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Smoke-free initiatives have gained significant momentum since India enacted comprehensive smoke-free legislation in October 2008. The International Union Against Tuberculosis and Lung Disease has actively supported various levels of government, legislators, civil society, and communities across the country to implement smoke-free public places and comply with the law. On World No Tobacco Day 2010, four jurisdictions demonstrated that public places within their jurisdictions were smoke-free. These jurisdictions cover a wide spectrum of demographic and geographic variation and include an entire state. The demonstration of being 'smoke-free' in these jurisdictions was supported by a simple survey that documented compliance with the smoke-free law in the country.
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INT J TUBERC LUNG DIS 15(4):565–566
© 2011 The Union
doi:10.5588/ijtld.10.0372
NOTES FROM THE FIELD
Compliance surveys: an effective tool to validate smoke-free
public places in four jurisdictions in India
P. G. Lal, N. C. Wilson, R. J. Singh
The Union South-East Asia Offi ce, International Union Against Tuberculosis and Lung Disease, New Delhi, India
Correspondence to: Pranay Lal, Tobacco Control, The Union South-East Asia Of ce, International Union Against Tubercu-
losis and Lung Disease, C-6, Qutub Institutional Area, New Delhi 110016, India. Tel: (+91) 11 4605 4400. Fax: (+91) 11
4605 4430. e-mail: plal@theunion.org, msharma@theunion.org
Article submitted 13 June 2010. Final version accepted 9 September 2010.
Smoke-free initiatives have gained signi cant momentum
since India enacted comprehensive smoke-free legislation
in October 2008. The International Union Against Tuber-
culosis and Lung Disease has actively supported various
levels of government, legislators, civil society, and com-
munities across the country to implement smoke-free pub-
lic places and comply with the law. On World No To-
bacco Day 2010, four jurisdictions demonstrated that
public places within their jurisdictions were smoke-free.
These jurisdictions cover a wide spectrum of demographic
and geographic variation and include an entire state. The
demonstration of being ‘smoke-free’ in these jurisdic-
tions was supported by a simple survey that documented
compliance with the smoke-free law in the country.
KEY WORDS: tobacco control; smoke-free; policy and
evidence
THE IMPLEMENTATION of tobacco control law
(Cigarettes and Other Tobacco Products Act, COTPA)
across India has been inadequate and its imple-
mentation variable.1 However, smoke-free initiatives
have gained signi cant momentum since India en-
acted comprehensive smoke-free legislation in Octo-
ber 2008.2 The International Union Against Tuber-
culosis and Lung Disease (The Union) has actively
supported various levels of government, legislators,
civil society, and communities across the country to
implement smoke-free public places and comply with
the law.3 On World No Tobacco Day 2010, four ju-
risdictions demonstrated that public places within
their jurisdictions were ‘smoke-free’. These jurisdic-
tions cover a wide spectrum of demographic and geo-
graphic variation, and include an entire state in the
north-eastern part of the country, Sikkim (with over
0.7 million people), a district in Tamil Nadu with a
mix of rural and u rban population, Vilupuram (~3 mil-
lion people), and the two cities of Shimla in Himachal
Pradesh (~0.5 million people), with a signi cant tour-
ist population, and Coimbatore (~1.6 million peo-
ple), also in Tamil Nadu, with a signi cant industrial
and labour population (Figure). The demonstration
of ‘smoke free’ in these jurisdictions was supported
by a simple survey that documented compliance with
the smoke-free law in the country.
METHODOLOGY
The smoke-free law requires compliance with a num-
ber of measures, and the presence/absence of these
was used as criteria for determining the level of com-
pliance. The survey criteria as prescribed by the law
include simple ‘measures’ such as the presence of sig-
nage and adherence to speci cations of the observed
signage, adherence to speci cations for designated
smoking areas, and the presence of smoking aids such
as ashtrays, lighters and matchboxes in buildings.
The survey also incorporated observation of active
smoking and signs of smoking in the recent past (e.g.,
the presence of cigarette butts or smell of tobacco
smoke) as indicators of non-compliance of a site. The
use of air quality measurement devices requires train-
ing and investment, and as these are not easily avail-
able, they were not deployed for these surveys.
Jurisdictions were studied for the dispersion and
number and density of public places, based on admin-
istrative divisions or units (such as wards in munici-
pal councils, blocks in districts, etc.). Based on these
criteria, representative sites were identi ed within each
unit. Simple randomised sampling was used to iden-
tify at least 25% of each type of public place enu-
merated within the jurisdictions, which were then
systematically visited, and a pre-tested questionnaire
was administered to the of cer in charge/administrator
of the identi ed site. Prominent public places such as
malls, bazaars, busy streets and large government com-
plexes were carefully included.
