Pranay Lal

How good is compliance with smoke-free legislation in India? Results of 38 subnational surveys

BACKGROUND India has been implementing smoke-free legislation since 2008 prohibiting smoking in public places. This study aimed to assess the level of compliance with smoke-free legislation (defined as the presence of no-smoking signage and the absence of active smoking, smoking aids, cigarette butts/bidi ends and smoking smell) and the role of enforcement systems in Indian jurisdictions. METHODS This was a cross-sectional, retrospective review of reports and primary data sheets of surveys conducted in 38 selected jurisdictions across India in 2012-2013. RESULTS Of 20 455 public places (in 38 jurisdictions), 10 377 (51%) demonstrated full compliance with smoke-free law. Educational institutions and healthcare facilities performed well at 65% and 62%, respectively, while eateries and frequently visited other public places (such as bus stands, railway stations, shopping malls, stadia, cinema halls etc.) performed poorly at 37% and 27%, respectively. Absence of no-smoking signage was the largest contributor to non-compliance across all types of public places. Enforcement systems were present in all jurisdictions, but no associations could be demonstrated between these and smoke-free compliance. CONCLUSION Smoke-free compliance in public places in India was suboptimal and was mainly related to the absence of no-smoking signage. This warrants further pragmatic and innovative ways to improve the situation.

Second-hand smoke: a neglected public health challenge.

Exposure to secondhand smoke (SHS) causes an estimated 5% of the global burden of disease, slightly higher than the burden from direct use of tobacco. This review highlights the urgent need to address this ignored public health issue by presenting the evidence and impact of SHS on those exposed using global studies including those from the South-East Asia Region. The burden of morbidity from SHS exposure is higher in low-income countries in Southeast Asia region compared to the rest of the world. SHS exposure affects those most vulnerable, especially women and children. While several countries in the region have enacted legislation which offer protection to those exposed to SHS, most measures are partial and inadequate. As a result, implementation and compliance at national and sub-national level within the countries of the Southeast Asia region is variable. Governments must ensure that legislation mandates comprehensive smoke-free environments in order to provide public health benefit which offers universal protection to everyone and everywhere. Where comprehensive legislation exists, stringent implementation and enforcement, along with awareness building, education and monitoring through regular compliance studies must be done to sustain smokefree status of public places within jurisdictions.

Correlates of tobacco quit attempts and cessation in the adult population of India: secondary analysis of the Global Adult Tobacco Survey, 2009–10

BackgroundNearly 275 million adults (15 years and above) use tobacco in India, which contributes substantially to potentially preventable morbidity and mortality. There is good evidence from developed country settings that use of tobacco cessation services influences intention to quit, with a higher proportion of attempts being successful in fully quitting. There is little evidence about cessation and quitting behaviour in the Indian context. This study assesses the socio-demographic characteristics and cessation services used by adults i) who attempted to quit smoked and smokeless tobacco and ii) who were successful in quitting.MethodsThe study was a cross-sectional secondary data analysis of the Global Adult Tobacco Survey, India, 2009–10. There were 25,175 ever tobacco users aged 21 years and above included in the study. Bivariate and multivariate logistic regression analysis was done to determine associations between socio-demographic variables and cessation services utilized with attempts to quit tobacco and successful quitting.ResultsOf the ever tobacco users, 10,513 (42%) made an attempt to quit tobacco, and of these 4,395 (42%) were successful. Significant associations were demonstrated between male gender, increasing educational attainment and higher asset quintiles for both those who attempted to quit and those who were successful. Younger age groups had higher odds of quit attempts than all except the oldest age group, but also had the lowest odds of successful quitting. Heath care provider advice was positively associated with attempts to quit, but both advice and use of cessation aids were not associated with successful quitting.ConclusionsThis study provides the first national evidence on the relationships between quitting attempts and successful quitting with socio-demographic characteristics, health care provider advice and use of cessation services. The findings of the study have important implications for scaling up tobacco cessation services in India, and indicate a need to re-examine in greater detail the effects of socio-demographic factors, type of tobacco product used and levels of dependency on quitting. Health system factors such as coverage and accessibility of cessation services, type of service, and its duration and follow up also have to be examined in detail to ascertain effects on quitting behavior.

Smoking trends among women in India: Analysis of nationally representative surveys (1993-2009).

Background: There is growing concern among policy makers with respect to alarming growth in smoking prevalence among women in the developing countries. Methods: Using disaggregated data from five nationally representative surveys: Global Adult Tobacco Survey 2010, National Family Health Survey-III (NFHS-III) 2004–2005, NFHS-II 1998-1999, National Sample Survey (NSS) 52nd Round 1995–1996, NSS 50th Round 1993-1994 we analysed female smoking trend from 1993-2009. Tobacco use among females was monitored for almost two decades focusing on gender, literacy, and state-specific trends among respondents aged >15 years. Results: Smoking use among women has doubled from 1.4% to 2.9% (P < 0.001) during the period 2005-2010. The prevalence of smoking increased with decrease in per capita State Gross Domestic Product and literacy status for both men and women. Conclusion: As the overall smoking prevalence grows, female smoking is growing at a faster rate than smoking among males, which is an emerging concern for tobacco control in India and requires the attention of policymakers.

