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ORIGINAL ARTICLE
Year : 2016  |  Volume : 60  |  Issue : 4  |  Page : 273-279  

Descriptive evaluation of cigarettes and other tobacco products act in a North Indian city


1 Associate Professor of Health Management, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Masters in Health Care Management Scholar, Department of Health Care Information Technology, International Institute of Health Management Research, New Delhi, India
3 Research Coordinator, Indian Institute of Public Health, Public Health Foundation of India, New Delhi, India
4 Medical Officer and State Nodal Officer (Tobacco Control), Department of Health and Family Welfare, Chandigarh, India

Date of Web Publication15-Dec-2016

Correspondence Address:
Sonu Goel
School of Public Health, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.195858

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   Abstract 


Background: India is a signatory to Framework Convention on Tobacco Control and also enacted cigarettes and other tobacco products Act (COTPA) in 2003. Objectives: To undertake a comprehensive assessment (Section 4, 5, 6, 7, 8, and 9 under COTPA) of legislation against tobacco products in a North Indian city. Methods: An observational, cross-sectional study was conducted at 108 public places which included educational institutions, offices, health institutes, transit sites, and hotels/restaurants. Structured checklists with compliance indicators for various sections under COTPA were used. Different brands of tobacco products were observed for pictorial warnings. Results: No active smoking was observed at 80.5% public places, while 54.6% places had displayed “No smoking” signage. About 68.5% public places were found free of evidence of smell/ashes of recent smoking, and 86.1% places had no smoking aids. Merely, one-third public places (36.1%) were complying with all Section 4 indicators. Around 42.3% point of sale had advertisements of tobacco products, and 73.1% had a display of tobacco products visible to minors. Around 60% educational institutions displayed signages as per Section 6b of COTPA, and 32.5% had tobacco shops being run within 100 yards of institution's radius. There was minimal smoking activity within the campus. Health warnings were present in 80.8% of tobacco products, more with Indian brands as compared to foreign brands. Conclusion: The city of Chandigarh, which was declared the first smoke-free city of India, showed poor compliance with COTPA.

Keywords: Cigarettes and other tobacco products act, compliance, evaluation, India, legislation


How to cite this article:
Goel S, Sardana M, Jain N, Bakshi D. Descriptive evaluation of cigarettes and other tobacco products act in a North Indian city. Indian J Public Health 2016;60:273-9

How to cite this URL:
Goel S, Sardana M, Jain N, Bakshi D. Descriptive evaluation of cigarettes and other tobacco products act in a North Indian city. Indian J Public Health [serial online] 2016 [cited 2019 Sep 17];60:273-9. Available from: http://www.ijph.in/text.asp?2016/60/4/273/195858




   Introduction Top


Tobacco use is a pandemic and is listed among one of the major etiologies of preventable and premature death.[1] Every year around 6 million people are killed due to tobacco use and is estimated to incur mortality of around 8 million people annually by 2030 with 80% in low- and middle-income group of developing countries.[2] Nearly, 1 million people die in India due to tobacco use.[3],[4] Global Adult Tobacco Survey (GATS) - India 2009–2010 estimates that 34.6% adults in India are current tobacco users with 47.9% males and 20.3% females.[5] To add to the brunt, almost one-third (29.9%) of adults aged 15 years and above are exposed to second-hand smoke in workplaces, 52.3% at home, and 29% at other public places.[5] India also ranks the highest in the world when it comes to oral cancer, with an estimated 90% of them due to tobacco use.[6] Tobacco not only affects the health but is also a major economic burden. In the year 2011, the economic cost credited to tobacco use leading to major diseases in India was estimated as 17,416 dollars, which accounts for 1.16% of the gross domestic product.[7]

To address the ever increasing menace of tobacco, a global public health treaty, namely Framework Convention on Tobacco Control (FCTC) was negotiated under the auspices of the World Health Organization in 2003. Despite being the third largest producer and second largest consumer of tobacco products, India was among the first signatory of FCTC.[8] The Indian government passed a legislation, cigarettes and other tobacco products (prohibition of advertisement and regulation of trade and commerce, production, supply, and distribution) Act, 2003, or cigarettes and other tobacco products Act (COTPA) to prohibit and regulate tobacco use in India. The Act has various sections, the key being Section 4 (prohibition of smoking in public places), Section 5 (ban on advertisements of tobacco products), and Section 6 (prohibition of sale of tobacco products to minors and within 100 yards of educational institutions).[9]