Prior to the survey, The Union worked closely with
the local authority in the jurisdiction and at least one
identi ed non-government organisation partner from
the civil society in building the capacity of designated
enforcers in each of these jurisdictions, developing an
enforcement strategy, ensuring that all closed public
places had signage identifying the designated enforcer
and systematic monitoring of compliance and track-
ing of penalties levied. The surveys were coordinated
SUMMARY
566 The International Journal of Tuberculosis and Lung Disease
through independent agencies with experience in
similar research identi ed by The Union with the con-
sent of the local authority.4 A survey questionnaire
was designed to cover the  ve criteria mentioned
above. The questionnaire was pre-tested in Ranchi,
where the  rst smoke-free compliance survey was
conducted in May 2009. The  ndings obtained from
the survey were designed with the intention of in-
forming policy makers and decision makers of the
progress towards a smoke-free environment. It also
aimed at garnering public support by informing the
public through media reports. The survey question-
naire was a spot observation administered by volun-
teers who had received training on recording and ana-
lysing data on these  ve criteria. The total cost of a
survey was between US$4500 and US$5000 per mil-
lion population surveyed.
RESULTS
Active smoking was not observed in more than 95%
of all public places visited during the survey. Well
over 90% of all public places in Vilupuram District,
Coimbatore City and the State of Sikkim had clear
signage prohibiting smoking that conformed to the
requirements of the law. Shimla had a slightly lower
proportion of signage conforming to law, at 80%.
The air in these public places was free of the smell of
tobacco smoke in most public places and very little
tobacco-related litter (cigarette butts, bidi ends) was
observed in these jurisdictions (Table).
CONCLUSION
Compliance surveys are a simple and cost-effective
tool for validating progress in the enforcement and
implementation of smoke-free public places. Positive
results reinforce political and administrative leader-
ship and commitment to the health of the commu-
nity, and provide an excellent lever to the media for
positive reporting around tobacco control. Strategic
communication of these results increases public aware-
ness and support in protecting individuals and their
families from the harmful effects of second-hand smoke.
There has also been considerable interest from neigh-
bouring jurisdictions to emulate this model and to
also declare their jurisdiction smoke free. It might be
helpful to disaggregate compliance data by type of
public place to better understand those areas that re-
quire stronger enforcement.
Acknowledgements
In Shimla, P K Verma, Economic Development Trust, New Delhi;
in Sikkim, C Khewa, Deputy Director, Planning, Monitoring and
Evaluation Wing, Department of Health, Government of Sikkim;
in Coimbatore and Vilupuram, C Alexander, Mary Anne Charity
Trust, Chennai. The assistance of M Sharma of the Union South-
East Asia Of ce in compiling the information is acknowledged.
References
1 John R M, Glantz S A. It is time to make smoke-free environ-
ments work in India. [Editorial]. Indian J Med Res 2007; 125:
599–603.
2 Ministry of Health and Family Welfare, Government of India.
The Gazette of India, May 30, 2008. GSR 417 (E). New Delhi,
India: 2008. http://mohfw.nic.in/smoke%20free%20rules.pdf Ac-
cessed June 2010.
3 International Union Against Tuberculosis and Lung Disease. Ad-
vancing towards a smoke-free world, country by country, city by
city. Paris, France: The Union, 2010. http://www.theunion.org/
news/advancing-towards-a-smokefree-world-country-by-country-
city-by-city.html Accessed February 2011.
4 International Union Against Tuberculosis and Lung Disease.
Health solutions for the poor. Paris, France: The Union. http://
www.theunion.org/images/stories/download/brochure/FINAL_
9Nov_Union%20brochure.pdf Accessed June 2010.
Figure Recent smoke-free jurisdictions in India.
