COTPA implementation status: An observational study in South Indian city

Globally, tobacco use accounts for eight million deaths every year - more than seven million of which are due to direct tobacco consumption and around 1.2 million are due to second-hand smoke1. This menace has affected people from all age groups across the world. In the year 2017-2018, economic burden from tobacco constituted more than 1 per cent of India’s GDP, and the direct health expenditures on treating tobacco-related diseases alone accounted for 5.3 per cent of the total private and public health expenditures in India in a year2.

In India, the prevalence of tobacco use has changed between the Global Adult Tobacco Survey (GATS) 1 (2009-2010) and 2 (2016-2017) (GATS 1: 34% and GATS 2: 28%)3. Tobacco use amongst adolescents aged 13-15 yr in India has increased over the years (13.7% in 2006 to 14.6% in 2009)3,4. Noticeably, the recorded prevalence of any tobacco use is about 11.2 per cent in the Union Territory (UT) of Puducherry3 - the location of the current study.

Being a signatory of the World Health Organization (WHO) Framework Convention on Tobacco Control, the Government of India enacted the Cigarettes and Other Tobacco Products Act (COTPA) in 20035–7. The enforcement of COTPA envisions halting and reversing the tobacco epidemic in India by empowering state officials to execute and protect various tobacco control activities as defined under various sections of the act8.

The National Tobacco Control Programme (NTCP) was launched by the Ministry of Health and Family Welfare (MoHFW), Government of India (GoI), in Puducherry for effective implementation of COTPA. In a thorough literature search, where the search returned a few studies from some parts of India, it was found that the compliance to various sections of COTPA was as low as 10 per cent and as high as 100 per cent. Amongst all the studies, it was observed that there was variation in the indicators that were used to assess compliance with tobacco control law9–13. It was found that none of the studies reported detailed compliance assessment from the UT of Puducherry. Against this background, this study was planned and conducted to assess the compliance of selected sections 4, 5, 6, 7, 8, 9 and 10 of COTPA, in Puducherry. Since the law is already enacted in Puducherry, the results of this study aimed to inform the policymakers and administrators as appropriate. This study also defines a tool/checklist to assess compliance with sections 4-10 of COTPA. Sections 4, 5, 6a, 6b and 7 (with 8, 9 and 10) of COTPA, respectively, deals with the prohibition of: smoking in public places, advertisement of cigarettes and other tobacco products at the point of sales (PoS), sale of tobacco products by/to the minors, sale of tobacco products in/around 100 yards of educational institutions (EIs) and sale of cigarettes and other tobacco products with specific packaging and labelling.

Material & Methods

This study was conducted in urban Puducherry during 2017-2018 following approval obtained from the scientific research committee and institute ethics board. Data collection was conducted during August-September 2017. The UT of Puducherry comprises four districts. The headquarters of this UT is in the Puducherry district, which is also a major tourist attraction with a population of around 0.95 million (Census, 2011)14. The district of Puducherry is administratively divided into urban and rural areas. The urban Puducherry of the Puducherry district comprises 90 wards under two municipalities and three towns14. The sample size for sections 4, 5 and 6a (PoS) of COTPA was calculated using OpenEpi v3.01 keeping a conservative proportion of 50 per cent as compliance level, absolute precision of 10 per cent, confidence limits of 95 per cent and considering a design effect of 1.5. The sample size of 160 was chosen to accommodate an additional 10 per cent non-permission rate. A convenience sample of 58 EIs and 29 unique tobacco packages were considered to assess compliance with section 6b and section 7 (with 8, 9 and 10) of COTPA, respectively.

Considering feasibility and resource constraints, 13 urban wards were selected randomly using computer-generated simple random numbers and that satisfied the minimum sample size for assessing sections 4, 5 and 6a of COTPA. A survey pathway was followed during the working/business hours for 15-30 min15. The pathway starting from multiple central points in each ward was followed and all the public places and PoS on both sides of the roads were taken as samples15. All the EIs of 13 wards (i.e. 52) were observed.

