Mumbai Tobacco: Role of Print

Mumbai Tobacco: Role of Print Media in Tobacco Control in Mumbai, India

The tobacco industry represents one of India's greatest dilemmas. Simultaneously a major domestic commodity and a threat to the health and well-being of India's general population, tobacco use has largely penetrated Indian culture in spite of the development of global and domestic policies aimed at curtailing its usage. Among the most aggressive of tactics adopted by the Government of India is its ban on media advertising for tobacco companies, which responds to the overwhelmingly positive portrayal of tobacco in India's advertising media. In principle, this policy initiative represents a major step in the fight against an addiction which annually causes millions of fatalities worldwide. In actuality, the literature review conducted hereafter demonstrates, this policy initiative has been pointedly weakened by the absence of meaningful enforcement measures and by the sociocultural penetration of positive imagery relating to tobacco usage. The study hereafter considers that this positive image is the outcome of a high level of saturation of tobacco advertising in various modes of print media and that an intervention in which this image is countered by a more realistic print media portrayal could help to significantly reduce the cultural status of tobacco in Mumbai.

The research will first provide some basic background on the preeminence of the tobacco industry in India. Subsequently, the discussion will identify tobacco usage as a public health problem for India. The following section would remark on the prevalence of tobacco usage and the tobacco industry in India. Subsequently, the research would identify the sociocultural dimensions of this issue such as the targeting of impoverished and uneducated consumers and the marketing of tobacco to children. Finally, the discussion will consider the role of the media both generally and specific to the print context in order to identify the nature of tobacco coverage -- both in terms of its positive portrayal of tobacco and in terms of its heavy saturation -- as well as to describe an intervention that would counter this with a more realistic print portrayal of tobacco and a counterbalance to the visibility of pro-tobacco messages.

Tobacco As a Problem:

Tobacco use in India is a significant public health problem. Cigarette smoking in particular is a significant presence in Indian culture and carries with it significant consequences for the health and well-being of the general population. Based on currently available statistics, it can be asserted that India is among the most heavily cigarette-addicted nations in the world. Quite to this point, Bansal et al. (2005) report that "India is the second largest producer and third largest consumer of tobacco worldwide. Of the 1.1 billion smokers worldwide, 182 million (16.6%) live in India accounting for consumption of 102 billion cigarettes per year." (Bansal et al., p. 201)

This reflects a serious public health crisis, levies a great toll on the public health system of India and denotes an issue problematically connected to India's commercial and consumer economies. It is for this reason that the efforts of the global community and the World Health Organization have focused on a collective policy adoption which would significantly impede on the ability of tobacco companies to market their product. According to the report by PTI (2010), "a WHO Treaty in 2003, ratified by 160 countries, recommended imposing a complete ban on advertising, promotion and marketing of tobacco products. Only 26 countries have done so, it said." (p. 1)

India is among those which would pass penetrating laws adhering to the new standards promoted by the WHO. Still, even with a total ban on cigarette advertising in the media, advertisers have had little difficulty remaining salient in the public sphere. Accordingly, John (2010) reports that "India banned tobacco advertising, promotion and sponsorship across all media in 2003, but tobacco companies continue to promote their products on public transport and storefronts." (p. 1)

Today, cigarette advertising, marketing and promotion remain vital and omnipresent in India and in the city formerly known as Bombay. According to Gupta et al. (2005), Mumbai "is a large, densely populated metropolitan city (density 16-461 inhabitants per km2) with a population of 9.93 million (1991 census). It is divided into three parts: the main (island) city, suburbs, and extended suburbs." (p. 1396). Modern day Mumbai is a city of prolific growth, is a center of commerce and can be seen as a cultural barometer for much of the nation of India. Accordingly, the high saturation of tobacco advertising and marketing is demonstrative of patterns impacting much of the country.

Indeed, the focus of this research on the intercession of media, politics and culture suggests that these dimensions have become inextricably linked with the marketing of tobacco products -- and cigarettes in particular. Quite to the point, the focus of policy initiative, as we will investigate in the subsequent section of the literature review, is on altering the advertising practices that appear so closely linked with the patterns of cigarette usage in mainstream culture. The literature review conducted hereafter takes a particular interest in considering each of these dimensions in and of itself as a way of producing an encompassing understanding of the tobacco problem in India and efforts to intervene there with.