Table Measure of compliance with smoke-free criteria in four jurisdictions
Criteria and indicator Coimbatore
n (%) Vilupuram
n (%) Sikkim
n (%) Shimla
n (%)
Type (population) Major industrial city
(~1.6 million) Semi-urban district
(~3 million) State (0.7 million) Capital city and
hill station
(~0.5 million)
Public places surveyed 110 105 1056 187
Public places observed no active smoking 110 (100) 105 (100) 1035 (98) 181 (97)
Display of signage 94 (85) 102 (97) 1003 (95) 153 (82)
Places where no tobacco smoke was detected 102 (93) 95 (91) 1035 (98) 165 (87)
Presence of articles that facilitate smoking 103 (94) 99 (94) 1024 (97) 166 (88)
Presence of cigarette/bidi butts 97 (88) 90 (86) 1035 (98) 172 (91)
India’s smoke-free efforts are gaining momentum i
Des initiatives « sans fumée » ont connu une croissance
signi cative depuis que l’Inde a mis en œuvre une légis-
lation complète « sans fumée » en octobre 2008. L’Union
Internationale contre la Tuberculose et les Maladies
Respiratoires a soutenu activement les différents niveaux
de gouvernement, les législateurs, la société civile et les
collectivités au sein du pays pour arriver à réaliser des
lieux publics « sans fumée » et à respecter la loi. Lors de
la Journée Mondiale Sans Tabac 2010, quatre juridic-
tions ont démontré que les lieux publics au sein de leurs
juridictions étaient « sans fumée ». Ces juridictions cou-
vrent un large spectre de variations démogra phiques et
démographiques et comportent un état entier. La dé-
monstration du caractère « sans fumée » de ces juridic-
tions a été con rmée par une simple enquête qui a mis
en évidence dans le pays la compliance à l’égard de la loi
« sans fumée ».
Las iniciativas en favor de los ambientes sin humo han
tomado fuerza en India desde la promulgación de una
legislación completa sobre ambientes sin humo de ta-
baco en octubre del 2008. La Unión Internacional Con-
tra la Tuberculosis y las Enfermadades Respiratorias ha
prestado un respaldo activo en diferentes niveles a los
legisladores gubernamentales, la sociedad civil y las comu-
nidades en todo el país para la puesta en ejecución y el
cumplimiento de la legislación sobre los espacios públi-
cos sin humo de cigarrillo. En el Día sin Tabaco 2010,
cuatro jurisdicciones demostraron que en su zona de in-
uencia los espacios públicos eran ‘sin humo de cigar-
rillo’. Estas jurisdicciones cubren un amplio espectro de
características demográ cas y geográ cas y abar can un
estado completo. La demostración del carácter ‘sin humo
de cigarrillo’ en estos territorios fue respaldada por una
encuesta sencilla que documentó el cum plimiento de la
ley de ‘espacios sin humo’ en el país.
RÉSUMÉ
RESUMEN
... There are guidelines to achieve and maintain high compliance of smoke-free law, which recommend the involvement of local administration and other stakeholders including non government organizations (NGOs) but they are rarely practiced (WHO, 2005;Lal, Wilson, & Singh, 2011;Goel, Ravindra, Singh, & Sharma, 2014;Hopkins, 2011). Against this background, current study assesses the impact of multi-stakeholder approach to achieve high compliance of a tobacco control programme. ...
... Compliance studies across the globe have shown good compliance to tobacco smoke-free legislation (Chapman, Borland, & Lal, 2001;Weber, Bagwell, Fielding, & Glantz, 2003;Wilson, Edwards, Maher, Näthe, & Jalali, 2007;Yong et al., 2010;Blanco-Marquizo et al., 2010). The findings of the current study are similar to other studies where 82%-100% of public places were found compliant with the tobacco smoke-free law in different jurisdictions of India (Lal et al., 2011;Goel et al., 2014). However, in contrast, Reddy et al. (2013) observed poor compliance (36%) in terms of active smoking. ...
... However, in contrast, Reddy et al. (2013) observed poor compliance (36%) in terms of active smoking. The current study showed high compliance at vulnerable places like transit points and hotels/bars (>90%) in contrast to other studies which had compliance as low as 33%, probably due to the intensive awareness activities and penalty drives in those locations (Lal et al., 2011;Barnoya, Montano, & Acien, 2007). ...
... [7] The smoke-free model was replicated in all 12 districts in the state and repeated compliance assessment studies were conducted [ Table 1]. [8,9] The enforcement was further strengthened in all the districts and based on the compliance of the smoke-free rules the International Journal of Noncommunicable Diseases / Volume 4 / Issue 1 / January-March 2019 entire state was declared as smoke-free in 2013. Huge media coverage, awareness generation, and enforcement drives motivated the residents of Tashijong village with a population of about 1000 in Kangra District to make their village Tobacco Free in 2010. ...
... Table 1 shows the results of the periodic compliance assessment of the smoke-free policies in the state. [8,9] P-protect people from tobacco smoke After achieving smoke-free city Shimla in 2010 Himachal became the first evidence-based smoke-Free state among large states in India in 2013. To protect people from tobacco 109181 violators has been panelized and UDS 197225 has been collected as fine for financing tobacco control since 2010 [ Figure 1]. ...