Study tool: An ‘Observation Checklist’ was developed, referring to the guide named assessing compliance from smoke-free laws, the COTPA 2003 and its amendments and guidelines for implementation of ‘Smoke-free Rules’16,17. The checklist was prepared and field tested in a different but similar setting. Geographic coordinates of all the EIs and PoS were recorded using the GPS device ‘Garmin-OREGON 550’. The photographs of violations were captured pertaining to section 5 (Supplementary File).

Statistical analysis: The data collected were entered in EpiData software version 4 (The EpiData Association, Odense, Denmark), and analyzed using STATA version 12 (Stata Corp LLC, College station, TX, USA). Indicators, which were developed for assessing and analysing compliance were presented as proportions. The list of indicators/checklist is attached as Supplementary File. The COTPA compliance around EIs was mapped using an open access program QGIS version 2.14.21-Essen (QGIS, 2018).

Operational definitions: The operational definitions of public place, EI, indirect advertisement and tobacco package were taken from amendments of COTPA18,19.

Results

Observed locations and compliance with sections of COTPA: About half (48%) of the total public places (N=178 public places) observed in the study were either hotels or restaurants or bars (Table I).

A total of five smoking indicators were used to identify COTPA compliance in public places (Table II).

Section 4: A little over one-third (63 out of 178 places, 35.8%) of the public places were found compliant with all five indicators. The levels are arranged in decreasing order of overall compliance (% in parenthesis, in the last column of Table II). Half of the public places had cigarette stubs lying close to the entrance. Of all the public places in the study, entrances of around two-third (120, 67%) of them were free of active smoking, around 90 per cent (90) of public places were free of any cigarette/bidi stubs. Almost three-fourth of the public places were found to be free from active smoking (139, 78%), cigarette/bidi stubs (131, 74%) and smoking aids (149, 84%).

Among 178 public places, the overall compliance with section 4 was found to be maximum at religious places (5 out of 9, 55%) and least at bus stops and construction sites (0%). Religious places, shopping malls, hospital buildings and libraries were fully compliant with the compliance indicators such as no active smoking (in premises), cigarette stubs and smoking aids, except a hospital where active smoking inside the boundaries was recorded. Of the total bars visited, 12 per cent were recorded as compliant with all the five indicators (Table II).

Out of 178 places, the no-smoking signage/s was/were displayed at less than one-tenth (14, 8%) of the premises; none of them was fully compliant with all the specifications laid for signage in the law. Of the 14 places (7.8%) displaying signage about a third (4, 28.6%) had signage at the entrance, almost half (6, 42.9%) had white background on signage, ‘No Smoking’ was mentioned in almost all places (85%), ‘Smoking Here Is An Offence’ was mentioned in four (31%) and three out of 14 (23%) places complied with the display of designation, name and phone number of a reporting officer. Among all categories of public places, the maximum proportion of government offices (18%; 4/22) displayed no-smoking signage.

Of all the public places surveyed, 14 had a smoking area, but only seven were eligible to have one. Among seven places, which were eligible to have a smoking area, none complied with all the specifications laid for designated smoking areas. The photographs of violations pertaining to section 4 are provided in Supplementary File.

Section 5: Out of 175 PoS, nearly three-fifth (105, 60%) had one or the other form of advertisement. Amongst them, nearly three-fourth (78, 74.3%) and two-third (69, 65.7%) had displayed direct and indirect advertisements, respectively. The compliance of tobacco product advertisement at PoS with COTPA was recorded least in Chinnakadai (18.7% among 13 wards), followed by Rajbhavan (37.5%). Product showcasing (67, 63.8%) and advertisement boards (61, 58.1%) were major forms of advertisement at the PoS (Figure). None of the advertisement boards complied with section 5 of COTPA. Although 17 out of 61 PoS had displayed the mandated health warning, only one PoS had complied with white background and black letters as per the COTPA guidelines.

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Figure

Form of advertisement at PoS (N=105). ^‡: One or more than one type of advertisements were displayed at PoS. ^§: Use of brand™ of any tobacco product on commercial board/poster for advertising goods other than tobacco. %: (n/N)×100, where n=number of PoS with the type of advertisement represented on x-axis and N=total number of PoS with any type of tobacco product’s advertisement. PoS, point of sales.

