Compliance with point-of-sale tobacco control policies and student tobacco use in Mumbai, India

Programme and policy perspectives towards a tobacco-free generation in India: findings from a qualitative study

OBJECTIVE

This study explored multistakeholder perspectives on existing adolescent-specific tobacco control policies and programmes, to advance India's transition towards a tobacco-free generation.

DESIGN

Qualitative semi-structured interviews.

SETTING

Interviews were conducted with officials involved in tobacco control at the national (India), state (Karnataka), district (Udupi) and village level. Interviews were audio recorded, transcribed verbatim and analysed thematically.

PARTICIPANTS

Thirty-eight individuals representing national (n=9), state (n=9), district (n=14) and village (n=6) levels, participated.

RESULTS

The study findings highlighted the need to strengthen and amend the existing Tobacco Control Law (2003) provisions, particularly in the vicinity of schools (Sections 6a and 6b). Increasing the minimum legal age to buy tobacco from 18 to 21 years, developing an 'application' for 'compliance and monitoring indicators' in Tobacco-Free Educational Institution guidelines were proposed. Policies to address smokeless tobacco use, stricter enforcement including regular monitoring of existing programmes, and robust evaluation of policies was underscored. Engaging adolescents to co-create interventions was advocated, along with integrating national tobacco control programmes into existing school and adolescent health programmes, using both an intersectoral and whole-societal approach to prevent tobacco use, were recommended. Finally, stakeholders mentioned that when drafting and implementing a comprehensive national tobacco control policy, there is a need to adopt a vision striving toward a tobacco-free generation.

CONCLUSION

Strengthening and developing tobacco control programmes and policies are warranted which are monitored and evaluated rigorously, and where adolescents should be involved, accordingly.

Decentralisation of the Compliance of Anti-tobacco Law in India: The Case of Higher Educational Institutions in New Delhi, India

Introduction This paper studies the decentralised compliance responsibility of India's tobacco control legislation, called the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act of 2003, with its rules, which the government has outsourced to higher educational institutions, studied through an example of New Delhi. The study looks into the three most important parameters of decentralised compliance. Two of these require the installation of signboards by higher educational institutions, and the third involves imposing and collecting fines against persons found smoking within the educational institutions. Regarding the boards, the first board is about the warning prohibiting the sale within 100 yards of educational institutions, and the second one prohibits smoking in educational institutions. The study also checks with the educational institutions whether there is a presence of cigarette and tobacco product vendors within 100 yards of the institution, where the sale of such products has been banned by law. The study also found educational activities to create awareness in the institutions for tobacco control and cessation. Methods Thirty-six higher educational institutions, including universities, were randomly selected and studied through a unique methodology using India's transparency law, i.e., the Right to Information Act 2005. The portions of the law, which was direct compliance, or related compliance by the higher educational institution was included in the study. This justified the decentralised responsibility of these higher educational institutions. Applications for information under the transparency law were requested and supplied. Out of the 47 institutions, in which information requests were filed, 36 provided the information under the law. Credible information was provided by the higher educational institutions and this information was collated and interpreted to provide insights into the compliance by the higher educational institutions. Results Only 44.4% of the institutions had a board prohibiting the sale of cigarettes and other tobacco products. This was a non-universal compliance by the higher educational institutions. 88.9 per cent had boards prohibiting smoking in the higher educational institutions. Only one out of the 36 had an instance of smoking recorded and collection of fines. While 47.2% reported to not have any instance of smoking and fine collection. Fifty per cent of the institutions had no record of fine collection amounting to defiance of the law. 75 per cent of institutions did some kind of awareness activities which was not a direct statutory requirement, but a recommended guideline. Conclusion The results show that the intent to decentralise the compliance of the tobacco control law in New Delhi by the higher educational institutions has not been universally successful and requires much effort for its on-ground penetration. Such studies have a policy impact as they serve as an example for the generalisability of such statutes, which only work when there is implementation from the bottom-up and when the deterrent is also strong with incentivisation to the educational institutions to implement tobacco control with vigour.

