BACKGROUND: India accounts for about two million tobacco-attributable adult deaths annually. As a federal democracy, India presents diverse socio-economic and regulatory contexts across states. India started economic liberalisation in 1990s and this is also the period when intense tobacco control reforms started. We, therefore, chose to use 10 Indian states over 1990-2017 period to understand macro factors (state regimes, tobacco industry influence, regulatory and civil society intervention) that explains a significant decline in tobacco use in order to inform present/future tobacco control.
METHODS: We used a fuzzy-set Qualitative Comparative Analysis technique. We sourced a range of qualitative and quantitative data to assess four macro conditions: (1) power and stability of political regimes, (2) the degree of tobacco industry interference, (3) tobacco control orientation within public policies, and (4) the civil society action for tobacco control. We studied 10 Indian states as cases. We used qualitative methods to calibrate the conditions and used fs-qca software for analysis.
RESULTS: We found that none of the conditions were necessary for the outcome though the absence of tobacco industry interference came closer to being a necessary condition. We identified three causal configurations explaining significant decline in tobacco use in Indian states: (1) (strong & stable regime) & (low tobacco industry interference); (2) (strong public policy) & (low tobacco industry interference); (3) (weak and unstable regime) & (strong public policy) & (strong civil society action). This solution had high coverage (0.81) and consistency (0.87) implying its importance and explanatory power.
CONCLUSIONS: The findings highlight the importance of strong tobacco control policies, civil society actions, and presence of powerful and stable regimes in Indian states for significant decline in tobacco use. However, these factors yield results when tobacco industry interference is absent/minimal. There is urgent need for a national policy in line with the WHO FCTC Article 5.3.