Most surveys conducted across the country have shown high compliance to Section 4 under COTPA ranging from 82% to 100% in four jurisdictions of India [10] to 93% in a district of Punjab,[11] 83% in Himachal Pradesh,[12] and 71.5% in Karnataka.[13] However, few studies showed poor compliance to the legislation with active smoking of 52.5%.[3] In most studies, educational institutions and offices showed the highest compliance, whereas most busy places like restaurants and hotels showed low compliance to Section 4 of COTPA. With respect to Section 5 of COTPA, very few studies have been conducted in India, which showed poor results.[14],[15],[16] Studies have shown that tobacco advertising and promotional activities in cinemas, billboards,[17],[18],[19] at the point of sale (POS),[15] or sponsorships [20] help in initiating smoking among people of different age groups, especially the youth.

It has been observed that tobacco products are sold to minors and within 100 yards of the school radius. The studies conducted in Mumbai and Odisha showed that 82.4% and 24.8% schools have tobacco selling establishments within the radius of 100 yards, respectively, while 36.6% respondents who were being sold tobacco products were minor.[21],[22] Few global studies have shown that pictorial warning that covers more than 50% can influence smoking behavior.[23],[24] However, till date no comprehensive assessment of the Indian legislation has been reported in the published literature. The aim of the current study was to conduct a comprehensive assessment of compliance to various sections of COTPA in Chandigarh.


   Materials and Methods Top


This cross-sectional study was conducted in Chandigarh, which is a union territory located in the Northwest India. It has a population of around 1.05 million, mostly urbanized (60%) or migratory residing in resettlement colonies (30%).[25] The Union Territory of Chandigarh was declared as the first city in India to become “tobacco smoke-free” in 2007 after a campaign led by local civil society, which pressured the local authorities to accelerate enforcement and public awareness.[26] GATS 2009–2010 reported that 14.3% of adults in Chandigarh are tobacco users.

A protocol along with a set of criteria and checklist to assess the level of compliance to different sections of COTPA was developed at a smoke-free national workshop (2012) conducted by the International Union Against Tuberculosis and Lung Diseases, India. A total of 16 experts from various settings, such as government, nongovernment organizations, academia, and international organizations working in the field of tobacco research, with a fairer presentation from across jurisdictions and regions of India, participated in the workshop. For compliance assessment, different categories of public places such as educational institutions, offices, health institutes, transit sites and hotels/restaurants, and tobacco shops were selected. The sample size was calculated keeping in view the compliance rate to various sections of COTPA at different jurisdictions in India and globally as 85% (ranging from 80% to 100%)[10],[11],[12],[13] absolute error at 8%, and nonresponders 10%. Thus, the minimum sample size came to 88, which were rounded off to one hundred public places. The entire Chandigarh city was divided into four zones based on the intersection of two major roads. A total of 25 public places were randomly selected based on their numbers (size) from each zone. A team of four investigators with a background of masters in public health were trained by the principal author of the study on different aspects and sections under COTPA. The data collection was done at unannounced timings from 15th April to 14th May 2014, with an average duration of stay at each location being 20–30 min. The study variables included were the absence of active smoking, signages display, smoking aids, no smoking boards at the gate of educational institutions, tobacco shops within 100 yards of school radius, cigarette/bidi butts/empty gutkha/khaini pouches in school campus, and health warnings on the packets.

The data were coded in MS-excel and analyzed using the Statistical Package for Social Sciences (SPSS Inc, in Chicago) version 16. Results were calculated as percentages rounded off to one decimal place. The permission from State Tobacco Control Cell, Chandigarh, was obtained prior to conduction of study.


