autonomous body working under the MoHFW, as a food industry representative.17 Ensuing the above-mentioned incidents of TII and government response, Indicator 3 obtained an average score of 3. On the positive side, it was also evident that the Government of India does not allow the tobacco industry representatives to attend COP to the WHO FCTC, obtaining a score of 0 for Indicator 4.
2. Tobacco industry related CSR activities
Based on scores on severity and frequency of incidence for Indicator 5A and 5B, this theme obtained a total score of 4 out of a maximum possible score of 5.
Article 5.3 guidelines recommend Member States to regulate CSR activities by the tobacco industry, to counteract the industry’s vested interests. However, in India, in accordance with the Companies (Amendment) Act 2017, it is mandatory for companies to invest 2% of their profits into CSR activities.18 Consequently, big tobacco companies in India invest in primary education, sanitation schemes, and health promotion programmes by funding various Non-Governmental Organisations (NGOs).19,20 The tobacco industry also promotes agriculture, solid waste management, women empowerment, health and sanitation programmes and overall development, in alignment with varied government schemes at national and state levels.20 It was also evident that the tobacco companies have diversified into food products, and now the food industry gets easy access to Governments’ programmes and partnerships.21
3. Benefits to the tobacco industry
The third theme of the India TII Index attained a total score of five out of a maximum score of 10.
As per Article 5.3 guidelines, the government should not provide benefits to the tobacco industry in any way. While the tobacco industry tried to derail the implementation of 85% PHWs on tobacco packs by making appeals in the Indian Courts, the Government of India remained firm with its decision to implement large 85% PHWs.22 A score of 0 was given to Indicator 6.
Conversely, benefits have been provided to the bidi industry in the forms of exemption from additional cess (tax). For example, the tax exemption for bidi manufacturers effectively widened under the GST regime from the units that produced less than two million sticks to units with less than INR two million annual turnovers.23 Tax exemption is also available for small registered manufacturing companies with less than 20 workers.23 Benefits and subsidies have also been given to tobacco growers and exporters.24 Thus, Indicator 7 obtained the highest (maximum) possible score of 5.
4. Unnecessary interactions with the tobacco industry
This theme obtained a total score of 12 out a maximum score possible of 15.
In India, the Indian Tobacco Board works with a motive to support tobacco growers (Flue-cured Virginia tobacco growers) and industry.25 Indian Tobacco Board also sponsors, assists, coordinates and encourages research and activities for the promotion of the tobacco.25 Moreover, Central Tobacco Research Institute (CTRI) conducts research to enhance the productivity and manufacturing of tobacco.26 In addition, according to a media report,27 a state Agriculture Minister in India, Members of Parliaments (MPs), Members of Legislative Assembly (MLAs) along with Tobacco Institute of India and Indian Tobacco Board were not only present at an award function organised by the tobacco industry but also encouraged tobacco growers to interact with state and central governments and advocate for decreasing tobacco taxes and increasing tobacco production. Thus, based on the above-mentioned incidents, an average score of 3 was given to the Indicator 8.
It was found that the industry bodies along with the Government are carrying extensive research and activities to address the issues regarding illicit trade and tobacco smuggling in India.28 A high score of 5 was given to the corresponding Indicator 9.
Five insurance companies, along with a Government-owned company have a 32% stake in a leading tobacco company in India.29 Investment by such government-owned and recognised organisations and companies directly conflicts with the government’s tobacco control agenda in India, based on which Indicator 10 obtained a score of 4.
5. Transparency measures
No media reports or government reports were found on government websites that require disclosure of meetings with the tobacco industry, which led to score of 5 for Indicator 11. In addition, Indicator 12 also attained a maximum score of 5 as there are no rules at the national level in India which require the disclosure of interactions between the government officials and the industry representatives. Hence, the theme of “transparency measures” obtained the highest maximum score of 10.
6. Conflict of interest
Based on the incidences of TII and government response for Indicator 13 – 15, this theme obtained a total score of 14 out of a maximum possible score of 15.
It was found that there is no national law related to Article 5.3 in the country which restricts the officials or other organisational bodies from taking contributions from the tobacco industry in any form. In fact, various members of the tobacco industry hold positions or serve as members of various national and state governing bodies in India,30 which is inconsistent with the principle of conflict of interest of Article 5.3 guidelines.
7. Preventive measures
In the given timeline, ten states, at state-level or district-level, in India had issued Article 5.3 notifications in their jurisdiction.10 National level guidelines for effective adoption and implementation of Article 5.3 do not exist. Following the incidents for Indicator 16 – 20, this theme attained a score of 21 of the maximum possible score of 25.
Discussion
The findings of this study highlighted that the tobacco industry in India collaborates with various public and private organisations, which indicates its direct or indirect engagement with the government and its programmes. Similar tobacco industry tactics have been documented in the global literature, illustrating industry’s influence on public health policies through its allied organisations.31 In addition, the findings of this study have shown the diversification of tobacco industry into food and other industries. As food industry, tobacco companies partner with government in implementing national health programmes and services.32 Consequently, the findings of this study reveal the involvement and penetration of the tobacco industry in various public and private sectors, which derails the effective implementation of Article 5.3 in India.