Assessing compliance to smoke-free legislation: results of a sub - national survey in Himachal Pradesh, India

Introduction: Exposure to second-hand smoke (SHS) is a serious public health concern. The Indian smoke-free legislation ′Prohibition of Smoking in Public Places Rules, 2008′ prohibits smoking in public places, including workplaces. Objective: To measure the status of compliance to legal provisions that protects the public against harms of SHS exposure, identifies the potential areas of violations and informs policy makers for strengthening enforcement measures. Design: A cross-sectional survey in 1401 public places across 11 district headquarters in Himachal Pradesh, India, using a compliance guide developed by partners of the Bloomberg initiatives to reduce tobacco use. Results: In 1401 public places across 11 district headquarters, 42.8% public places had signage; in 84.2% public places, no smoking was observed and in 83.7%, there was absence of smoking accessories such as ashtray, matchbox and lighter . Tobacco litter like cigarette butts was absent in 64.7% of the public places. Overall, at the state level, there was more than 80% compliance on at least three of the five indicators. Among all categories of public places, educational institutions and offices demonstrated highest compliance, whereas most frequently visited public places, eateries and accommodation facilities had least compliance. Conclusions: The compliance to ′Prohibition of Smoking in Public Places Rules, 2008′ was variable in various district headquarters of Himachal Pradesh. This study identified the potential areas of violations that need attention from enforcement agencies and policymakers.

Multilateral development banks and socially responsible investments – the case of tobacco

Globally, tobacco kills more people than HIV-related conditions or AIDS, tuberculosis and malaria combined. In 1991, The World Bank, the world’s largest lender, pledged that it would no longer support tobacco-related projects. It was expected that other financial investors would follow, but most did not respond to this call. As a result, several financial institutions continue to invest in tobacco and fuel an epidemic to an unprecedented scale. Using tobacco as a case in point, this review highlights the continuing investments among financial institutions which do not conform to ‘socially responsible investments’ and calls for monitoring and reporting such unethical practices. The paper also underscores the need to harmonise the numerous criteria, principles and voluntary codes that govern socially responsible investing and ensure that financial institutions comply with them.

Estimating the Size of Tendu Leaf and Bidi Trade Using a Simple Back-of-the-Envelop Method

Since independence from the British in 1947, India has relied heavily on forest resources, including extraction of tendu leaves, to provide livelihood options for its marginalised tribal and forest-dependent communities. Tendu leaves are used to make bidis, an indigenous leaf-rolled cigarette made from coarse uncured tobacco, tied with a coloured string at one end. It is widely smoked in the Indian subcontinent and is gaining popularity globally, especially in USA, Germany, Middle East, Eastern Europe and Japan (Tobacco Board of India 2010). Bidis are harmful and pose a serious challenge to the health of youth globally and especially in the US where a health advisory warns of the potential harm (CDC http://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/bidis_kreteks/). Curiously the use of tendu to make bidis is more recent, with the accidental discovery of tendu as the most suitable leaf to wrap tobacco and make bidis. The tendu tree (Diospyros melanoxylon or the black or east Indian ebony) grows in degraded deciduous forests of peninsular India, where once sal trees (Shorea robusta) were felled to make railway sleepers. Tendu leaves are available for plucking soon after the tobacco crop is ready and cured, when most other deciduous trees have shed their leaves in summer (April–June). Tendu leaves have all the characteristics of an excellent wrapper material—they are large and pliable, and do not crack on rolling when dry; their leathery texture is also more acceptable than the veins and rough textures of other leaves; and they match well with and augment the taste of tobacco, without interfering with the tobacco flavour. The first bidi factory was set up in 1911 in Jabalpur in erstwhile Central Provinces (now in the state of Madhya Pradesh), where tendu was most abundantly available. Bidis found wide consumer acceptance especially during the ‘Swadeshi andolan’ (a civil disobedience movement to boycott Imperial British goods during India’s struggle for independence) which was started by Mahatma Gandhi in 1920. This uplifted the prestige of the bidi that even educated Indians started smoking bidis instead of cigarettes. The two World Wars further spurred the use of bidis as they accompanied Indian soldiers to far-flung places (Lal 2009).

Tobacco control in India: where are we?