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Section 6 (a): Of the 175 PoS, more than two-third (n=115) were free of any display of tobacco products within the visual range of minors. Among three categories of PoS, the compliance was lowest amongst temporary kiosks (11%; 1/9). The sale of tobacco products to customers who could easily be identified as minors at the first glance was not seen in almost 80 per cent (138, 78.9%) of the PoS. This compliance varied from 66 per cent at temporary kiosks to 82 per cent at the permanent ones. The sale of tobacco products by minors was not found at 97 per cent (170 out of 175) PoS. None of the PoS displayed signage indicating ‘Prohibition of sale to the person below 18 yr’.

Section 6 (b): Almost half (12 out of 25, 48%) of the government EIs and one-third (12 out of 33, 36%) of the private EIs had at least one PoS within 100 yards of their boundaries. All the EIs were free from active smoking or sales of tobacco inside the campus. About 79 per cent of EIs were free of any cigarette/bidi stubs or Gutkha/Khaini pouches. One (private school) out of 58 EIs was found displaying the signage indicating ‘prohibition of tobacco around EIs’ or ‘Tobacco-free institute’ as per section 6 (b) of COTPA.

Sections 7, 8, 9 and 10: The compliance with components of specified health warning was as low as zero for smokeless tobacco and bidi packages due to the absence of manufacturing date. The textual and pictorial contents of the health warning were found to be least compliant in relation to foreign cigarettes (1 out of 8, 12.5%) as they did not use the pictures as mandated in the law. None of the smokeless tobacco packages had health warning printed with 300 dots per inch or more, due to which the warning looked hazy. The misleading content on principal area of the package was found in almost 80 per cent of Indian cigarette packages and 100 per cent of packets used for foreign cigarettes. The promotional messages such as menthol, mint flavour, special filter, kings, push the capsule in the filter, switch the capsule and world’s finest taste in America or the images indicating the promotion of the product were observed on all foreign cigarette packages (Table III).

Discussion

Section 4: The compliance with smoking indicators in public places in our study was 35.8 per cent, which was similar to the study (36.1%) by Goel et al20. Almost three-fourth of the public places in the present investigation were found to be free from active smoking. In studies pertaining to no-smoking compliances reported by Goel et al21, Kumar et al9 and Jain et al10 observed 94, 81.5 and 80.5 per cent compliance, respectively. The difference in observations between these studies might be due to application of different study criteria. Hence, use of uniform checklist or a nationalized framework to monitor compliances with COTPA is strongly recommended.

The level of compliance with respect to the absence of smoking aids (lighters, ashtrays, matchsticks, etc.) in public places observed in the present study (a little over 80%) was similar to the compliance reported in the study conducted by Goel et al20 in Chandigarh. The compliance with the display of no-smoking signage in public places was eight per cent in the present study which was similar (7.2%) to a study conducted by Kaur et al22. Although the latter study was conducted only amongst restaurants in Chennai, the similarity in the results could be due to the fact that the majority of public places (24.5%) participating in the present study were restaurants. This finding should prompt authorities to identify the root cause of such low levels of compliance. The reasons might be ignorance or lack of awareness of the law, financial limitations, lack of willingness on the part of participating parties, etc.

Compliance with the display of no-smoking signage varied across studies: 54 per cent (Goel et al20), 89.5 per cent (Goel et al21) and 90 per cent (Jain et al10). Studies showing 89.5 per cent (Mohali, Punjab) and 90 per cent (Alwar, Rajasthan) compliance reported that the high level of compliance was either due to the presence of a district-level task force for implementation of COTPA (as is the case in Mohali, Chandigarh) or might be attributed to strict enforcement of COTPA by the state government (the case with Alwar, Rajasthan)10,21. The results of the present study suggest the need to take certain steps for better compliance in future.

