Perception of Threat and Efficacy in Contracting COVID-19 Infection among Tobacco Users - A Cross-sectional Analytical Study from Four Indian States.

BACKGROUND: To trigger quit intention and practice of preventive measures for COVID-19 among tobacco users; it is imperative for them to be well aware of the fact that they are at higher risk of COVID-19 infection and should be at higher efficacy to practice preventive measures for the disease as compared to nonusers of tobacco. OBJECTIVES: This community-based cross-sectional analytical study was conducted from April 2020 to May 2020 among 1203 adult participants to compare the threat and efficacy perception among users and nonusers of tobacco. MATERIALS AND METHODS: Perception of threat was assessed using three questions on perceived threat and one question on perceived susceptibility; whereas perception of efficacy was assessed using four questions each on self-efficacy and response efficacy through telephonic interview. RESULTS: There was no significant difference in the overall threat perception among users and nonusers of tobacco. However, state-wise analysis showed that tobacco users had higher perception of threat for SARS-CoV-2 infection in all the states except Telangana. The overall perception of efficacy among tobacco users was significantly higher as compared to nonusers of tobacco. CONCLUSION: The study calls for active collaboration between tobacco control enthusiasts and the Government to promote awareness of a higher risk of COVID-19 disease among tobacco users. In essence, the study's implications extend beyond COVID-19 and can guide targeted efforts to promote awareness, behavior change, and collaboration in the context of other infectious diseases among tobacco users.

Comparative assessment of implementation of Cigarette and Other Tobacco Products Act in three States of India: A pre-post study.

BACKGROUND OBJECTIVES: The Cigarette and Other Tobacco Products Act (COTPA) limits the sale of tobacco products, promotion and advertising and packaging of tobacco products in India. Periodic monitoring of the level of compliance with all sections of COTPA is obligatory to assess the effectiveness of the act. METHODS: This pre-post study aimed to assess the change in the level of compliance with different sections of COTPA in selected States. A total of 3849 and 2176 samples were assessed during the study in November 2020 and October 2021, respectively; using the EpiData Software. RESULTS: Average compliance with section 4 of COTPA was highest in Puducherry during baseline [51.88%, prevalence ratio (PR)=0.72, 95% confidence interval (CI): 0.51-1.02] and in Telangana during endline assessment (66.1%, PR=0.6, 95% CI: 0.48-0.74). A visible change with section 5 of COTPA was observed in Telangana (40.08 to 93.12%, PR=0.04, 95% CI: 0.02-0.07). Compliance with section 6a of COTPA decreased in Puducherry (81.34 to 71.83%, PR=1.84, 95% CI: 1.14-2.95) and increased for Meghalaya and Telangana. The average compliance with sections 7, 8 and 9 (for Puducherry 51.09 vs . 48.8%, Meghalaya 54.94 vs . 46.18% and Telangana 73 vs . 51.91%, respectively) decreased in all States. An increase in average compliance was observed with sections 4 and 5 ( P =0.19 and 0.11, respectively) and a decrease with sections 7, 8 and 9 ( P =0.02) of COTPA in all three States. For sections 6a ( P =0.06) and 6b ( P =0.01), a mixed response was noted. INTERPRETATION CONCLUSIONS: The findings of this study suggest that the level of compliance with sections 4 and 5 of COTPA increased because they are strictly monitored compared to sections 7-9, which are less enforced by the States. There is a need to monitor sections 7-9 (pack warning) to fulfill the objectives related to the World Health Organization (WHO) Framework Convention on Tobacco Control.

Legal Challenges in Tobacco Control: Historical and Qualitative Analysis of Litigations in Karnataka.

Background: Tobacco use is a major cause of disease and death in India. Karnataka, a southern Indian state with 12 million tobacco users has a fair share of this burden. The Government of Karnataka has used an ensemble of regulations to reduce tobacco use. Studies indicate that litigations have been used by the tobacco industry to challenge tobacco control regulations at the national level. There is a dearth of studies on how litigations have been used at a state level. Objectives: To historically analyse the tobacco-related litigations so as to better understand how laws/regulations have been used and contested by various stakeholders in advancing or resisting the tobacco control efforts in Karnataka. Methods: We used a retrospective qualitative analysis of tobacco-related litigations adjudicated by the Karnataka High court. We systematically searched a legal database and selected 39 litigations for analysis. We mapped these cases in a spreadsheet and used thematic content analysis of the court judgements. Results: Our study demonstrated that tobacco regulations and legal challenges arise from a range of laws related to food, pharmaceuticals, municipal affairs and taxation in addition to tobacco-specific laws. We found that tobacco regulations have been intensely litigated, predominantly by parties with commercial interests in tobacco that resisted these regulations. Comparatively, there were very few litigations from public health advocates demanding stricter tobacco control regulations. Conclusion: Analysis of litigations helps in identifying legal challenges that inform tobacco control authorities to anticipate and prepare for future challenges in implementing tobacco control regulations. Tobacco control agencies need adequate legal personnel and resources to effectively respond to these challenges.

Pricing of tobacco products: Pre and post GST implementation.