A specific emphasis on Mumbai extends from the observation that this most populous city of India, and the second most populous city in the world suffers from a serious permeation of tobacco use in a multitude of forms. According to the study by Gupta et al. (2005), Mumbai residents reported high levels of malady and fatality as these related to tobacco use. In particular, Gupta et al. found that "the risk of deaths from respiratory diseases (RR 2.12, 95% CI 1.57 -- 2.87), tuberculosis (RR 2.30, 95% CI 1.68 -- 3.15), and neoplasms (RR 2.60, 95% CI 1.78 -- 3.80) were significantly higher in male smokers than never tobacco users." (Gupta et al., 1395)

Women too are evidenced to be vulnerable to and impacted by the permeation of tobacco use. Sorenson et al. (2005) report that though considerable variation may be observed based upon region and geography, "about one third of women use at least one form of tobacco, although rates among women vary considerably by region (from approximately 15% to approximately 65%). In general, cigarettes account for an estimated 20% of tobacco consumption; about 50% of tobacco is consumed in the form of bidis, that is, traditional, leaf-wrapped unfiltered cigarettes." (p. 1004) Though considerably lower than the penetration amongst men, which Sorenson et al. list as having 65% usage penetration, this denotes a public health problem which does target female users in growing numbers.

Ultimately, this also underscores the fact that India is contending with a major healthcare crisis where tobacco use and addiction are concerned.

Prevalence:

The tobacco industry is both extremely powerful and extremely profitable in India. Its prevalence is considerable in the discussion over policy implementation, in the defining of India's culture and in the landscape of its media. Today, this prevalence is being held up to the light of policy discussion. Wrangling over policy issues in India demonstrates the intense pressure under which the government has attempted to achieve some level of compromise between tobacco's economic prevalence and its medical consequences. The powerful interests of tobacco companies run directly contrary to public health priorities. Therefore, various policy interventions instigated by popular outcry and public interest have been designed in particular to impose upon the influence rendered by tobacco advertising efforts. Critical among recent policy developments, Citizen News Service (CNS) (2010) reports on recent legislation requiring tobacco companies to use 'pictorial health warnings' on packs of cigarettes. This issue, CNS reports, demonstrates the continuing uphill climb for legislators in the face of intense tobacco industry pressure. Accordingly, CNS reports that "in a detractive decision of the Ministry of Health and Family Welfare (MoHFW), Government of India (GOI), the implementation of new pictorial health warnings has been deferred to December 1, 2010 from the earlier commitment of introducing them from June 1, 2010." (CNS, 1)

This denotes the difficulty that the GOI has had in taking a firm stance with the tobacco lobby. This is a conversation that takes on added importance as we consider the difficulty with which the GOI has addressed issues of advertising in the print media context. As this review ultimately demonstrates, legal efforts to curtail the visibility of tobacco in print advertising have been limited in their effectiveness. Its enormous influence in India and its wealth of legal resources make the tobacco lobby a formidable political force. CNS reports that a public health advocacy group called the Advocacy Forum for Tobacco Control (AFTC) has taken a lead role in calling for a more meaningful intervention effort on the part of the GOI. AFTC is an assembly of various groups located in India and collaborating on the efforts to research and address the impact of tobacco use on the health, policy and economy of the nation.

According to one of its representatives, the recent delay in implementing more graphic pictorial warnings "is another example of possible interference in public health policy by either tobacco industry, their allies or supporters of tobacco trade. Because the tobacco industry sells a product that kills one million people in India annually, therefore, industry's interests will always be in conflict with public health. It is high time that national tobacco control policies in India are congruent to what India is obligated to do by ratifying the international global tobacco treaty - WHO Framework Convention on Tobacco Control (WHO FCTC).'" (CNS, 1)

This underscores the basic policy position of the AFTC as it has voiced the public demand for more aggressive product-labeling. Particularly, the AFTC has reported on evidence that current health warning policies lack effectiveness. This has underscored the push for pictorial warnings depicting the mouths of tobacco users who have developed cancer. (CNS, 1) This is an important consideration as it helps to delineate an appropriate intervention strategy within the print media. The AFTC is working based off of findings in other developing nations that demonstrate the effectiveness of the pictorial warnings as a deterrent, especially to young users. As the research will demonstrate recurrently, there is a great need to intervene in the initiation of addiction for young users and other particularly vulnerable demographics such as those residing in the deeply impoverished and broad rural regions of India. Here, CNS reports, "the coalition collectively highlighted the importance of pictorial warnings in conveying the harmful health effects of tobacco to users, especially in rural areas and those unable to read and write." (p. 1) This is a lesson which our research demonstrates would be well-minded where the design of a print media intervention is concerned.