Compliance With Higher Education-Related Tobacco Control Law Provisions by Institutions of National Importance in India

Introduction India formulated an anti-tobacco and anti-smoking law in 2003 in response to its resolutions in the United Nations' bodies. This law has been detailed subsequently to make it focussed on educational institutions, which are supposed to perform on-ground action in a decentralized manner. The first step is to put up signboards prohibiting the sale of cigarettes and tobacco products within 100 yards, the second is prohibiting smoking within the campus, and the third is implementing the law related to collecting fines from the offenders as well as the presence of vendors within 100 yards. Additional information on awareness activities was also sought. The focus of this paper is on India's premier educational institutions called the "Institutions of National Importance" by the Indian legislature. These are India's premier public institutions which have the maximum focus of the Indian government by making them of high quality, and non-compliance with the tobacco control law in these institutions should be taken seriously. Methods The paper checked for compliance with the Indian Tobacco Control Law in 79 of these Institutions of National Importance. The requirement for information to be collected from institutions was first derived from the legal act and the rules. Then, the Right to Information Act of 2005, India's transparency law, was used to file applications for information, and certified information from the institutions was collected and reported. Results Only 39.2% of the institutions had the requisite boards prohibiting sales within 100 yards of the institutions. The requirement of having boards prohibiting smoking fared a little better at 73.4% of institutions complying but was not universal. A total of 43% of institutions denied the information pertaining to the collection of fines, either by not providing a requisite reply or stating that this was not part of the record. The information regarding the presence of vendors was not universally supplied with 65.8% of institutions stating the same to not in record or not within the purview. With respect to the awareness activities though, 72.2% of the institutions stated to have some awareness activity for tobacco control and cessation. Conclusion The results show an overall weak compliance with the law. India's health regulators and educational watchdogs must implement anti-smoking and anti-tobacco laws strictly in Indian educational institutions as this is where young people are found. Something as simple as the installation of signboards by educational institutions cannot be overlooked by them. The law must become stricter with deterrence. This must be most intense in the Institutions of National Importance which form the premier institutions in India and become the role model for other institutions in India.

Compliance of Sections 4-7 of Cigarette and Other Tobacco Products Act (COTPA) 2003 in India-A Systematic Review and Meta-analysis

In view of the vast variability of the compliance of Sections 4-7 of COTPA in India, a need for a collective evaluation appeared appropriate and timely. The aim of this review was to specifically analyze the country wide compliance of Section 4,5,6a and 6b,7 of COTPA along with the displays of signage on No Smoking (NoSmok) and Tobacco Free Institution (TFI). Studies published between 2003-December 2020 reporting compliance/non compliance (C/NC) were reviewed. Eligible study designs were observational studies and brief reports. To obtain the effect measure, Med Calc version 20 was used. 60 full text articles were assessed for eligibility and included in the qualitative and quantitative synthesis. The compliance for the Sections 4,5, 6b and 7 was 71.97% (95%CI:61.87-81.05, I2 =99.70%), 58.95% (95%CI:44.90-72.28, I2=99.53%), 51.08% (95% CI:39.30-62.81, I2=99.46%), 57.60% (95%CI:37.58-76.40, I2=99.48%) respectively whereas for the NoSmok and TFI board display it was 42.30% (95%CI:32.53-52.39, I2=99.75%) and 26.81% (95%CI:9.94-48.25, I2=99.51) respectively. Compliance of the Section 6a, sale of tobacco products to and by the minors was 66.39% (CI:49.50-81.36, I2=99.69%) and 94.11% (95%CI:78.54-99.99, I2=99.76%) respectively. This study observed a significant variability in compliance of Sections 4-7 of COTPA. It points to a critical need for a robust, self - sustained and effective enforcement mechanism countrywide to eliminate potential for any NC. Amendments to the COTPA appear critical for a policy reform and an optimal implementation.

Neighbourhood tobacco retail access and tobacco use susceptibility in young adolescents in urban India

BACKGROUND

Neighbourhood tobacco retail access may influence adolescent tobacco use. In India, we examined the association between neighbourhood tobacco retail access and cognitive risks for tobacco use during early adolescence.

METHODS

In 2019-2020, a population-based sample (n=1759) of adolescents aged 13-15 years was surveyed from 52 neighbourhoods in Mumbai and Kolkata. Neighbourhood tobacco retail access was measured as the frequency of visits to tobacco retailers, mapped tobacco retailer density and perceived tobacco retailer density. We estimated associations between neighbourhood tobacco retail access and cognitive risks for tobacco use (perceived ease of access to tobacco, perceived peer tobacco use and intention to use tobacco).

RESULTS

There was high neighbourhood tobacco retail access. Tobacco retailer density was higher in lower income neighbourhoods (p<0.001). Adolescent frequency of tobacco retailer visits was positively associated with cognitive tobacco use risks. Mapped tobacco retailer density was associated with perceived ease of access in Kolkata but not in Mumbai, and it was not associated with perceived peer tobacco use nor intention. Perceived tobacco retailer density was associated with perceived ease of access and perceived peer use, but not with intention. In Kolkata, higher perceived retailer density and frequency of tobacco retailer visits were negatively associated with perceived ease of access.

