Upendra Bhojani’s research while affiliated with All India Institute of Hygiene and Public Health and other places

Introduction The tobacco industry (TI), driven by profit motives, consistently conceals health risks through deceptive strategies, notably in countries like India. These tactics create vulnerabilities that hinder effective tobacco control measures and enable the TI to exploit legal gaps. Understanding these TI strategies is essential for policymakers to take appropriate preventive and corrective measures in order to limit tobacco industry interference (TII) in policy-making. The study aims at understanding the trend of TII in India between 2019 and 2023. Methodology The secondary data from the Global Tobacco Industry Interference report, consisting of seven major domains of the TII index, viz. policy participation, corporate social responsibility (CSR) activities, industry benefits, unnecessary interaction, transparency, conflict of interest, and preventive measures, were retrieved. A composite score was obtained after adding scores of different domains, for each year. Results The findings of the study demonstrated an initial improvement in India’s implementation of WHO FCTC Article 5.3, as evidenced by a decreasing score between 2019 and 2021. However, this trend halted in 2023, with data showing a slight increase in the score. When compared with other Asian countries, India shows marginal improvement in score than Cambodia, China, Indonesia, Lao PDR, Malaysia, Myanmar, Nepal, Philippines, Thailand, and South Korea. Some of the countries in the region, including India, Pakistan, Bangladesh, Sri Lanka, Myanmar, Brunei, China, and Vietnam experienced a decline in TII. Discussion There has been a rise in CSR activities, forms of unnecessary interactions of TII with policymakers, and participation in policy development; however, improvements are observed in providing benefits to the TI, conflict of interest, and preventive measures. In order to fortify the regulatory framework, it is imperative to create awareness among stakeholders on conflict of interest, denormalize corporate social responsibility (CSR) initiatives by the TI, provision of a watchdog for TII in the country and “whole of government” approach in implementation of FCTC Article 5.3.

Introduction The tobacco industry intends to ensure continuing marketing of tobacco products by influencing and interfering in tobacco control policies. This paper assessed trends of tobacco industry interference (TII), the level of implementation, and the government’s response to enforcing Article 5.3 guidelines in India to safeguard tobacco control efforts from commercial and other vested interests of the tobacco industry. Methods We conducted a descriptive comparative analysis of four consecutive India TII Indexes (January 2018-December 2021) based on the seven key 5.3 recommendations and twenty indicators to capture (i) the Level of Industry Participation, (ii) Corporate Social Responsibility (CSR) Activities, (iii) Benefits to the Tobacco Industry, (iv) Forms of Unnecessary Interactions, (v) Transparency, (vi) Conflict of Interest, and (vii) Preventive Measures. The Southeast Asia Tobacco Control Alliance’s (SEATCA) TII Index was used to undertake this assessment. Results The comparative analysis showed that the overall score of the India TII Indexes over the years decreased from 72 (2018) to 57 (2021). Improvements were shown over the years in adherence to Article 5.3 for limiting unnecessary interactions with the tobacco industry, avoiding conflicts of interest, and having preventive measures. However, major gaps were observed in restricting industry participation, regulating their so-called CSR, providing benefits to the industry in the form of incentives, exemptions, and maintaining transparency. Conclusion The study provides the status of implementing Article 5.3 and its guidelines in India. Given the gaps in the existing measures, India needs to comprehensively adopt Article 5.3 guidelinesin all states and union territories adopting whole-of-government approach. There is an urgent need to establish an observatory for periodic compilation of the TII indexes to monitor the tobacco industry and report violations at the national and sub-national levels.

