title: Implementation of graphic health warning labels on tobacco products in India: the interplay between the cigarette and the bidi industries.
abstract: OBJECTIVE
  To understand the competition between and among tobacco companies and health groups that led to graphical health warning labels (GHWL) on all tobacco products in India.
  
  
  METHODS
  Analysis of internal tobacco industry documents in the Legacy Tobacco Document Library, documents obtained through India's Right to Information Act, and news reports.
  
  
  RESULTS
  Implementation of GHWLs in India reflects a complex interplay between the government and the cigarette and bidi industries, who have shared as well as conflicting interests. Joint lobbying by national-level tobacco companies (that are foreign subsidiaries of multinationals) and local producers of other forms of tobacco blocked GHWLs for decades and delayed the implementation of effective GHWLs after they were mandated in 2007. Tobacco control activists used public interest lawsuits and the Right to Information Act to win government implementation of GHWLs on cigarette, bidi and smokeless tobacco packs in May 2009 and rotating GHWLs in December 2011.
  
  
  CONCLUSIONS
  GHWLs in India illustrate how the presence of bidis and cigarettes in the same market creates a complex regulatory environment. The government imposing tobacco control on multinational cigarette companies led to the enforcement of regulation on local forms of tobacco. As other developing countries with high rates of alternate forms of tobacco use establish and enforce GHWL laws, the tobacco control advocacy community can use pressure on the multinational cigarette industry as an indirect tool to force implementation of regulations on other forms of tobacco.
authors.affiliation: Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Sujatha
authors.initials: S
authors.lastname: Sankaran
authors.affiliation: Faculty of Social Sciences, University of Helsinki, Helsinki, Finland.
authors.forename: Heikki
authors.initials: H
authors.lastname: Hiilamo
authors.affiliation: Department of Medicine, Center for Tobacco Control Research & Education, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Stanton A
authors.initials: SA
authors.lastname: Glantz
mesh_terms: D003906:Developing Countries; D006801:Humans; D007194:India; D007391:International Cooperation; D008119:Lobbying; D011356:Product Labeling / Q000331:legislation & jurisprudence*; D012907:Smoking / Q000331:legislation & jurisprudence*; D019460:Tobacco Industry / Q000331:legislation & jurisprudence*; D062789:Tobacco Products / Q000009:adverse effects*; D014030:Tobacco, Smokeless / Q000009:adverse effects
keywords: Advocacy; Global health; Non-cigarette tobacco products; Packaging and Labelling; Tobacco industry