   Results Top


Overall 108 public places were visited by research investigators which included 25.9% hotels and restaurants, 18.5% health institutions, 19.4% government buildings, 33.3% educational institutions, and 2.7% transit sites. About one-third (36.1%) of public places were complying with all the indicators under Section 4 of COTPA. However, compliance varied from place to place, with educational institutions showing the highest compliance (50.0%) followed by hotels and restaurants (39.2%), government buildings (33.3%), and health institutions (15.0%), while least compliance was observed at transit sites (0.0%). None was found smoking in government buildings, while few people were found smoking in health institutions (10%), educational institutions (19.5%), and hotels and restaurants (32.2%). In contrast to the above, smoking was found at all transit sites. The compliance to display of “No Smoking” signages ranged from 15.0% at health institutions to 66.6% at transit sites and educational institutions. Smoking aids were not seen in 86.1% of places and 68.5% places were free from recent tobacco/smoke smell [Table 1].
Table 1: Compliance in public places to Section 4 of Indian smoke-free legislation

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Tobacco advertisements were present in 42.3% of the shops selling tobacco products, thus violating Section 5 of COTPA. Health warnings on advertisements were present at permanent kiosks (80.0%) followed by permanent shops (21.4%), whereas no health warnings were present on advertisements displayed at temporary kiosks. It was observed that the size of advertisement board exceeded in 4 (15.4%) tobacco POSs. Overall, 3.8% of shops were complying with all the indicators of Section 5 of COTPA [Table 2].
Table 2: Compliance to tobacco products advertisements and health warnings at point of sales

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None of the POSs had vending machines for selling tobacco products and tobacco products at these locations were not sold to minors, thus giving 100.0% compliance to the Act. However, tobacco products were placed at places which were easily visible to minors in 73.1% of POSs. Thus, around 26.9% of POS were complying with all the indicators of Section 6a of COTPA [Table 3].
Table 3: Compliance to Section 6a of Indian smoke-free legislation at point of sales

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The overall compliance of the educational institutions toward Section 6b of COTPA was found to be 37.5%. Signages on the gates were present in 60% of educational institutions, while people were found smoking tobacco products in 12.5% of educational institutions. Public schools displayed more signages as compared to private schools (65.0% vs. 55.0%). Despite the presence of more anti-tobacco signages in public schools, more number of tobacco shops was observed within 100 yards of public schools as compared to private schools (35.0% vs. 30.0%). Percentage of smoking within the campus was more in private schools (15.0% vs. 10.0%) [Table 4].
Table 4: Compliance to Section 6b of Indian smoke-free legislation at various educational institutions

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A total of 78 different tobacco products were checked for compliance toward Section 7, 8, and 9 of COTPA. Health Warning (Smoking Kills/Tobacco Kills) was present in 63 (80.8%) tobacco products. In accordance with the Act, health warning was written on the pack in white font and black background in 58 (74%) tobacco products, the word “warning” was written in red font and black background in 54 (69.2%) tobacco products, and picture of warning was not distorted in 92.3% (n = 72) packs of tobacco products. Indian made cigars (100%) was most compliant with laws related to health warnings followed by Indian-made cigarettes (93.3%), foreign-made cigars (86.1%), smokeless form of tobacco (75.4%), and bidi (58.8%). Foreign-made cigarettes showed the least compliance (35.8%) toward various indicators of Section 7 of COTPA [Table 5].
Table 5: Compliance to health warnings on packets of different tobacco products

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   Discussion Top


This is the first study which had undertaken a comprehensive assessment of Indian legislation against tobacco products in one jurisdiction of India. This is because FCTC recommends regular monitoring and compliance of smoke-free laws in each country and requires the establishment of well functional controlling mechanisms.[27] Despite the fact that smoke-free laws have been implemented in many countries around the world, their strict enforcement is still a challenge. The compliance is even more difficult in low- and middle-income countries like India in comparison to high-income Western countries due to lack of enforcement and regulatory infrastructure and mechanisms.