There is a growing interest in studying and unpacking implementation of policies and programmes as it provides an opportunity to reduce the policy translation time lag taken for research findings to translate to policies and get implemented and understand why policies may fail. Realist evaluation is a theory-driven approach that embraces complexity and helps to identify the mechanisms generating the observed policy outcomes in given context. We aimed to study facilitators and barriers while implementing the Cigarettes and Other Tobacco Products Act, 2003 (COTPA) a comprehensive national tobacco control policy, and the National Tobacco Control Programme (NTCP), 2008 using realist evaluation. We developed an initial program theory (IPT) based on a realist literature review of tobacco control policies in Low- and Middle-Income Countries (LMICs). Three diverse states —Kerala, West Bengal, and Arunachal Pradesh— with varying degree of implementation of tobacco control law and program were chosen as case studies. Within the three selected states, we conducted in-depth interviews with 48 state and district-level stakeholders and undertook non-participant observations to refine the IPT. Following this, we organized two regional consultations covering stakeholders from 20 Indian states for a second iteration to further refine the program theory. A total of 300 Intervention-Context-Actor-Mechanism-Outcome (ICAMO) configurations were developed from the interview data, which were later synthesized into state-specific narrative program theories for Kerala, West Bengal and Arunachal Pradesh. We identified five mechanisms: collective action, felt accountability, individual motivation, fear, and prioritization that were (or were not) triggered leading to diverse implementation outcomes. We identified facilitators and barriers to implementing the COTPA and the NTCP, which have important research and practical implications for furthering the implementation of these policies as well as implementation research in India. In the future, researchers could build on the refined program theory proposed in this study to develop a middle-range theory to explain tobacco control policy implementation in India and other LMICs.

Background: Children of parents who use tobacco and alcohol are at increased risk for a variety of adverse outcomes, including emotional, social, behavioral, and cognitive problems. Parental smoking and alcohol use can also lead to nutrient deficiencies in children, as well as poor birth outcomes such as restricted growth. Among adivasi communities, disproportionately higher malnutrition, and increasing substance use could be contributing to persistent and inter-generational developmental disadvantages. However, there is limited research on the long-term health implications of parental substance use on children after birth. The proposed study will examine the effects of parental substance use on child growth and developmental outcomes in adivasi communities in southern Karnataka. Methods: The research design involves a longitudinal cohort study, in which lactating/postnatal women and their partners along with other household members are recruited. This is the first large-scale adivasi birth cohort study to examine the effects of substance use among parents and other family members after delivery on infant growth and developmental indices. Information on the household socio-demographics, wealth index, diet, delivery information, depression, social support, morbidity status, substance use details, and child development with anthropometric details in baseline and follow-up visits shall be recorded. The study targets to recruit a sample size of 650 newborns and family members. The primary outcome is child growth parameters whereas the secondary outcome is early childhood development in terms of gross motor, fine motor, language, and social domain. The total duration of the study is five years (2021-2026). Discussion: The study offers a comprehensive examination of parental substance use and its effect on child development in an adivasi community in south India. This will help researchers identify significant risk thresholds and better understand the consequences of parental substance use on infant development utilizing the prospective adivasi family cohort. The study will also address the long-term under-representation and neglect of such studies among adivasi populations and enable a long-term research engagement with the community. The study could inform policy and practice related to addressing substance use disorders and their effects on children. The public health implications include prioritizing the issues of parental substance use, and identification of early interventions to prevent adverse health outcomes in children.

Background Tobacco use and the associated health burden is a cause of concern in India and globally. Despite several tobacco control policies in place, their sub-optimal and variable implementation across Indian states has remained a concern. Studies evaluating the real-world implementation of policies such as Cigarettes and Other Tobacco Products (COTPA) or National Tobacco Control Program (NTCP) in India and its association with reductions in tobacco use are limited. In this paper, we analyse data from a nationally representative survey to examine how policy implementation is associated with the tobacco use prevalence in India. Methods We analysed data from the Global Adult Tobacco Survey (GATS 2016–17) India using multivariable logistic regression. The dependent variables were the use of smoked tobacco, smokeless tobacco, and tobacco in any form. The independent variables were proxies of implementation of the COTPA and the NTCP. We followed a step-wise backward elimination technique to reach the best fit models. Results People exposed to no-smoking signages had lower odds of using tobacco (OR = 0.70, p < 0.001). People exposed to second-hand smoke (OR = 1.51, p < 0.001) and tobacco product advertisements (OR = 1.23, p < 0.001) had greater odds of using tobacco. Exposure to tobacco advertisements was associated with higher odds of using smokeless tobacco (OR = 1.23, p < 0.001), and smoked (OR = 1.33, p < 0.001) forms of tobacco. Conclusion We find significant association between the implementation of tobacco control laws/programs and tobacco use in India. Our findings highlight the potential that policy implementation holds in reducing population-level tobacco use thus drawing attention towards the implementation phase of policies. The findings have implications on prioritising enforcement of specific tobacco control measures such as smokefree laws, modifying COTPA signages to encompass all tobacco products including against smokeless tobacco use and strengthening indirect advertising restrictions. Future research could focus on developing and validating predictors specific to policy implementation to support policy evaluation efforts.