CONCLUSIONS

Efforts to reduce neighbourhood tobacco retail access in India may reduce cognitive tobacco use risk factors in young adolescents. The frequency of tobacco retailer visits and perceived tobacco retailer density increased cognitive risks, though there were some exceptions in Kolkata that further research may explain.

Spatial analysis of outdoor tobacco advertisement around children and adolescents in Indonesia

There is a major gap of action by the Indonesian government to control tobacco advertisement. This study aimed to compare outdoor tobacco advertisements (OTAs) in locations with and without OTA bans in relation to their proximity to children and adolescents. Global positioning system coordinates of all OTAs visible from the streets in Banyuwangi and Surabaya in East Java province were collected and analysed to determine their density at 0-100, >100-300 and >300-500 m from facilities used by children and adolescents. Hotspot analysis was conducted to identify places with exceptionally high densities of OTAs. The number and density of OTAs in Surabaya, where there was no policy for controlling OTAs, were greater than those in Banyuwangi, where OTAs were partially banned. Regardless of the existence of a ban, OTAs were 2.6-3.4 times denser in areas closer to facilities used by children and adolescents than further apart. The OTA point hotspots approximated the hotspots of tobacco retailers and facilities used by children and adolescents in both locations. A partial ban may only have a small impact. A total advertising ban, including at point of sale, should be encouraged for both locations for optimal protection of children and adolescents.

E-cigarette retailer storefront availability following a nationwide prohibition of e-cigarettes in India: A multicentric compliance assessment

INTRODUCTION

This study aimed to assess the availability of retailer storefronts that continued to sell electronic nicotine/non-nicotine delivery systems (ENDS/ENNDS) in India, and characterise such retailers following the promulgation of 2019 Indian Ordinance and Act (Ordinance/Act) that prohibit ENDS/ENNDS nationwide.

METHODS

Discreet observations were conducted of retailer storefronts across different socioeconomic zones in nine major cities of India (Bengaluru, Chandigarh, Dehradun, Delhi, Indore, Kolkata, Ludhiana, Raipur, and Ranchi) from 28 November 2019 to 22 January 2020 to identify the availability of ENDS/ENNDS (i.e. electronic cigarettes, e-cigarette liquid, e-cigarette accessories, heated tobacco products (HTPs), and HTPs accessories). We report the number and proportion (%) of retailers that sold ENDS/ENNDS. Other characteristics of the retailers are also described, including indirect evaluation of the retailer's awareness of the Ordinance/Act.

RESULTS

Of the 199 retailer storefronts visited, 37 (18.6%) sold ENDS/ENNDS and, therefore, did not comply with the Ordinance/Act. The highest availability of non-compliant retailers was in Kolkata (n=26; 83.9%). The majority of the non-compliant retailers were tobacco retailers (n=35; 94.6%), sold e-cigarettes (n=22; 59.5%), and e-cigarette accessories (n=24; 64.9%). Although many of the non-compliant retailers displayed their ENDS/ENNDS products (n=33; 89.2%) and did not feature health warnings related to ENDS/ENNDS (n=32; 86.5%) in the stores, nearly 90% (n=33) were aware of the Ordinance/Act.

CONCLUSIONS

Despite a nationwide ban, ENDS/ENNDS are still available in major cities in India, and concentrated in a particular city. Indian authorities should focus on law enforcement to ensure that the prohibition is effectively implemented.

Exposure to the advertisement of toombak at the point-of-sale among adolescents in Khartoum State, Sudan: A cross-sectional study

INTRODUCTION

This study aimed to assess the association between toombak (smokeless tobacco) advertisement at point-of-sale (PoS) and its use among adolescents in Sudan.

METHODS

A cross-sectional school-based and self-administered questionnaire study was conducted. Schools were randomly selected using a one-stage stratified sampling procedure, during 2013–2014, as part of a larger research project focusing on the use of toombak among secondary school students in Khartoum State, Sudan. The sample size was 1526 students. Data were collected on exposure to toombak advertisement, social acceptability, perceived accessibility to toombak, susceptibility, and toombak use.

RESULTS

A total of 41.8% of the adolescents were exposed to an advertisement at PoS, while 12.5% perceived direct access to toombak, 5.3% reported that they were susceptible to use toombak, and 10.9% were ever toombak users. Exposure to the advertisement of toombak at PoS was found to be associated with the older age group (44.3%) (p≤0.05). Males were more than females (45.2% vs 38.8%; p≤0.05). Those exposed to toombak advertisements at PoS reported more social acceptability towards toombak (48.9% vs 37.6%; p≤0.001) and direct accessibility to toombak (68.8% vs 47.2%; p≤0.05). Ever toombak users reported higher exposure to advertisements than non-users (54.5% vs 40.3%; p≤0.001).

