Compliance with tobacco control policies in India: an examination of facilitators and barriers

A mixed-methods evaluation of the indoor and outdoor smoking ban in dining venues in Armenia: Early successes and challenges

INTRODUCTION

Since March 2022, Armenia introduced a comprehensive smoking ban on all types of tobacco products in indoor and outdoor areas of hospitality venues. We aimed to rapidly appraise the implementation of the ban in the dining areas of the capital Yerevan and explore any differences in compliance and enforcement patterns between indoor and outdoor areas of the venues.

METHODS

We used a mixed-methods approach through quantitative air quality monitoring, qualitative observations, and in-depth interviews (IDIs). We visited one venue in each remote district of the city and more venues from the central districts that have a much higher density of dining areas. Overall, we made 24 measurements of PM2.5 particles, 24 unobtrusive observations in the 19 visited venues, and 11 IDIs with six visitors and five workers. We used Stata13 for the analysis of numerical data and completed direct deductive content analysis of the textual data.

RESULTS

Active tobacco use was observed in 12 out of 24 venues (50.0%) with more cases of smoking in outdoor areas (10 out of 12; 83.3%). No warning by workers or no reports to the police were observed. We detected elevated levels of PM2.5 particles in indoor and outdoor areas. The IDIs revealed predominantly negative attitudes towards the outdoor ban and the lack of awareness of and readiness to engage in the enforcement measures. The lack of enforcement by the owners and the respective bodies was mentioned as a contributor to continued violations of the ban. The change in the dynamic and the characteristics of the visitors, cleaner air, and less unpleasant work were mentioned as important positive aftermaths of the ban.

CONCLUSIONS

The Government of Armenia should enhance the monitoring and enforcement activities and organize tailored awareness-raising campaigns to inform the general public and the hospitality industry of the health and social implications of the ban.

Trends in age of tobacco use initiation over time in Bangladesh, India and Pakistan: analysis of cross-sectional nationally representative surveys

OBJECTIVE

Tobacco use begins at an early age and typically leads to a long-term addiction. The age of initiation for tobacco use is not well studied in South Asia, where 22% of tobacco smokers and 81% of smokeless tobacco (SLT) users reside.

METHODS

Data from the nationally representative Global Adult Tobacco Surveys in India, Bangladesh and Pakistan were analysed to examine patterns of initiation among smokers and smokeless tobacco users.

RESULTS

Data on 94 651 individuals were analysed, of which 13 396 reported were ever daily smokers and 17 684 were ever SLT users. The proportion of individuals initiating tobacco use before the age of 15 years has increased over time. The rates of SLT initiation among those aged 15-24 years increased markedly in Bangladesh (by 7.8%) and Pakistan (by 37.7%) between 1983 and 1999-2000. Among males, the increase in SLT initiation was higher in individuals aged below 15 years compared with other age groups in India and Bangladesh. Smoking initiation among females aged below 15 years has also significantly increased in India over time. Compared with the initiation of tobacco smoking before the age of 15 years, a greater increase in the proportion of SLT users was observed in urban areas.

CONCLUSION

Our findings indicate that the proportion of youth initiating tobacco (both smoking and smokeless) before the age of 15 years has increased over time in all three countries. Moreover, variations in age at initiation for different types of tobacco products across countries, and by rurality, were noticeable. Younger youths (aged up to 15 years) should therefore be a priority population for tobacco control interventions. Strategies such as raising the legal age of tobacco sale and use to 21 years, and, other measures under WHO Framework Convention on Tobacco Control (FCTC), may prevent underage use and avert lifelong addiction to tobacco products.

Awareness, perceptions of and compliance with tobacco control policies among naswar vendors in Khyber Pakhtunkhwa Pakistan

INTRODUCTION

Regulatory compliance in the retail environment is integral to the success of tobacco control. We assessed compliance among naswar (smokeless tobacco product widely used in South Asia) vendors with tobacco control laws. We also assessed their awareness of tobacco-related harms and policies and perceived effect of policies on their sales.

METHODS

We surveyed 286 naswar vendors in three districts of the Khyber Pakhtunkhwa province of Pakistan. We recruited general and specialty vendors from urban and rural areas through multistage cluster sampling. Compliance was measured for promotion, sale to/by minors and tax paid on naswar. We used logistic regression analyses for assessing the association between the outcome variables (awareness of tobacco harms and laws, perceptions about the effect of policies on business and compliance with laws) and their predictors.