Regular and more systemic compliance monitoring by the local authorities can provide comprehensive picture of compliance with different aspects of the law. Compliance of smoke-free legislation at public places has shown variations from city to city, public place to public place, and country to country. Very high levels of compliance ranging from 95% to 100% have been observed in different parts of the globe such as the USA, Australia, Ireland, and New Zealand in the bars, pubs, and restaurants.[28],[29] In India too, Sikkim, Villupuram district, Coimbatore district, Shimla city in Himachal Pradesh, and Punjab have been declared smoke-free following the results of individual compliance studies.[10],[11],[12] However, a few studies conducted in Northern and Southern part of India have found poor compliance to Section 4 of COTPA terms of active smoking.[30]

A total of 97% public places selected in Chandigarh for the study showed compliance rate above 50% toward Section 4 COTPA. Although no active smoking was observed at 80.5% of the public places, only 68.5% of public places were found free of evidence of smell/ashes of recent smoking which gives evidence of smoking activities. Best compliance was shown by educational institutions followed by hotels and restaurants, and the worst compliance was observed by transit sites, similar to other studies.[31]

The present study showed little correlation between display of “NO SMOKING” signages and smoking in public places as there was paradoxically higher smoking activity in public places with more display of signages for instance at transit sites. This may be due to good administration followed in educational institutions, whereas transit places show poor compliance because of influx of people from states with poor compliance to legislation.[31] Hence, monitoring and controlling proper compliance in these places become difficult.

The present study observed a violation of Section 5 at different types of POS, the findings being similar to other studies.[15] It has been observed that tobacco industry uses different modes of promoting the tobacco products which can be advertisements in the form of dangles and big advertising boards and promotions in the form of free coupons and displaying the unit cost of tobacco products on the advertising boards.[15] Despite stricter rulings being issued by the Supreme Court in 2013 on restricting advertisements of tobacco products at POS, it is not being followed to the fullest.

Similar to Section 4 of COTPA, educational institutions performed well with regards to Section 6 of COTPA. However, some violations occurred in and around the campuses, which may be due to lack of proper monitoring by administrators within the institutions and also a lack of strong policies to keep in check the violating factors outside the campuses. Studies have documented a strong association between smoke-free campuses and students behavior toward smoking.[32],[33] Various studies conducted globally has shown the attitude of school personnel toward the usage of tobacco products and supportive measures on tobacco control policies.[33],[34] Studies have shown that school principals who were former or never smokers enforced the smoke-free law more vigilantly in comparison to those who were current smokers. They were also quite supportive (87%–95%) on different measures for tobacco control.[32]

Around 66% of foreign made cigarettes did not have health warnings as required under the Act. However, health warnings were found to be universal in cases of Indian cigars and approximately 60% of the bidi packets as documented in other studies.[35],[36] Similar to the findings of the present study, it was pointed out in a study that foreign brands being sold in malls and high-end stores do not carry proper statutory warnings.[36],[37] Considering these facts, Union Ministry has proposed to have a mandatory health warning on 85% space of cigarette packs and other tobacco products, out of which 60% will be devoted to pictorial warnings, while 25% will be covered by textual warnings.[38] This step will make India join Thailand in the list of mandating the biggest health warnings on all tobacco products.

The city of Chandigarh, which was once declared as the first smoke-free city of the country in the year 2007, has lost its momentum after almost a decade. This may be due to multiplicity of reasons. The tobacco control nodal officer in Chandigarh is the sole person looking after the tobacco control activities in Chandigarh, without funding from central government and U.T. Chandigarh. Besides, he had additional charges of the hospital which hamper his tobacco control activities. The funds generated by issuing challans (imposing fine on offenders) are deposited in the general treasury without being utilized in tobacco control activities. The present study has a limitation that it was done for a short period of time which has restricted the collection of data from a limited number of public places.


   Conclusion Top


It is concluded that the city of Chandigarh, declared as the first smoke-free city of India, showed poor compliance with COTPA. It is, therefore, suggested that a fully functional tobacco control cell should be established with adequate funding for Information Education and Communication (IEC) activities along with need-based research on tobacco control. A proper compliance mechanism needs to be re-enforced which needs the active involvement of all stakeholders including Chandigarh administration and other nongovernmental organizations. Intensive IEC should be supplemented with strict enforcement like issuance of challan and filing of court cases against offenders. These cases need to be highlighted in local print and nonprint media.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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