CONCLUSIONS

Exposure to toombak advertisements at PoS was found to be high and associated with increased toombak use in Khartoum State, Sudan, in addition to increasing social acceptability to its use and perceived easy accessibility. The current law, which bans toombak advertisement and promotion at PoS, needs to be enforced.

Tobacco company strategies for maintaining cigarette advertisements and displays in retail chain stores: In-depth interviews with Korean convenience store owners

INTRODUCTION

This study gathered data from store owners regarding the advertising and display of, and the contractual arrangements and promotional activities related to, the sale of tobacco products in convenience stores.

METHODS

In-depth interviews were conducted with three owners of convenience stores in South Korea: to examine the procedures for managing the sale of tobacco products; for allocating the advertising allowance for such products; and for coordinating the promotional activities of tobacco companies.

RESULTS

All tobacco advertisements and displays in convenience stores are installed and managed in accordance with the contract between the tobacco companies and the convenience store headquarters. The headquarters receives an allowance from the tobacco company in return for maintaining and displaying their product and promotional materials. The headquarters then pays a monthly advertising allowance to each franchisee as an operating subsidy. However, the owners also stated that tobacco companies provide financial incentives directly to them to engage in illegal promotional activities.

CONCLUSIONS

Because tobacco advertisements and displays at convenience stores are related to the profitability of these products, the participants in these relationships have become increasingly entangled. Illegal promotional activities must be monitored to limit tobacco sales and advertising. Furthermore, efforts to ban the advertising and display of tobacco products at the point of sale must be based on the development of policies emerging from an understanding of the roles of the major stakeholders.

I have heard about it for the first time from you! Implementation of tobacco control law by police personnel in India

Setting and Objetives: Police personnel, alongside other key stakeholders, are responsible for implementing the Cigarettes and Other Tobacco Products Act (COTPA) in India. This study aimed to assess knowledge and attitudes about COTPA among police personnel and explore enablers and barriers in implementing it. Design: This convergent parallel mixed-methods study used a self-administered questionnaire (quantitative) and key informant interviews (qualitative). Of 300 police personnel across all eight police stations in Daman, 155 participated. Quantitative data were analysed using descriptive statistics and the χ² test. Qualitative data from in-depth interviews of six key informants from all coordinating departments were analysed thematically. Results: Overall, 63.2% of responders were aware of any tobacco control law in India, and only 12.9% were trained in its implementation. One person had conducted inspections for COTPA compliance in the last 12 months. The majority (78.1%) of the police personnel, and significantly more tobacco non-users than users (81.2% vs. 52.9%, P = 0.016), felt that enforcing anti-tobacco regulations is one of their most important functions. Perceived benefits of the act and formal authority to act were the two main enablers of COTPA implementation. Lack of awareness and coordination, competing priorities, concentration of authority with higher-ranking officials and evasion of the law by retailers and the public hampered effective implementation of the law. Conclusion: Knowledge about the COTPA was average and implementation poor. Sensitisation and training of implementers, systematic transparent reporting and creating awareness among public are recommended for effective implementation.

Child awareness of and access to cigarettes: impacts of the point-of-sale display ban in England

INTRODUCTION

England introduced a tobacco display ban for shops with >280 m² floor area ('partial ban') in 2012, then a total ban in 2015. This study assessed whether these were linked to child awareness of and access to cigarettes.

METHODS

Data come from the Smoking, Drinking and Drug Use survey, an annual survey of children aged 11-15 years for 2010-2014 and 2016. Multivariate logistic regression models assessed changes in having seen cigarettes on display, usual sources and ease of access to cigarettes in shops RESULTS: During the partial display ban in 2012, 89.9% of children reported seeing cigarettes on display in the last year, which was reduced to 86.0% in 2016 after the total ban (adjusted OR 0.58, 95% CI 0.50 to 0.66). Reductions were similar in small shops (84.1% to 79.3%)%) and supermarkets (62.6% to 57.3%)%). Although the ban was associated with a reduction in the proportion of regular child smokers reporting that they bought cigarettes in shops (57.0% in 2010 to 39.8% in 2016), we did not find evidence of changes in perceived difficulty or being refused sale among those who still did.

DISCUSSION

Tobacco point-of-sale display bans in England reduced the exposure of children to cigarettes in shops and coincided with a decrease in buying cigarettes in shops. However, children do not report increased difficulty in obtaining cigarettes from shops, highlighting the need for additional measures to tackle tobacco advertising, stronger enforcement of existing laws and measures such as licencing for tobacco retailers.