Sociocultural Aspects of the Tobacco Industry:

Sorenson et al. (2005) inform the sociocultural dimension to our discussion, indicating that the context of Mumbai alone helps to reveal the connection between socioeconomic status and usage. Incorporating such variables as level of education attainment and occupation into an examination of tobacco-risk indices in Mumbai, Sorenson et al. demonstrate that there is indeed a need to take policy actions that might help to diminish the vulnerability of those who are demonstrated to be particularly susceptible to nicotine addiction. Sorenson et al. report that in a Mumbai-based "risks were higher among illiterate participants (male OR = 7.38, female OR = 20.95) than among college educated participants. After age and education had been controlled, odds of tobacco use were also significant according to occupation; unskilled male workers (OR = 1.66), male service workers (OR = 1.32), and unemployed individuals (male OR = 1.84, female OR = 1.95) were more at risk than professionals." (Sorenson, 1003)

This seems to suggest that education might play an important role in reducing the penetration of tobacco use into Mumbai society. Indeed, this is the primary motive for a print media intervention. Therefore, this intervention would have to inherently increase the coverage saturation of tobacco in contexts where these vulnerable demographics are likely to be exposed. It also denotes an approach to such intervention that is largely pictorial in nature so as to reach those of limited educational background. The research by Sorenson et al. offers the determination that tobacco use may be connected to a lack of access to proper education on its impact. This suggests that the pictorial approach to warning labels on tobacco products could carry a real and measurable reduction to those populations which have demonstrated the greatest vulnerability and should therefore also be considered as an aspect of the print media intervention.

This pictorial approach should also be viewed as relevant to what is likely the greatest sociocultural trespass committed by the tobacco companies. Namely, the fact that so many tobacco users ultimately die of cancer and heart disease means that tobacco companies must constantly work to keep a steady influx of new customers. This denotes the priority of targeting younger smokers, a trend which diverges heavily from prevailing legal and ethical discourse on the subject. Though many policy initiatives have been dedicated to standing between the tobacco companies and younger would-be users, TNN (2005) reports that poor regulatory oversight is allowing for an array of marketing loopholes that are directly contrary to the nature of this pattern. An example that TNN reports on is that of 'anytime cigarettes,' which are availed by unmanned vending machines in various contexts throughout Mumbai. As TNN reports, "an unmanned machine contravenes the spirit of the law, making cigarettes accessible to street children who already spend more on tobacco products than on food and nutrition, says anti-tobacco lobbyist Shobha John, adding that research shows that a street child spends most of his income -- as much as Rs 173 a month -- on cigarettes." (TNN, 1)

Here, the article refers to what research demonstrates to be a connection between conditions of poverty and a proclivity toward cigarette addiction. Accordingly, the TNN article describes the degree to which this addiction impacted 'street children' at extremely high rates. Accordingly, the article reports that homeless and impoverished children between the ages of 13 and 18 form a large portion of the cigarette buying public. This denotes a multilayered set of health consequences for a demographic which is already highly vulnerable to illness, injury and early mortality.

Evidence also suggests that tobacco companies have designed product lines with the nefarious intention of appealing to younger users. So is this suggested in the research by Joshi (2006), which claims that bidis are a particular problem where the marketing of tobacco to youths is concerned. Joshi reports that "Bidis are Indian cigarettes, wrapped in tendu or temburini leaf and secured with a string at one end of the cigarette. This relatively small tobacco product provides a powerful dose of chemicals. Bidis contain more than three times the amount of nicotine and more than five times the amount of tar than regular cigarette smoke. Bidis come in flavored varieties such as strawberry, chocolate, and mango and are subject to complaints by those who believe makers of bidis are trying to appeal to a young audience." (p. 605)

This echoes concerns cited in the area of policy legislation and suggests that the nature of the current public health crisis in India is today more commercial and cultural than it is legal. Evidence suggests that the GOI's efforts at reducing the influence of tobacco advertisers is as unsatisfactory as its efforts at reducing usage in public spaces.