The Ministry of Health and Family Welfare (MoHFW), Government of India (GoI) which is responsible for the implementation of COTPA, should collaborate with the Ministry of Tourism, Ministry of Road Transport and Highways, Ministry of Railways and Traders’ Unions and identify the problems faced in public places with respect to implementing the law23. The awareness of the laws and policies amongst various ministries and stakeholders might serve as a good first step towards better implementation of the policies. The difficulties faced by the owners of public places through respective unions for implementation of the law must be discussed and addressed.

Section 5: Less than half of the 175 PoS surveyed in our study were free of advertisements. A study conducted by Jain et al10 and two other studies by Goel et al20,24 showed 93, 57.7 and 0 per cent compliance, respectively. This variation in the compliance levels could be due to varied levels of implementation of COTPA in different geographic settings. Of all the PoS displaying advertisements, 28 per cent had displayed a health warning. Similarly, in a study by Goel et al24, 80 per cent of PoS were found violating provisions of Section 5 for display of tobacco advertisement boards. Presence of illuminated/backlit advertisement boards were also reported which is in line with the present study (Supplementary file, Pictures, Section 5). The low level of compliance observed in our study underlines that the purpose of creating the law is being defeated. The Ministry of Commerce and Industry is charged with the formation of policies related to commerce including but not limited to the sale of tobacco and its products. Scientific literatures have suggested that policy implementation depends on the policy dissemination at various levels, awareness of policies, planning and others25. There can be various ways to raise awareness about the policies, which can be explored through various channels like the National Cadet Corps (NCC), which can mobilize its volunteers to reach out to their peers and parents to improve awareness about the harms of tobacco and also about tobacco control laws26. NCC volunteers can keep vigilance in public places for potential breach of few sections of tobacco control laws.

Section 6: None of 175 PoS surveyed in this study complied with section 6 (a) of COTPA – a finding in line with the results of the investigations conducted by Yadav et al12 and Govil et al27, which also showed a complete non-compliance with section 6 (a). In the present study as well as in others, compliance was at less than three-fourth of the total EIs observed. Such observation hints at the tactics used by the tobacco industry to capture the attention of schoolchildren and youths through sales and display of various forms of advertisements at PoS at the proximity of EIs24.

Presence of a board stating ‘Tobacco-free Institution’ at EIs was very low across several studies such as the ones by Balappanavar et al28 (3% of 15 EIs) and Goel et al29 (0 per cent at Dhar and Una) including ours.^, However, higher compliance was observed in a study conducted by Goel et al29 (76% in Ernakulam and 50.2% in Jhunjhunu).^, The reason for the difference could be due to the existence of tobacco control committees in EIs of Ernakulam and Jhunjhunu. Tobacco control committees can be established in EIs for effective implementation and monitoring of section 6 of COTPA. As suggested in the revised guidelines for tobacco-free EIs, published by MoHFW, GoI, the EI should designate Tobacco Monitor(s) from amongst their staff, an official or a teacher or a student representative (the student from class IX onwards). Health and Wellness Ambassadors should also be designated as Tobacco Monitors. The name, designation and phone number of the Tobacco Monitor(s) should also be mentioned on the signages30.

Sections 7, 8, 9 and 10: In the present study, all (100%) tobacco packages displayed health warnings unlike the studies done by Goel et al20 (80.8%) and DS et al13 (86.5%). The high compliance observed in the present study might be due to the use of a convenience sample, and to the smaller number of tobacco packages (n=29) assessed compared to the other investigations (78, and 37, respectively). Most of the packages had displayed compatible size of health warning (62%), which was similar to a study conducted in Bhubaneshwar (69%)31. Importantly, the latest implementation of Packaging and Labelling Amendment Rules of COTPA came into being in 2014. In order to monitor packaging of tobacco products sold or imported in India, greater coordination between the MoHFW and the Ministry of Commerce and Industry need to be fostered. Noticeably, plain packaging is suggested by the WHO rather than with promotional narratives such as with menthol etc32.

In conclusion, poor compliance with COTPA is obvious. An umbrella framework with state-specific, target-based and milestone-driven action plan, can be created under the purview of Digital India Program (DIP) by the Department of Monitoring and Evaluation of NITI Aayog. This may ensure implementation of laws at grassroots level.