RESULTS

Most vendors (70%) were aware of tobacco-related harms of naswar. Although educated vendors were more aware of tobacco control policies, the greatest awareness was for a ban on sales to/by minors (21% overall). The majority of vendors (76%) violated this policy (measured by self-report), and violations were more common among rural than urban vendors (OR 2.27, 95% CI 1.05 to 4.96). Most vendors (71%) violated a ban on promotion of naswar. Vendors perceived tax increases and sales ban to/by minors as most detrimental for business.

CONCLUSIONS

There was poor awareness and compliance among naswar vendors in Pakistan with tobacco control laws. This study finds potential areas for policy interventions that can reduce urban/rural disparities in implementation of and compliance with tobacco control laws.

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.

Compliance with the smoke-free public places legislation in Nepal: A cross-sectional study from Biratnagar Metropolitan City

Background

Smoke-free legislation banning tobacco smoking in public places was implemented across Nepal in 2014 with the ambition to reduce the impact of second-hand smoking. As part of a comprehensive policy package on tobacco control, the implementation of the legislation has seen a marked reduction in tobacco consumption. Yet there remains uncertainty about the level of compliance with smoke-free public places.

Objectives

This study assesses the compliance with smoke-free laws in public places and the factors associated with active smoking in public places in Biratnagar Metropolitan City, Nepal.

Methods

A cross-sectional study was conducted in the Biratnagar metropolitan city in Province 1 of Nepal from July to December 2019. A total of 725 public places within the metropolitan city were surveyed using a structured survey tool. Active smoking was the primary outcome of the study which was defined as smoking by any person during the data collection time at the designated public place.

Results

The overall compliance with smoke-free legislation was 56.4%. The highest compliance (75.0%) was observed in Government office buildings. The lowest compliance was observed in eateries, entertainment, and shopping venues (26.3%). There was a statistically significant association between active smoking and the presence of ‘no smoking’ notices appended at the entrance and the odds of active smoking in eateries, entertainment, hospitality, shopping venues, transportations and transits was higher compared to education and health care institutions. None of the ‘no smoking’ notices displayed fully adhered to the contents as prescribed by the law.

Conclusion

As more than half of the public places complied with the requirements of the legislation, there was satisfactory overall compliance with the smoke-free public places law in this study. The public venues (eateries, shopping venues and transportations) that are more frequently visited and have a high turnover of the public have lower compliance with the legislation. The content of the message in the ‘no smoking’ notices needs close attention to adhere to the legal requirements.

Implementation of the Uttarakhand Tobacco Free Initiative in Schools, India, 2016

PURPOSE AND OBJECTIVES

A process evaluation, the Uttarakhand Tobacco Free Initiative (UTFI), was conducted in 49 public high schools and colleges in the state of Uttarakhand, India, to measure program implementation, provide feedback to school administrators, and identify barriers to tobacco control.

INTERVENTION APPROACH

UTFI aims to 1) raise awareness and provide education and tools for teachers and school administrators about the dangers of tobacco use and secondhand smoke, 2) encourage participation in student-led activities to promote tobacco-free initiatives, and 3) enforce tobacco-free school policies in the state of Uttarakhand.

EVALUATION METHODS

We used the CDC evaluation framework to document key components and lessons learned from the UTFI. We distributed questionnaires to 71 teachers and principals in December 2016, to assess awareness of school activities and policies related to the initiative. Descriptive statistics were computed for quantitative data, and a thematic content analysis was used for qualitative data.

RESULTS

Of the 71 participants, 66 (92.9%) were aware of tobacco use policies in schools, and 63 (88.7%) agreed policies were enforced. Sixty-six participants (93.0%) said that they taught tobacco prevention-related topics, and 41 of 70 respondents (58.6%) reported that a student-led group helped to enforce tobacco-free policies in their schools. Of 69 respondents, almost all (n = 66) reported satisfaction with UTFI implementation. Challenges identified were related to tobacco products being readily accessible near school premises, lack of tobacco prevention materials, and tobacco use by school staff.

IMPLICATIONS FOR PUBLIC HEALTH

Successes of UTFI were documented by measuring different components of the process, including implementation of program activities and teacher and principal satisfaction. Results might help enhance key processes for the initiative and highlight some barriers to implementation, such as enforcing tobacco control policy off school premises. Continued efforts are needed to prevent tobacco use among young people.