INDIA IS A COUNTRY of staggering numbers. It is home to nearly 275 million tobacco users,1 a number that exceeds the population of Indonesia and Canada combined, and a population that would make this the fourth largest country in the world should they unite. Every year more than one million male smokers (or a population greater than that of Brussels) die prematurely from smoking.2 Add to this the large numbers of individuals who chew tobacco (164 million users) and those exposed to secondhand smoke, and the equation becomes a public health nightmare. Nearly 74% of the global burden of death from chewing tobacco use is in India.3 India’s tobacco epidemic is driven by a huge variety of tobacco products that is not completely understood, and which varies widely by geography, population, sex, age, socio-economic status and educational attainment. India also prides itself on being a leader in tobacco control among developing countries. Since 1998, state governments have set the trend by enacting subnational laws to protect youth from exposure from secondhand smoke. The Government of India, taking its cue from the states and the impending obligations it had to meet under the World Health Organization’s (WHO’s) Framework Convention on Tobacco Control (FCTC), promulgated comprehensive national legislation in 2003. To institutionalise tobacco control, in 2007 the Government dedicated funds for a pilot phase of a new National Tobacco Control Programme (NTCP), covering 42 districts in 21 states. By the end of 2017, the NTCP is expected to cover more than 400 districts in 31 states. Complementing the efforts of the government are civil society groups who are backed by the generous support of the Bloomberg Initiative to Reduce Tobacco Use, its international technical partners and national civil society and government partners. The partners of the Bloomberg Initiative have been working tirelessly to implement tobacco control interventions in India at national and subnational level. Since 2007, over 250 000 government officials, civil society partners, media and academics have been sensitised to and trained on tobacco control in India by the International Union Against Tuberculosis and Lung Disease. As tobacco control implementation has progressed, compliance surveys using tested protocols have declared 107 districts and cities as smokefree jurisdictions, protecting over 228 million people. In May 2013, the Ministry of Health & Family Welfare managed, through food safety rules, to ban gutka, a mixture of areca nut and tobacco, a ban with which all states have complied. Intensive mass media campaigns in more than 17 languages and efforts to raise tobacco taxes at subnational level have also proved effective. Despite this massive commitment and energy, challenges to advance tobacco control remain. The tobacco industry has access to the highest levels of policy making, and has succeeding in challenging and reversing tax and pack warning measures at different times. Industry tactics have further demotivated the over-burdened government officials. In November 2016, the gains made so far in tobacco control (and efforts of tobacco industry to reverse them) will come out clearly when the collaborative survey by the Centers for Disease Control and Prevention (CDC), the WHO and the Government of India will present the status of tobacco use in India. Until then, tobacco control advocates must continue their fight against all odds.

UN Development Programme and non-communicable diseases

In her Comment (Feb 16, p 510), Helen Clark from the UN Development Programme (UNDP) has overlooked the problematic association between development agencies and the tobacco industry, which continually undermines global efforts to combat noncommunicable diseases (NCDs). The tobacco industry promotes sale and consumption of addictive and disease-causing substances that fuel NCDs. Its stated and vested interests are directly opposed to public health priorities. Because of a lack of adherence to exclusion criteria and standards for partnerships, such companies largely responsible for causing the NCD epidemic have ironically become development partners of UN agencies. The Global Environment Facility (GEF), an initiative of the UNDP (and the World Bank), led projects in the Philippines, Panama, Uganda, and Tanzania, which received funds from tobacco companies. In Tanzania, GEF supported an aff orestation programme to sustain tobacco farming. Partners, such as Global Business Coalition on Health and UN Global Compact, partner with corporations in the tobacco industry. The openness of the UN systems confers upon the tobacco industry an undeserved legitimacy, facilitates its access to global policy making, and ultimately distorts health priorities. UNDP’s agenda to combat NCDs is thus called into question by its partnership with an industry that contributes overwhelmingly to the crisis.

Promoting operational research through fellowships: a case study from the South-East Asia Union Office.

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins Sans Frontières (MSF) jointly developed a new paradigm for operational research (OR) capacity building and started a new process of appointing and supporting OR fellows in the field. This case study describes 1) the appointment of two OR fellows in The Union South-East Asia Office (USEA), New Delhi, India; 2) how this led to the development of an OR unit in that organisation; 3) achievements over the 5-year period from June 2009 to June 2014; and 4) challenges and lessons learnt. In June 2009, the first OR fellow in India was appointed on a full-time basis and the second was appointed in February 2012-both had limited previous experience in OR. From 2009 to 2014, annual research output and capacity building initiatives rose exponentially, and included 1) facilitation at 61 OR training courses/modules; 2) publication of 96 papers, several of which had a lasting impact on national policy and practice; 3) providing technical assistance in promoting OR; 4) building the capacity of medical college professionals in data management; 5) support to programme staff for disseminating their research findings; 6) reviewing 28 scientific papers for national or international peer-reviewed journals; and 7) developing 45 scientific abstracts for presentation at national and international conferences. The reasons for this success are highlighted along with ongoing challenges. This experience from India provides good evidence for promoting similar models elsewhere.