Tobacco control in India - a civil society perspective

Background:
Considering the magnitude of the tobacco menace, India ratified the FCTC in 2004, becoming the seventh country to do so. Following this, Tobacco control has been implemented in India for more than a decade, through comprehensive tobacco control legislation like Cigarette and Other Tobacco Products Act (COTPA). Implementation is being ensured by the extensive lobby by civil society or judicial interventions. There has been a delay in achieving the outcomes as obligated by FCTC. Therefore, it is crucial to understand and document civil society perspectives on the status of tobacco control in India, to accelerate the process, which is explored in the present study.

Methods:
This was an exploratory study conducted using purposive sampling. Pioneering experts (n= 9) who were actively working in tobacco control in the state of Tamil Nadu, India for more than a decade, were interviewed with their consent, using a semi-structured interview schedule. The interview was audio-recorded, transcribed and analysed using thematic analysis.

Results:
The activists report that unlike other major public health issues, tobacco control is given least priority across the country, thus resulting in poor enforcement of tobacco control policies. Five major themes emerged as challenges to tobacco control; enforcement, industry interference, awareness, cessation services and media. Though the experts perceive that tobacco control is possible, industry interference on the judiciary, executive and legislative level is a major hindrance at present. The results also highlight that lack of interdepartmental co-ordination among different departments responsible for enforcement and their ignorance about their role in tobacco control is also a deterrent. Need for establishing cessation facilities were felt crucial.

Themes	Enforcement		Industry Interference	Awareness		Cessation Services		Media
Sub Themes	Lack of enforcement	Need for effective enforcement	Lobbying of tobacco industry	Lack of awareness	Integration of awareness into school curriculum	Inadequate cessation services	Strengthening of cessation services	Paradoxical projection of tobacco	Media as an ambassador for tobacco control
Sample Quotes	“There is no particular agency to provide enforcement. The government mechanism is not functioning very well.” “So many sections under the COTPA act have not been notified and enforced till now. The implementation is very poor.”	“I feel COTPA has to be enforced more strictly and this can increase its effectiveness.”	“Tobacco industries employ surrogate advertising that has adverse effects.” “Tobacco industries are keeping close contacts with politicians and policy makers. They try to influence them and this is a major challenge.”	“Awareness is highly necessary in the rural areas more than the urban areas.” “The concerned authorities themselves are unaware of COTPA and the various sections under it in detail.” “There are still a lot of misconceptions relating to tobacco and its related products”	“Early initiation can be curbed by giving interventions at schools.” “Early intervention and awareness through lessons will encourage and promote awareness amongst the youngsters”	“ The practitioners providing cessation services themselves are not aware of the correct methodology for tobacco cessation”	“Every health personnel in the country has to be educated on the tobacco cessation methodologies”	“Contradictory messages are being projected through films with regard to the use of tobacco products. “section 5 (COTPA) violation by the film industry”	“Articles relating to ill effects of tobacco usages so that will help in awareness of the same. “Showcasing advertisement featuring the ill effects of tobacco use in cinema theatres is very effective.”

[Perspectives of Tobacco Control Experts]

Conclusions:
Tobacco industry interference is a big challenge for tobacco control in India. However, the experts are optimistic about making tobacco control a reality.

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