Research also confirms the major sociocultural concern that this advertising can be shown to target particularly vulnerable groups. Most disturbing, Bansal et al. tell, is the evidence suggesting that advertising and marketing tactics in the region can be show to pursue young tobacco users. Accordingly, Bansal et al. report that "advertisements and product placements at low heights and next to candies at point of sale were easily accessible by children." (Bansal et al., 201) This is not an idle concern either. This may connect closely with the rate of tobacco penetration amongst India's youths. Here, alarmingly high numbers suggest that the fatality rate and health of Indian youth have been directly threatened by the cultural popularity of cigarettes. Bansal et al. report that the "the 2000 Global Youth Tobacco Survey (GYTS) of youth aged 13-15 years in 12 Indian states estimated that tobacco use in any form was greater than 40% in nine north eastern states." (Bansal et al., 201)

The youth culture has shown itself both to be particularly vulnerable to such penetration and distinctly receptive to cigarettes in contrast to many other products which are marketed to the young. ANI (2010) reports that "the particular content of tobacco marketing resonates with youth and that the vivid imagery in tobacco advertising captures their interest, although teens typically are more resistant to the promotional seduction of other products." (p. 1)

This denotes the high penetration of a positive portrayal of cigarettes in print media contexts appealing to youths. It also denotes that addiction can be an outcome of social pressures or opportunities relating to cigarette smoking. This suggests one of the more pressing cultural challenges presented to the GOI as it juggles the pressure of the tobacco industry with the outcry from public health advocacy groups. This is a major sociocultural crisis with serious public health implications. It also demonstrates a connection between the penetration of usage and the predominance of an overwhelmingly positive portrayal of tobacco use in print media pre-intervention.

Role of Media:

As the section above denotes, the Government of India has indeed created or passed many policy initiatives designed to reduce the saturation of tobacco advertising through all manner of media outlet. However, its legislation has more often than not been blunted by its own incapacity to enforce any of said policies. The voluntary nature of policies designed to limit or remove tobacco advertising from public media outlets denotes that these policies ultimately have little power or meaning. So denotes the informational website provided by Cancer Patients Aid Association India (CPAA). The CPAA finds that the progress in legislation has a clear counterpoint in the power and persistence of the tobacco companies where advertising is concerned. This occurs relatively unrestrained in spite of the laws which are now being extending from the international community through to the developing sphere. The CPAA reports on this point that "in general, advertising control is extremely lax. Only a voluntary code to regulate advertising by the tobacco industry has come through so far. Coming into effect from October 1st, 1998, it attempts to ban public personalities from endorsing tobacco products and disallows ads that attribute a better life to the intake of tobacco. The code also seeks to clamp down on surrogate ads, like cricket gear. Unfortunately, the code has proved ineffective, as the organisation that drafted it, the Advertising Standards Council of India (ASCI), is a self-regulatory body with no powers to enforce the code by punishing offenders." (CPAA, 1)

The high permeation of tobacco use in the Mumbai region is, based on all available evidence, not incidental. The penetration of tobacco marketing specific to the region demonstrates that tobacco companies have invested a concerted interest in expanding the print media presence of tobacco. Accordingly, Bansal et al. (2005) report that based on their on-site research, "cigarette advertising was ubiquitous in the environment, present in news and in film magazines, but not in women's magazines or the newspapers." (Bansal et al., 201)

This is to indicate that at this juncture of the research, which may be defined as pre-intervention, there is a high saturation of coverage in certain print media and that this saturation depicts cigarettes in an overwhelmingly favorable light.

