Banning Gutkha: Paternalism in Public Health or Pro-Active Advocacy?

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I have been meaning to write about this matter for a few days now, just never managed to make time for it. There has been a huge hue and cry over the banning of gutkha in certain states of India. While the public health professionals have more or less welcomed the move, the smokeless tobacco industry has hit back. In a series of prominent advertisements put out in the leading dailies, they have tried to highlight the plight of their industry and garner public support and sympathy for their cause.

I am presenting some of these adverts that have caught my eyes:

T1-10

The above advert, a quarter page plea, was published on 1st October, 2011. The following one came up on the 10th of the same month:

10-10

The third one followed a mere 5 days later, on the 15th of October:

image

Ranging from the emotional to the economic, they have run through the gamut of reasons and arguments to augment their case. A slight hint at the nexus between the policy makers and big tobacco, represented by the cigarette industry, has also been made. This harkens back to the early days of the war against smoked tobacco, when the causal relationship between cigarette smoking and lung cancer was not strongly established.

However, I shall stray from the ban-all policy. I mean increasing prices, implementing legislations against public smoking, levying taxes and spreading awareness about the ills of smoking has helped to curb the rampant smoking levels but still, smoking remains a social illness that refuses to go away. A blanket ban is now being tried with the smokeless cousin – the gutkha. It remains to be seen how this works out.

Now, there is always the debate whether one should assume a pro-active, sometimes paternalistic role, while implementing public health measures like banning of gutkha or restrictions on smoking or one should provide everyone with the required information and evidence and then let the people make the decision for themselves. Now I am a big supporter of individual freedom and shared decision making, no matter what the issue. In a paternalistic move to ban gutkha, a number of stakeholders (the producers and the consumers of the product, primarily) were left out of the decision making matrix. This is, in my opinion, not the way to go.

The truth remains that until and unless people are made aware of the extent of damage caused by a particular substance, simply banning it will not solve the problem. It might make it worse as unregulated, fly-by-night scamsters may come up with poorer quality and adulterated products that impose a greater risk on the individual. A similar problem was envisioned with the illegal status of commercial sex workers who were rendered vulnerable to sexually transmitted infections and homosexual people, especially men having sex with men (MSMs) who refused to come out of hiding for fear of legal persecution and hence were left in the shadows.

However, the ground reality remains that in a nation like India, sometimes, it is very difficult to establish such great shared decision making platforms. In a largely agricultural, rural-based population with poor levels of education, behavior change is a difficult task. The thing is, entrenched behaviors, like use of intoxicants is difficult to weed out merely by passive processes like behavior change communication, which, I believe, is, on the best of days, a weak and anemic tool to counter the menace of smoking or drinking or substance abuse in general. Hence, the easier and better (or so perceived) method is cracking the legislatory whip. Banning gutkha.

So while it does not gel with my ideals of perfect public health policy-making, it does seem to be the only one which has the highest probability of working out well. Some may say this was a choice where the least poor alternative got selected.

What is your opinion? Paternalism or power to the people?

Skeptic Oslerphile, Scientist at the Indian Council of Medical Research, National Institute of Cholera and Enteric Diseases. Interests include: Emerging Infections, Public Health, Antimicrobial Resistance, One Health and Zoonoses, Diarrheal Diseases, Medical Education, Medical History, Open Access, Healthcare Social Media and Health2.0. Opinions are my own!

11 Comments

  1. A well timed article. Not many days ago, I was looking at these advertisements, with a fair amount of surprise – the advertiser really has worked hard to get their act straight!

    The individual freedom and shared decision making are good points indeed. Then there is the fear of spurious products making a foray into the grey market. But in India, where true education (not just mere degrees) has evaded the multitudes, you need to impose such blanket bans.

    Let’s hope that this will curb the number of oral cancer cases and the disgusting issue of gutkha-chewing people spitting in every damn corner of the city will be a thing of the past.

    • I am not very hopeful about the abatement of the spitting epidemic. It seems too naive to expect that to go down. However, the blanket ban is only on the sale and not on the production. So it is a weird set up right now. Basically, so many compromises have been made, it makes not much sense in the larger public health context of the nation. One can only hope it helps. Only time shall tell whether such myopic policies can make a significant difference to the outcomes…

  2. I was waiting for you to write on this and wondering why it did not catch yur eye….
    personally I would like to have tobacco in all forms to be declared as an illegal substance and ban its production sale distribution and even consumption. Theseactivities should be considered a criminal offence.. I demand this based on the equity priniciple of law when so many drugs under trial with cures for so many diseases are banned only because they are faintly carcinogenic… On th other hand a strong cacinogen like tobacco is sold for only a few bucks openly across the streets… this is grossly unfair …

    • While I do not disagree with your assessment, all I am saying is that, in the ideal world, people would be informed about the risks/benefits of their actions and then they would be allowed to make an informed decision based on their knowledge. Also, though I do not intend to nit-pick (and I am just playing the Devil’s advocate here, mind you!), I do not think equating medicines and tobacco is fair. Prescription drugs cannot come with a label of “Statutory warning, etc. etc.” and the patient has really no option but to take the drug when he needs to. So the question of personal choice or shared-decision-making is moot. However, when it comes to drugs, booze and ‘baccy, he gets to make his own choice! If he wants to follow the Tagorean philosophy of “ami jeneshune beesh korechhi paan”, then, well, what can you do? 🙂

      • Well then why not allow people to take dangerous prescription drugs which are teratogenic / carcinogenis .. or whatever… if the patient gives an informed consent why make a fuss for drug regulation etc.!!..after all it is a personal choice and shared-decision making… !!
        why should tobacco not be a drug.. provide one scientific rational for it and I will accept that my logic is flawed..
        and yeahh patients do have the option of taking and not taking drugs.. doctors only prescribe.. for chronic diseases a lot of patients are non-complaint..

    • True that. Tobacco has had so much financial clout, that it was almost impossible to isolate it as a restricted substance. But then again, by the same logic, alcohol should also get banned. Where does it stop?

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