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Summary
India has made signicant progress in tobacco control in the past decade, leading to a
decrease in overall consumption. However, tobacco-related illnesses and deaths continue to
aect Indians disproportionately across dierent states due to various factors. These include
socioeconomic, cultural, commercial, political, and regional disparities that have hindered
the eective implementation of tobacco control measures. To tackle this issue, we conducted
a multi-site study using interviews, eld observations, and stakeholder consultations to
identify the barriers and facilitators of tobacco control implementation. The insights from
this research can be utilized by policymakers, program managers, and implementers to
strengthen tobacco prevention and control eorts at the national, state, and district levels.
Background
Tobacco use is the leading preventable cause of disease and death worldwide and kills over
1.3 million adults in India each year.[1] According to the 2nd round of the Global Adult Tobacco
Survey (GATS), approximately 28.6% (267 million) of Indian adults use tobacco.[2] To combat
this, India introduced the Cigarettes and Other Tobacco Products Act (COTPA) in 2003, which
prohibits public smoking, advertising, tobacco sales to minors and near educational
institutions, and mandates pictorial health warnings.[3] The Government also initiated the
National Tobacco Control Programme (NTCP) in 2007-08 to support COTPA implementation.
This study sought to explore the variations in tobacco control outcomes among Indian states,
identify factors inuencing successes, and uncover barriers to implementation.[4]
Methods
h
Policy Brief
Evaluation of Tobacco Control Policy Implementation
in India - Anushthana
Key Findings
There is a signicant association
between the implementation of policies
and prevalence of tobacco use in India.
People who encountered “No Smoking”
signs exhibited a decreased likelihood
of consuming tobacco.
When individuals were exposed to
second-hand smoke, their chances of
tobacco use increased.
Tobacco product advertisements were
linked to increased likelihood of
tobacco use, including both smokeless
and smoked tobacco consumption.
Awareness of the dangers of using
smoked and smokeless tobacco products
was related to a lower likelihood of
using tobacco products.
Diversity of implementation across
Indian states was observed with nine
states showing an improvement in all
four proxy indicators of implementation
between GATS 1 and GATS 2.
Five strategies identied were
Awareness, enforcement, intersectoral
coordination, review systems and
tobacco industry interference in a
common context with limited nancial
and human resources and lack of
political will.
Five mechanisms identied were
collective action, felt/perceived
accountability, individual motivation,
fear, and prioritization leading to diverse
implementation outcomes.
Project Milestones
Inside Implementation
Conducted eight webinar episodes
covering youth access, tobacco
advertising and promotion, public
smoking, role of CSOs and academia,
and leadership in tobacco control.
Conferences
Participated and presented papers
(oral/posters) in 13 public
health/tobacco control conferences at
the national, regional, and international
levels – virtual and in-person.
Workshops
Organized 4 and participated in 9
workshops (virtual and in-person) on
public health, research methods, and
tobacco control.
Stakeholder Engagement
Organized and facilitated 3 stakeholder
engagement activities; engaged with 90
stakeholders across 20 Indian states.
Project Milestones
Research outputs
Published 10 manuscripts in high-
impact public health journals, co-
wrote 2 book chapters, 2 blogs, and 5
project reports. 5 outputs in-review
and 5 papers in preparation.
Capacity Building Courses
Completed 15 courses covering public
and global health, realist evaluation
methods, health policy and systems
research, governance, ethics and conict
of interest, industry interference, medical
anthropology, Climate change and
planetary health.
Presentations
Disseminated research methods and
ndings at internal and external fora
including seminars, journal clubs,
and invited talks with public health
institutes, dental colleges,
universities, and state-level ocials
Teaching engagement and Media
coverage
Invited to teach on tobacco control,
public and urban health, implementation
research, and tobacco industry
interference.
Project activities covered in 6 media
outlets including local newspapers and
funder spotlight.
Factors inuencing implementation of tobacco control policies in low-and
middle-income countries and in India.[5]
FACILITATORS
BARRIERS
Prioritization of tobacco control
Sustained, consistent and incremental eorts lead to long term
population level changes.
Normalization
Parents think it is acceptable to send children to buy tobacco
and vendors not asking for age proof in shops make it dicult
to enforce tobacco control.
