Are we doing enough to protect right to clean air ?

Bobby Ramakant *

Despite overwhelming evidence from around the world on positive health benefits of enforcing smoke-free policies, countries in South and South-East Asia are yet to achieve desired enforcement of smoke-free laws. More political will and strategic programming are key elements of good smoke-free programmes. At the recently concluded 4th Union Asia Pacific Region Conference on Lung Health (APRC 2013) in Hanoi, Viet Nam, countries were appealed to strictly enforce smoke-free laws on the ground and maximize potential public health outcomes.

Incidentally it is the smoke-free laws that have been best implemented around the world out of the broad range of evidence-based tobacco control measures countries can take. This was stated clearly in the latest Global Progress Report on implementation of the WHO Framework Convention on Tobacco Control (WHO FCTC) 2012.

According to this 2012 Global Progress Report: The article attracting the highest reported implementation rate, with more than 65% average implementation rates across the 126 Parties [countries or regions such as EU that have ratified the treaty] analysed" is WHO FCTC Article 8 (Protection from exposure to tobacco smoke). Perhaps we have a much longer way in tobacco control yet because implementation of smoke-free laws on the ground is certainly unsatisfactory in most settings. The Global Progress Report 2012 itself adds: "Majority of Parties still fall short of complying with the timeline recommended by the guidelines for implementation of [WHO FCTC] Article 8, suggesting that covering all types of public places with smoke-free measures is often difficult."

At APRC 2013, a session focussed on experience sharing between those who were instrumental in implementing smoke-free laws. Dr Rana J Singh, Senior Technical Advisor (tobacco control) at the South-East Asian office of the International Union Against Tuberculosis and Lung Disease (The Union) said that India not only has a comprehensive domestic tobacco control law but also had ratified the global tobacco treaty (WHO FCTC) early-on in February 2004. Both the Indian domestic tobacco control law and the WHO FCTC have strong salient features on smoke-free policies. India had declared the country smoke-free on 2nd October 2008. But in terms of implementation despite major advancements, much remains to be desired.

The Section 4 of India's domestic tobacco control law (formally called the Cigarette and Other Tobacco Products Act 2003) refers to ban on smoking in public places. The Rules on how smoking will be banned in public places across the country from 2nd October 2008 were notified in May 2008.

It is obvious who will benefit from weak or poor implementation of smoke-free laws: the tobacco industry. When Indian Health and Family Welfare Ministry was asked by an applicant under Right To Information (RTI) Act, 2005, in a case hearing in Central Information Commission in November 2008, that why tobacco control laws are not being strictly enforced, the ministry official replied that tobacco industry interference and pressure was not letting it enforce tobacco control laws in the country. Tobacco industry interference in public health policy is well documented. But WHO FCTC, the global tobacco treaty, has a unique set of guidelines, formally called WHO FCTC Article 5.3, that require all the Parties to "protect these [public health] policies from commercial and other vested interests of the tobacco industry in accordance with national law".

So it is high time that awareness of benefits of smoke-free laws and breathing in cleaner air are acknowledged widely and the movement to enforce them is built grounds-up.

Dr Rana J Singh said to Citizen News Service – CNS that smoke-free laws emerged as "the most acceptable and popular tobacco control policy intervention to implement in India."

Dr Rana J Singh enumerated the districts and states that have prepared and declared themselves smoke-free to reinforce the national law which had made entire country smoke-free on 2nd October 2008. He also discussed at length various mechanisms to build capacity of different stakeholders, monitor and evaluate progress and improve compliance in different public and private settings.

Dr Rana J Singh said that "success of tobacco control interventions and their sustainability depends on: capacity created, political and administrative support to tobacco control, partnerships established, diffusion of good practices among government and civil society at the grassroots level, and creation of administrative systems that sustain tobacco control within jurisdictions." In addition to these measures highlighted by Dr Singh, one must always monitor tobacco industry and take stringent measures as per WHO FCTC Article 5.3 to stop industry interference in health policy.