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... However, the legislation requires monitoring for its effective implementation in order to ensure whether legal provisions are being followed, so that decisions can be used for midcourse correction. 1 2 Since the enactment of COTPA 2003, studies have been conducted in India to measure its compliance. [3][4][5][6] However, most of these studies have been conducted in a small number of public places or cover a specific geographical region, thus are not representative. Further, these surveys do not measure the association among multiple compliance indicators and smoking in public places. ...
... In previous studies wherein compliance monitoring to smoke-free law in four jurisdictions of India-Sikkim state, Vilupuram district and Coimbatore city in Tamil Nadu and Shimla city in Himachal Pradesh-was assessed using a similar study tool reported compliance rates varying from 82% to 100%. 3 Another study by Kumar et al, wherein compliance surveys in 38 jurisdictions across India were recorded, reported that 51% of the sites demonstrated full compliance with smoke-free law. 4 In our study, active smoking was found in just 2% of the sampled public places. A previous study by Goel et al in one of the districts of the state of Punjab in the year 2010 had observed that people at 6% of the public places were found actively smoking. ...
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... On World No Tobacco Day 2010, four jurisdictions demonstrated that public places within their jurisdictions were "smoke-free." [3] Tobacco use is one of the most important preventable causes of morbidity and mortality in India. It is essential to study the existent knowledge about tobacco use and cigarette smoking to formulate the intervention for addressing this problem in the community. ...
... The air in these public places was free of the smell of tobacco smoke in most public places and very little tobacco-related litter (cigarette butts, bidi ends) was observed in these jurisdictions. [3] In this study, education was significantly associated with better knowledge of the fact that smoking is harmful and is an economic burden. Higher proportion of literate study subjects was aware of the fact that smoking is banned in public places and wanted the government to take hard actions to control the smoking epidemic. ...
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... In the present study, out of 105 sites studied, there was display board only at 45 sites (42.9%) and only 15.2% of the total displays matched recommended specifications. and these results were almost similar to study by Lal et al., [20] in four Indian jurisdictions and Rijhwani et al., [19] . In contrast, reports by Tripathy et al., [21] and Sharma N, et al., [22] in another health-care institution observed the display of signage compliance to be 28%. ...
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... 7 There is complicated legislation addressing the various types of tobacco use, enforced to different extents at various administrative levels across the country. 59 Legislation India's anti-tobacco legislation was first passed at the national level in 1975, the Cigarettes Act 21 ; this was largely limited to statutory warning 'Cigarette Smoking is Injurious to Health' to be displayed on cigarette packs and advertisements 60,61 but it did not include non-cigarettes 22 and proved to be inefficient. 21 The Prevention and Control of Pollution Act of 1981 considered smoking as air pollutant and The Motor Vehicles Act 1988 made smoking illegal in public vehicle. ...
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... 28,29 In India too, Sikkim, Villupuram district, Coimbatore district, Shimla city in Himachal Pradesh, and Punjab have been declared smoke-free following the results of individual compliance studies. [10][11][12] However, a few studies conducted in Northern and Southern part of India have found poor compliance to Section 4 of COTPA terms of active smoking. 30 A total of 97% public places selected in Chandigarh for the study showed compliance rate above 50% toward Section 4 COTPA. ...
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Objectives: In Turkey, smoking has been banned in hospitality establishments since July 2009. The objective of this study was to determine noncompliance to the smoke-free law and its change in 2 consecutive years in enclosed spaces of hospitality venues and also to evaluate the factors associated with noncompliance. Study design: This is an observational study. Methods: Hospitality venues in Istanbul were visited, and data were collected through direct observation and interviews. Observation of smoking, cigarette butts or existence of ashtrays were defined as noncompliance. The survey was repeated in 2 consecutive years; the venues were visited both in 2013 and 2014. Logistic regression was used to evaluate factors associated with noncompliance. Results: In 2013, 450 establishments were visited, and in the next year, 367 (81.6%) were revisited. Noncompliance for 2013 and 2014 were 49.0% and 29.7%, respectively. The highest violation was observed in bars and traditional coffeehouses. There was a significant decrease in noncompliance from 2013 to 2014 among restaurants and cafés, while such a change was not observed among bars and traditional coffeehouses. In the multivariate analysis, venues other than restaurants, venues that did not have no-smoking signs and venues which had been issued fines previously had increased probability of noncompliance. Conclusions: While compliance to smoke-free law had increased significantly within 1 year, almost one third of the venues were still violating the law in 2014. The venues which were issued fines continued to violate the law. There is a need to strengthen enforcement efforts and revise the methods of enforcement and penalties in hospitality establishments.