According to Arori et al. (2010), one of the primary imperatives for an intervention in the print media context would be not to reduce the presence of tobacco in advertising but to counteract it. Indeed, the intervention would take a decidedly negative stance on a product which saturates the marketplace with positive imagery. Arori et al. (2010) report that "tobacco advertising, through various media, creates positive product imagery or associations in the minds of young people." (Arori et al., 283)

Evidence suggests that the visible presence of tobacco in print media is already extremely high. With respect to our sociocultural concerns over the marketing of tobacco to youths in Mumbai, a recent research endeavor suggests that print media is rife with tobacco advertising. The level of pre-intervention visibility of tobacco in print media is decidedly high and one-sided. Indeed, the study by Sinha & Gupta (2007) reports on this point, indicating that "over 2/3rd students saw tobacco products advertisements in . . . outdoor print media and over half in newspaper and social events. About 10% students had some object with tobacco products brand names and were offered free sample of tobacco products." (p. 1)

These numbers suggest that the penetration of print media featuring tobacco products is extremely permeating, and problematically so amongst youth populations. It is thus that an intervention focused this way would enter into a context in which the visual implications of tobacco advertising are already highly familiar. As the findings here above demonstrate, the presentation of tobacco in print media is decidedly one-sided. Though laws have failed at this juncture to impose an enforceable level of control over the marketing tactics of tobacco companies, an intervention might enter into the one-sided conversation of Mumbai's print advertising industry and produce a counterpoint in the coverage of tobacco. To this juncture, the conversation is dominated by the voice of the tobacco industry. This is so even in the face of policy pressure to adhere to the ban on advertising. Research such as that by Arori et al. indicates that this ban is intended as a way of intervening in the access of potential young smokers to the positive imagery of tobacco use foisted upon them by print advertising. Arori et al. report that "the fact that this study demonstrates that students have reported exposure to tobacco advertising at places . . . where it is banned (like print media etc.) after a complete ban on advertising was enacted in 2004, suggests that a comprehensive ban on advertising (and subsequent enforcement of that ban) may be required to protect youth from this exposure. The current law allows point of sale advertising; therefore students could have reported seeing advertisements on hoardings. Thus, the results of our study provide additional support for the policy recommendation for enforcement of a comprehensive ban on tobacco advertising in order to effectively lower tobacco prevalence rates." (Arori et al., 283)

In light of the impending pressure on tobacco companies to curtail advertising in the eventuality, many companies have redoubled their efforts in the area of print media advertising. So indicates the text by Bansal et al., which finds that "in view of the iminent enforcement of the ban on tobacco advertisements, cigarette companies are increasing advertising for the existing brand images, launching brand extensions, and brand stretching." (p. 201) These tactics suggest that without a sound and meaningful enforcement of the ban on advertising, any intervention would come into direct confrontation with the wealth of print advertising conducted by the tobacco companies. Indeed, this suggests that the tobacco companies will tend to respond to any intervention with an increase in their investment in print advertising. In the text by Bansal et al., we can see that print advertising is largely used to counteract the negative presentation of tobacco products which is channeled through any such intervention campaign. This might suggest that in the outcome of an intervention process, the current nature of India's unenforceable advertising ban means that coverage and visibility of tobacco will only increase. And in the event that this increase is largely experienced as a one instigated by the tobacco companies, the portrayal of tobacco products is likely to take on a distinctly more positive image direction

The discussion conducted in the section on the 'sociocultural' aspects of the tobacco industry does promote consideration of he problem of targeting youth in tobacco advertising. The use of print advertising in contexts typically experienced by younger demographics denotes that an intervention process would require a similar medium focus. Namely, an intervention in the print media would increase the visibility and coverage of tobacco use in this context but would insert a negative perspective on the subject into a context where image presentation is largely positive. This is underscored in the research by Braun et al. (2008), who point out that an intervention program would sensibly enter into the same contexts where tobacco companies have dominated the coverage of cigarettes and other tobacco products and to contribute a counterpoint to this portrayal. The use of medically-driven data, images and ideas in the print medium as a way of shifting the print-media coverage of tobacco would simultaneously increase the visibility of tobacco in this context but would do so while adding a counterpoint to the public discussion.