This study also highlighted that CSR activities are an entry point for the tobacco industry to build public-private partnerships with various health and non-health sectors in India. Existing global literature also supports such instances and point towards the misleading nature of CSR activities by the tobacco industry.33 Some Asian countries like Thailand and Sri Lanka have completely banned CSR activities to counteract conflict of interest.34 However, India still requires to de-normalise tobacco industry participation in CSR activities to curb conflict of interest within various health and non-health sectors.
Additionally, the findings of this study emphasised that while ten states in India have issued Article 5.3 notifications, no rules have been adopted at the national level which restrict or limit interactions between government officials and the tobacco industry. The study highlighted that there is lack of law in the country that prevents officials and other organisational bodies (from health or non-health departments) from taking contributions or partnering with the tobacco industry. This further aggravates the issue of conflict of interest.
The findings of this study were included in the Asia TII Index 2018 developed by SEATCA.34 The Asia TII Index highlighted the implementation of Article 5.3 in 14 countries (Brunei, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar, Philippines, Thailand, and Vietnam, Bangladesh, India, Japan, Republic of Korea and Sri Lanka). Of the 14 countries, included in the Asia TII Index, India’s score was 72 and was ranked fourth from bottom, when all countries were organised on scores ranging from 21 (Brunei) to 85 (Japan).34 As per the Asia TII Index 2018, this score highlights the need for curbing TIIs in India to reach a lower score (better implementation of Article 5.3). Countries like Thailand: 42, Philippines: 45 and Sri Lanka: 51, showed better implementation of Article 5.3 in the Asia TII Index as compared to India.
While the SEATCA TII Index has been standardised and is in use for many years providing clear guidelines on how to assign and adjust scores, there could be small degree of subjectivity. The results relied on publicly available information and assessor’s interpretation of frequency and severity of TIIs was a concern while undertaking this study. We kept the later to a minimum through periodic exchanges among researchers (including developers of SEATCA TII Index tool) and reviews by technical experts were involved to assign scores. Nonetheless, using this index creates a benchmark that can document and track progress on Article 5.3 implementation in India. This has important implications for monitoring TIIs and thereby, informing multi-stakeholder action to strengthen tobacco in India.
Conclusion
This study underscores an exigent need to introduce Article 5.3 at the national level to avoid TIIs in India. It also highlights the need to sensitise government and NGOs and development sector partners and civil society on the conflict of interest related to partnership with tobacco industry. It is encouraging that some states in India have issued Article 5.3 notifications, however there is a need for comprehensive guidelines at the national level which would be implemented and enforced across all departments, in all the states/union territories across India.
Supplementary Material
What is already known
Tobacco Industry Interference (TII) is a major road block for implementing tobacco control policies. In order to counteract TIIs, World Health Organization’s Framework Convention on Tobacco Control recommends enforcing Article 5.3 guidelines to Member States for “protection of public health policies from the commercial and other vested interests of the tobacco industry”. However, studies have shown that the implementation of Article 5.3 is still suboptimal, especially in Low and Middle-Income countries (LMICs). Evidence also highlights that there is a fundamental and irreconcilable conflict between the tobacco industry’s interest and public health policies in India.
What this study adds
This study underscores an exigent need to introduce Article 5.3 at the national level to avoid TIIs in India. It also highlights the need to sensitise government, civil societies and development sector partners on the conflict of interest related to partnership with tobacco industry.
Acknowledgements
The authors would like to thank Southeast Asia Tobacco Control Alliance (SEATCA) for providing technical advice in conducting this study.
Funding
This study was based on the SEATCA TII Index methodology and was supported by UK Research and Innovation (UKRI) with funding from the Global Challenges Research Fund (MR/P027946/2). The Tobacco Control Capacity Programme (TCCP) is a programme of capacity development and research co-ordinated by the University of Edinburgh, Scotland and involves 15 partner institutions from Africa, South Asia and the United Kingdom. Funding from TCCP was received only for the time efforts of TCCP authors (AC, SB, GN and MA) for undertaking this study. Technical inputs were received from the non-TCCP Indian colleagues (UB, CA, PL and PCG) without any provision of funding from TCCP or any other support. UB was supported for his time spent on this paper through the Wellcome Trust/DBT India Alliance Fellowship (IA/CPHI/17/1/503346).
Footnotes
Ethics
Since this study involved a desk review, the authors assert that all procedures contributing to this study comply with the ethical standards of the relevant institutional committees.
An ethics approval was obtained from the Centre for Chronic Disease Control (CCDC), New Delhi India for conducting this study [IRB00006330].
Declaration of Conflicting Interests
No conflict of Interest
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