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.

Implementing smoke-free policies in low- and middle-income countries: A brief review and research agenda

INTRODUCTION

Some low- and middle-income countries (LMICs) struggle to implement smoke-free policies. We sought to review the academic and gray literature, and propose a research agenda to improve implementation of smoke-free policies and make them more effective in LMICs.

METHODS

We reviewed 10 databases for variations of (‘implementation’ /‘enforcement’ /‘compliance’) and (‘smoke-free’ /‘ban’ /‘restriction’) and (‘tobacco’ /‘smoking’). We also reviewed cited sources and the gray literature including non-governmental organization reports.

We included articles that described problems that arose, attempted solutions, lessons learned, and research questions posed regarding smoke-free policy implementation in LMICs. We excluded studies of high-income countries, institution-level implementation, voluntary smoke-free policies, smoke-free homes, and outdoor smoke-free policies.

RESULTS

The academic literature review led to 4931 unique articles, reduced to 1541 after title screening, 331 after abstract screening, and 101 after full-text review. The citation and gray literature review led to an additional 179 publications of which 67 met the inclusion criteria. In total we retained 168 sources. We conducted a narrative review and synthesis of the literature, extracting key themes and noting research gaps.

CONCLUSIONS

We find that progress is urgently needed in five categories: identifying the critical lessons learned for effective implementation, evaluating different enforcement approaches, learning how to rejuvenate stalled smoke-free policies, learning how to increase ground-level will to enforce policies, and developing a conceptual framework that explains implementation. Investigation into these topics can improve implementation of smoke-free policies in LMICs.

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.

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

BACKGROUND

We measured how student tobacco use and psychological risk factors (intention to use and perceived ease of access to tobacco products) were associated with tobacco vendor compliance with India's Cigarettes and Other Tobacco Products Act provisions regulating the point-of-sale (POS) environment.

METHODS

We conducted a population-based cross-sectional survey of high school students (n=1373) and tobacco vendors (n=436) in school-adjacent communities (n=26) in Mumbai, India. We used in-class self-administered questionnaires of high school students, face-to-face interviews with tobacco vendors and compliance checks of tobacco POS environments. Logistic regression models with adjustments for clustering were used to measure associations between student tobacco use, psychological risk factors and tobacco POS compliance.

RESULTS

Compliance with POS laws was low overall and was associated with lower risk of student current tobacco use (OR 0.48, 95% CI 0.26 to 0.91) and current smokeless tobacco use (OR 0.40, 95% CI 0.21 to 0.77), when controlling for student-level and community-level tobacco use risk factors. Compliance was not associated with student intention to use tobacco (OR 0.50; 95% CI 0.21 to 1.18) and perceived ease of access to tobacco (OR 0.73; 95% CI 0.53 to 1.00).

CONCLUSIONS

Improving vendor compliance with tobacco POS laws may reduce student tobacco use. Future studies should test strategies to improve compliance with tobacco POS laws, particularly in low-income and middle-income country settings like urban India.

Tobacco Use and Effects of Professional Advice on Smoking Cessation among Youth in India

Objective:

Healthcare professionals and addiction programs play important roles in tobacco use prevention and cessation activities. In this study, we analyzed the prevalence of tobacco use and the impact of smoking cessation advice through programs/professionals among a nationally representative sample of youth in India.

Methods:

The data were obtained from the Global Youth Tobacco Survey (GYTS) 2009 dataset from a nationally representative school based survey of 8th to 10th grade students in India (n=14,543). Professional or provider advice for smoking cessation was analyzed with reference to quitting smoking. Descriptive analysis was performed for tobacco and smoking prevalence and the types of tobacco products used. Logistic regression was employed to assess any associations between professional or program advice and quitting smoking.

Results:

The overall prevalence of current tobacco use was 13.5%. About 76% were never tobacco users and 9.3% were former tobacco users. The prevalences of smoking, smokeless tobacco and poly tobacco use among current tobacco users were 35.1%, 43.3% and 21.5% respectively. Among the never smokers, 80% were weakly and 20% were strongly susceptible. Recipients of advice from a program or professional showed higher odds (OR=5.3) of quitting smoking.

Conclusion:

Professional and program advice to quit smoking is very effective for youth in India. More programs and healthcare professionals must be employed to prevent and encourage youth to abstain from the use of tobacco.