Rana J Singh

Effective smoke-free policies in achieving a high level of compliance with smoke-free law: experiences from a district of North India

Background Compliance survey of smoke-free law is an effective means of measuring progress towards a smoke-free society. They also help policy makers to take action where strengthening measures are required. India has a comprehensive tobacco control law known as Cigarettes and Other Tobacco Products Act (COTPA 2003) which prohibits smoking in public places and requires display of ‘No smoking’ signages with proper specifications at conspicuous points. However, its implementation and enforcement are still a matter of concern. Aims and objectives To ascertain the level of compliance with smoke-free law in public places of a district of North India. Methodology A cross sectional study was conducted in the months of November–December 2011 in district SAS Nagar Mohali of North India. The public places including hotels/restaurants/bars/shopping malls, government offices, educational institutions, healthcare facilities and transit stations were surveyed. The study tool was adapted from the guide on ‘Assessing compliance with smoke-free law’ developed jointly by the Campaign for Tobacco Free Kids, Johns Hopkins Bloomberg School of Public Health and International Union against Tuberculosis and Lung Disease. Results The overall compliance rate towards section 4 of COTPA was 92.3%. No active smoking was observed in 94.2% of the public places. In 90% of the public places ‘No Smoking’ signage were displayed as per COTPA. Health and educational institutions had maximum compliance with the smoke-free law while transit sites showed the least compliance. Conclusions Compliance to the smoke-free law was high in the study.

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.

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.

Promoting tobacco cessation by integrating 'brief advice' in tuberculosis control programme

Background: There is an enormous health burden caused by the co-prevalence of tuberculosis (TB) and tobacco use in India. This intervention study was undertaken in district Vadodara, Gujarat, India to promote tobacco cessation by integrating ′brief advice′ for tobacco cessation in TB patients who were tobacco users and registered for treatment under TB control programme, based on the tested strategies advocated by World Health Organization (WHO) and the International Union against Tuberculosis and Lung Diseases (The Union). Materials and Methods: Brief advice for tobacco cessation based on five A′s, advocated by the WHO and the UNION was incorporated into the on-going TB Control programme in India in the year 2010. The tools were developed for education, training and capturing data. All the registered TB patients receiving directly observed treatment short-course (DOTS) who used tobacco in any form were offered brief advice during routine interaction for treatment. Results: A total of 46.3% of TB patients, predominantly males (89.6% males and 10.3% females) were current users of tobacco; 39.1% used smokeless tobacco, 35.9% were smokers and 25% were dual users, that is, smoked as well as used smokeless tobacco. At the end of treatment, of the 67.3% patients who were offered brief advice, quit tobacco use, 18.2% re-lapsed while 14.5% were lost to follow-up. Conclusion: A significant numbers of TB patients use tobacco with adverse impact on TB control programmes. Our study shows that it is feasible to introduce ′brief advice′ strategy as a cost effective intervention for tobacco cessation among TB patients with careful monitoring.

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.

Low-Cost Air Quality Monitoring Methods to Assess Compliance With Smoke-Free Regulations: A Multi-Center Study in Six Low- and Middle-Income Countries

INTRODUCTION Many low- and middle-income countries (LMICs) have enacted legislation banning smoking in public places, yet enforcement remains challenging. The aim of this study was to assess the feasibility of using a validated low-cost methodology (the Dylos DC1700) to provide objective evidence of smoke-free (SF) law compliance in hospitality venues in urban LMIC settings, where outdoor air pollution levels are generally high. METHODS Teams measured indoor fine particulate matter (PM2.5) concentrations and systematically observed smoking behavior and SF signage in a convenience sample of hospitality venues (bars, restaurants, cafes, and hotels) covered by existing SF legislation in Mexico, Pakistan, Indonesia, Chad, Bangladesh, and India. Outdoor air PM2.5 was also measured on each sampling day. RESULTS Data were collected from 626 venues. Smoking was observed during almost one-third of visits with substantial differences between countries-from 5% in India to 72% in Chad. After excluding venues where other combustion sources were observed, secondhand smoke (SHS) derived PM2.5 was calculated by subtracting outdoor ambient PM2.5 concentrations from indoor measurements and was, on average, 34 µg/m(3) in venues with observed smoking-compared to an average value of 0 µg/m(3) in venues where smoking was not observed (P < .001). In over one-quarter of venues where smoking was observed the difference between indoor and outdoor PM2.5 concentrations exceeded 64 µg/m(3). CONCLUSIONS This study suggests that low-cost air quality monitoring is a viable method for improving knowledge about environmental SHS and can provide indicative data on compliance with local and national SF legislation in hospitality venues in LMICs. IMPLICATIONS Air quality monitoring can provide objective scientific data on SHS and air quality levels in venues to assess the effectiveness of SF laws and identify required improvements. Equipment costs and high outdoor air pollution levels have hitherto limited application in LMICs. This study tested the feasibility of using a validated low-cost methodology in hospitality venues in six LMIC urban settings and suggests this is a viable method for improving knowledge about SHS exposure and can provide indicative data on compliance with SF legislation.

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.

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.

Unravelling India's tobacco epidemic--priorities and recommendations for the second round of Global Adult Tobacco Survey (GATS).

The Global Adult Tobacco Survey, or GATS, has proved to be an invaluable tool for policymakers. In India, it highlighted the alarming rates of prevalence of use and risks both nationally and at state level. However, a rapid analysis of GATS-India shows that there are limitations in methods (sampling, questionnaire, measures undertaken to ensure data quality and management), which may impact the estimates of prevalence. This review discusses these potential weaknesses and recommends measures that can be adopted in the next round of surveys to overcome the limitations.