Adequate training and capacity building
Training ocials would empower them to counter the tobacco
industry, engage civil society, create enforcement plans, accept
their role, raise funding, improve sustainability, and become
champions for tobacco control.
Low commitment and priority
Ocials’ limited commitment and competing health priorities
cause delays in implementing tobacco control measures.
Knowledge sharing
Platforms to exchange learnings from diverse contexts will
help implementers anticipate and address bottlenecks.
Stigma
Mental health stigma prevents people from using cessation
services located in the same setting.
Empowerment
Community-based organizations with the help of task forces
and mobile courts led to timely enforcement in certain
settings.
Fear / Deterrence
Ocials are hesitant to enforce smoke-free laws due to
concerns about public opposition, litigations, and resistance
from the hospitality sector. Low nes do not deter people
making enforcement less eective.
Citizen participation
When the general public engage and accept the program
implementation is facilitated in a sustainable manner.
Legitimacy crisis
Ocials are unable to enforce the law unless their role is
legitimized through notications (government circulars or
orders).
Nudge
Communicating shared values by a central authority nudged
government departments to align priorities, develop a group
identity and create a positive working environment
Bribery
Enforcement was negatively impacted by ocials'
susceptibility to bribery
Advocacy
Civil society organizations’ advocacy exposed tobacco industry
investments in the government. Media advocacy is also crucial
in exposing tobacco industry interference and catalyzing
action.
Mistrust
Mistrust due to siloed organizational cultures causes
misunderstandings, rivalry, confusion, and dissatisfaction
among sta, leading to demotivation and retention issues.
Tobacco industry tactics (Manipulation, Persuasion,
Intimidation)
Tobacco industries manipulate government and public
opinion by discrediting science, preempting actions and
spreading misinformation. The industry directly and
indirectly persuades the public and policymakers by liaising
with allied industries to dilute and delay legislation. They
intimidate governments with large and continuous legal
battles to align policies with their interests and stall policy
implementation.
Recommendations
• Initiate intersectoral coordination during the policy formulation process and continue
throughout the implementation phase to ensure departmental buy-in.
• Identify and counter tobacco industry interference to tackle implementation barriers.
• Encourage community representatives to participate in COTPA implementation to
foster group action.
• Clarify accountability pathways and strengthen supportive supervision at district/sub-
district levels to nudge accountability from ocials and timely action.
• Integrate practices for appreciating performance within existing systems.
• Prioritize monitoring systems to record implementation progress which can be utilized
as valuable data points for future research.
• Undertake long-term site-specic research that captures the political economy and
produces contextual data to be incorporated into the policy-making process.
• Develop and validate tools and indicators designed to measure implementation
outcomes
• Amend the law to keep it relevant to the current times (increase penalties, clarify
clauses on indirect or surrogate advertisements, tobacco use portrayal in Over the Top
(OTT) platforms that are routinely violated, allocate more human and nancial
resources, strengthen policies at the state/national level to prevent tobacco industry
interference in tobacco control, and update the COTPA law enforcers manual.
References
1. World Health Organization RO for SEA. WHO
Factsheet. 2018 [Internet] [cited 2023 Jul
5];Available from:
http://www.searo.who.int/entity/noncommunicable
_diseases/
2. GATS-2 Global Adult Tobacco Survey FACT SHEET
INDIA 2016-17.
3. India | Tobacco Control Laws [Internet]. [cited 2023
Jul 5];Available from:
https://www.tobaccocontrollaws.org/legislation/ind
ia/summary
4. Hebbar PB, Dsouza V, Bhojani U, Van Schayck OCP,
Babu GR, Nagelhout G. Implementation research
for taking tobacco control policies to scale in India:
a realist evaluation study protocol. BMJ Open
[Internet] 2021 [cited 2023 Jul 5];11(5). Available
from: https://pubmed.ncbi.nlm.nih.gov/34006563/
5. Hebbar PB, Dsouza V, Bhojani U, Prashanth NS, Van
Schayck OCP, Babu GR, et al. How do tobacco
control policies work in low-income and middle-
income countries? A realist synthesis. BMJ Glob
Health [Internet] 2022 [cited 2023 Jul 5];7(11).
Available from:
https://pubmed.ncbi.nlm.nih.gov/36351683/
This research was funded by DBT/Wellcome Trust India
Alliance awarded to Dr. Pragati Hebbar
[IA/CPHE/17/1/503338]