The burden of tobacco use is disproportionately high in low- and middle-income countries (LMICs). There is scarce theorisation on what works with respect to implementation of tobacco control policies in these settings. Given the complex nature of tobacco control policy implementation, diversity in outcomes of widely implemented policies and the defining role of the context, we conducted a realist synthesis to examine tobacco control policy implementation in LMICs. We conducted a systematic realist literature review to test an initial programme theory developed by the research team. We searched EBSCOHost and Web of Science, containing 19 databases. We included studies on implementation of government tobacco control policies in LMICs. We included 47 studies that described several contextual factors, mechanisms and outcomes related to implementing tobacco control policies to varying depth. Our initial programme theory identified three overarching strategies: awareness, enforcement, and review systems involved in implementation. The refined programme theory identifies the plausible mechanisms through which these strategies could work. We found 30 mechanisms that could lead to varying implementation outcomes including normalisation of smoking in public places, stigmatisation of the smoker, citizen participation in the programme, fear of public opposition, feeling of kinship among violators and the rest of the community, empowerment of authorised officials, friction among different agencies, group identity among staff, shared learning, manipulation, intimidation and feeling left out in the policy-making process. The synthesis provides an overview of the interplay of several contextual factors and mechanisms leading to varied implementation outcomes in LMICs. Decision-makers and other actors may benefit from examining the role of one or more of these mechanisms in their particular contexts to improve programme implementation. Further research into specific tobacco control policies and testing particular mechanisms will help deepen our understanding of tobacco control implementation in LMICs. PROSPERO registration number: CRD42020191541.

Background: Tobacco use is a major cause of disease and death in India. Karnataka, a southern Indian state with 12 million tobacco users has a fair share of this burden. The Government of Karnataka has used an ensemble of regulations to reduce tobacco use. Studies indicate that litigations have been used by the tobacco industry to challenge tobacco control regulations at the national level. There is a dearth of studies on how litigations have been used at a state level. Objectives: To historically analyse the tobacco-related litigations so as to better understand how laws/regulations have been used and contested by various stakeholders in advancing or resisting the tobacco control efforts in Karnataka. Methods: We used a retrospective qualitative analysis of tobacco-related litigations adjudicated by the Karnataka High court. We systematically searched a legal database and selected 39 litigations for analysis. We mapped these cases in a spreadsheet and used thematic content analysis of the court judgements. Results: Our study demonstrated that tobacco regulations and legal challenges arise from a range of laws related to food, pharmaceuticals, municipal affairs and taxation in addition to tobacco-specific laws. We found that tobacco regulations have been intensely litigated, predominantly by parties with commercial interests in tobacco that resisted these regulations. Comparatively, there were very few litigations from public health advocates demanding stricter tobacco control regulations. Conclusion: Analysis of litigations helps in identifying legal challenges that inform tobacco control authorities to anticipate and prepare for future challenges in implementing tobacco control regulations. Tobacco control agencies need adequate legal personnel and resources to effectively respond to these challenges.

Objective To understand how food laws are used, contested and interpreted to ban certain forms of chewing tobacco in India. Methods A qualitative study analysing all the tobacco-related litigation under the food laws in India. We used an inductive thematic analysis of the litigation contents. Results The tobacco industry systematically deployed litigation to (1) challenge the categorisation of smokeless tobacco products as food, and hence, questioned the use of food laws for regulating these products; (2) challenge the regulatory power of the state government in banning tobacco products via the food laws; and (3) challenge the applicability of the general food laws that enabled stricter regulations beyond what is prescribed under the tobacco-specific law. Conclusion Despite facing several legal challenges from the tobacco industry, Indian states optimised food laws to enable stricter regulations on smokeless tobacco products than were feasible through use of a tobacco-specific law.