Such concerns are responsible for legislation which insists that any advertising which can be demonstrated to market tobacco products to minors would be considered prohibited. The article by the India Media Agency (2004) indicates that such legislation has significantly altered the complexion of some print media. Levels of compliance are particularly underscored by the new advertising opportunities available to other marketing organizations separate from the tobacco industry. Still, monitoring of print media is reportedly incomplete and lacking in thoroughness. Moreover, the process of so-called 'surrogate advertising' is allowing tobacco companies to market their brand image and name while advertising for non-tobacco products. On this point, according to the India Media Agency, "even though the huge hoardings space occupied by tobacco companies have been vacated, some surrogate advertising by ITC for Wills Sport and Wills Lifestyle is still visible. 'The ads will have to be monitored by the Information and Broadcasting (I&B) Ministry but no action against erring companies has been initiated. However, the Health Ministry is part of the inter-ministerial committee set up by the I & B. Ministry which monitors ads from time-to-time,' the Health Ministry official added. The Ministry is expecting some litigation with regard to surrogate advertising." (IMA, 1)

This suggests that the high level of pre-intervention saturation of positive tobacco brand imagery remains in place even as policy legislation works to redress it. This suggests that the intent to tip the scales toward a more negative portrayal of tobacco products in some media would require a significant investment of resource and intuition. Indeed, the great wealth and entrenchment of tobacco in such a context makes any effort at promoting a counterpoint inherently challenging. While the intervention would add a more visible reflection of the anti-tobacco position in the print medium, it would be ambitious and unrealistic to suggest this coverage saturation could necessarily compete with the portrayal provided by the tobacco industry absent of a significant intensification in the ability of lawmakers to enforce emerging policies.

This is an important point on with respect to the impact that print advertising can be shown to have on smokers in Mumbai. Indeed, the positive pre-intervention coverage of cigarettes and tobacco products does have a demonstrable impact on the desire and proclivity of the individual to engage in tobacco use. According to Vishnu (2010), "people with high exposure to tobacco advertising are twice as likely to have tried smoking and three times as likely to have smoked in the past month, compared to those with low exposure. Exposure to tobacco advertising also is associated with higher intent to smoke in the future among the never-smokers." (p. 1)

The media presentation of tobacco products has produced a distinct cultural presence for tobacco in India which is, if not rationally viewed as positive, drawn into positive association with existing cultural values such as youthful coolness or male ruggedness. The approach taken by advertisers and the relative success which continues to be achieved through the print media in particular suggests that additional layers are necessary to the current discourse if change in cultural habits is to be achieved. According to the study by Reddy & Gupta (2004), a major need reflected in current policy enforcement shortcomings is that related to a change of culture. To Reddy & Gupta, there is a certain degree of social preparedness required for the reduction of smoking in both advertising and public places to have its intended impact. This seems to endorse the case throughout the research for practical intervention in focused contexts. Reddy & Gupta endorse this perspective, arguing that "for any legislation to be successful there is a need for adequate preparedness on the part of civil society, locally and globally, with regard to awareness of the existing problem and acceptance of the necessity for such legal measures. At the global level, India has been a forerunner in the negotiations leading to the Framework Convention on Tobacco Control, which was ratified by India in February 2004." (Reddy & Gupta, iii)

However, in the view of Reddy & Gupta, this point of leadership in ratifying global agreements on the subject does not ensure that the nation's population is culturally ready to accept the impetus underscoring the laws. Evidence suggests that the penetration of India's culture by cigarettes and tobacco in general is at an extremely high level and that this level denotes the entrenchment of a positive image in pre-intervention coverage on or portrayal of tobacco. Reddy & Gupta report that "on the world tobacco map, India occupies a very special place. As the second most populous country in the world, India's share of the global burden of tobacco-induced disease and death is substantial. As the second-largest producer and consumer of tobacco in the world, the complex interplay of economic interests and public health commitments becomes particularly prominent in the Indian context." (Reddy & Gupta, 2-3)

These matters, however, often pale in consideration for individual users when held up against the portrayal of tobacco which saturates print advertising. As the section above points out, one media tactic relating to the marketing of tobacco products is the extension of the image of the sexy, smooth and rugged male. For instance, as Bansal et al. report based on a Mumbai-derived study, "women were not depicted smoking, but were present in cigarette advertisements -- for example, a woman almost always accompanied a man in 'the man with the smooth edge' Four Square campaign.'" (p. 201)