INNOVATIVE APPROACH

An innovative approach in enforcing smoke-free laws was presented by Dr Tara Singh Bam, Technical Adviser, of The Union (Indonesia). A Mayors' alliance was established to accelerate enforcement of smoke-free laws in Indonesia.

This innovative approach to increase political will and commitment in Indonesia becomes all the more important when we realize that the country is yet to ratify the WHO FCTC – the global tobacco treaty. Perhaps the tobacco industry's presence in the country weighs heavy on public health. According to another report published in May 2012 in Jakarta Post, "Indonesia currently has 57 million smokers, equivalent to 36 per cent of its total population. It is a big market for the tobacco industry. Despite the increasing number of campaigns on the hazards of smoking, according to a survey, cigarettes are only second to rice in terms of priority spending among poor families."

Despite tobacco industry's attempts to thwart progress on public health, different parts of the country have enacted local smoke-free laws in the past years. For example, Bogor, came up with its local 100% smoke-free law in 2009 and enforced it in 2010; Palembang had its local 100% smoke-free law passed in 2009 and enforced in 2010; and Jakarta passed 'Implementation of regulation of the clean air act 2005' which was revised and ensured 100% smoke-free indoor policies in 2010.

Mayors' Alliance of tobacco control was an outcome of consolidation of sub-national smoke-free efforts in Bogor, Palembang and Jakarta. Since May 2010 a discussion was held with Ministry of Health and tobacco control network as well as Mayors of Palembang, Bogor and Governor of Jakarta to consolidate sub-national smoke-free efforts. By November 2010, Ministry of Home Affairs had agreed to establish a Mayors' Alliance and on 25th January 2011, the Alliance was formally established. Initially the alliance was joined by the 12 Mayors, Governor of Jakarta and Minister of Health.

This Mayors' Alliance had the mandate to develop and implement local regulations for 100% smoke-free public places and workplaces, and public transport; to expand its membership to other cities and districts; to reciprocate the support of the Ministry of Health by backing its initiatives to consolidate tobacco control implementation; and to make national policy advocacy for FCTC ratification and other tobacco control laws and regulation.

Dr Bam discussed the activities of Mayors' Alliance since then which includes: building local evidences and policy toolkits, conducting mayor-talk-mayor meetings, sustained media engagement around tobacco control, and most importantly among other measures, countering tobacco industry interference.

Dr Bam said as an outcome of Mayors' Alliance, five cities have banned tobacco advertisements and efforts are on in similar direction in other cities as well. A ministerial decree to guide sub-national governments on smoke-free policy establishment and implementation was released in February 2011 which was another outcome of the Mayors' Alliance policy advocacy efforts.

Another game changing outcome of Mayors' Alliance and its sustained political advocacy for stronger tobacco control domestic laws and FCTC ratification was that the President of Indonesia signed the tobacco control domestic law on 24 December 2012. President Susilo Bambang Yudhoyono had signed the Government Regulation No. 109/2013, "Protection of Materials Containing Form of Addictive Substances Tobacco Products for Health" which came into effect since then (24 December 2012). This regulation requires cigarette producers to comply with this law within 18 months from 24 December 2012, and include government approved health warnings in writing and pictorial graphic health warnings at the front and back of the cigarette packets, among other provisions.

"Political commitment is a key" rightly said Dr Bam. "Mayors' Alliance has built a political awareness among sub-national leaders that tobacco control saves lives and save money. So far 59 Mayors have joined this Alliance" said Dr Bam.

There are some tips to improve implementation of smoke-free laws in the Global Progress Report 2012 too. According to this report, efforts to achieve full implementation of Article 8 would benefit from: the adoption of measures to cover all types of public places, without exception; the introduction of binding and enforceable measures instead of non-binding voluntary agreements; and the promotion of smoke-free policies through public information and awareness-raising campaigns.