There is ample evidence stating that any taxation policy that effectively increases the real price of tobacco products reduces its use. In the past, several countries have documented instances; wherein the intended effects of tobacco taxation were undermined by aggressive pricing strategies of the industry. However, there is a dearth of such evidence in Indian context. Hence, the current study was conducted to ascertain the changes in the retail price of locally available tobacco products during pre and post GST period in India. This cross-sectional analytical study was conducted among all available tobacco products in the states of Meghalaya, Odisha, Puducherry and Telangana. The information on maximum retail price (MRP) pre and post GST implementation on tobacco products was gathered from the owners of Point of Sale (PoS), vendors and retailers of various tobacco products. The results showed that of the total 154 brands observed pre and post GST implementation, 33.12% [95%CI 25.75-41.15] did not exhibit any increase in their price. The proportion of tobacco product brands with decrease/no change in price was a higher in Meghalaya (PR = 44; 95%CI: 6.32-306.3), Odisha (PR = 23; 95%CI: 3.25-162.7) and Puducherry (PR = 1.48; 95%CI: 0.1-22.84) as compared to Telangana. As compared to cigarettes, smokeless tobacco (PR = 1.84; 95%CI 1.16-2.89) and bidi (PR = 1.74; 95%CI: 0.78-3.9) had more number of brands with a decrease/no change in price post GST implementation. Moreover, four new brands of smokeless tobacco were introduced into the market following GST implementation. The study clearly suggests a departure from the outcomes envisaged by taxation policy on tobacco products in the country. Given the importance of price as a determinant in tobacco use especially among youth, there is an urgent need for strengthening our tax regime for tobacco products.

National level E-Resource Centre for Tobacco Control (E-RCTC): One stop solution to information on tobacco control in India.

The existing information on tobacco control, though highly valuable, is lying scattered at different sources. Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh in collaboration and technical support of International Union against TB and Lung Diseases (The Union) undertook an initiative to start a national level E-Resource Centre for Tobacco Control (E-RCTC) with an aim to provide relevant information on tobacco control under one roof thereby countering the misleading facts on tobacco control which exist on various web engines. The national level E-Resource Centre for Tobacco Control was developed in three stages. In the span of less than 3 years, the portal is open in public domain with over 2,36,019 visitors from around 80+ countries (as on 23rd July 2020), and growing. The portal showcases an array of valuable and vital information related to tobacco control initiatives under various heads like: Policies and Legislations, Circulars and Orders, National Tobacco Control Programme (NTCP), Publications and IEC Materials. India's first national level Resource Centre for Tobacco Control has proved to be a much-needed step in the country for facilitating speedy implementation of World Health Organization- Framework Convention on Tobacco Control (WHO-FCTC), MPOWER and other tobacco control interventions. Even with its limitations like absence of an interactive mechanism among a few others, the Resource Centre is nothing less than a storehouse of knowledge as it showcases content that are immensely helpful for the tobacco control community. Constant efforts are being made to improve the national level E-Resource Centre for Tobacco Control website and minimize the drawbacks.

Depiction of tobacco in Indian mass media: A content analysis.

BACKGROUND: Although exposure to tobacco content on mass media is a well-grounded source for early initiation, less is known on how tobacco is portrayed in mass media. OBJECTIVES: To determine the proportion of tobacco appearances and the percentage of pro or anti-tobacco messages in the selected print, electronic and internet based Indian mass media. METHODS: The content analysis was conducted among selected categories of: top two daily newspapers in terms of readership, topmost Television channel in terms of viewership and top five trending videos on YouTube. The tobacco appearances in newspaper, television (five minute interval) and YouTube (one minute interval) were recorded and coded as pro or anti-tobacco messages. RESULTS: Tobacco appearances were present in 0.3% of 9373 [95% CI: 0.2-0.5] advertisements reviewed in Newspapers; all of which were pro-tobacco messages. Among the total 1512 intervals watched on Television, 18.1% [95% CI: 16.2-20.1] had tobacco appearance. There were a total of 289 tobacco incidents in television of which 92.4% were pro-tobacco messages. Out of the total 900 videos watched on YouTube, 11.44% [95% CI: 9.49-13.65] had tobacco appearance. Among the 206 tobacco incidents present in YouTube, 98.5% were pro-tobacco messages. CONCLUSIONS: The study documented considerable extent of pro-tobacco depictions in Indian mass media.

Prevalence and factors associated with the sale of loose cigarettes at Point of Sale: A cross-sectional analytical study from four Indian states.

BACKGROUND: The Framework Convention on Tobacco Control (FCTC) has established that sale of loose cigarettes increases the affordability and accessibility of tobacco for minors. Acknowledging this threat to public health, the Department of Consumer Affairs, Government of India amended the Legal Metrology Act to prohibit sale of loose cigarettes. Regardless, over 70% of the total cigarette sale in the country is in the form of loose cigarettes majority of which is being sold at unrecognized, unrecorded and unregulated informal sector of economy. However, there is a paucity of studies examining the factors associated with sale of loose cigarettes and further research is warranted in the country to know the dynamics of this issue. OBJECTIVE: To determine the prevalence and the factors associated with the sale of loose cigarettes at Point of Sale (PoS) in the selected four Indian states. METHODS: A community based cross-sectional analytical study was conducted among a total of 2044 PoS in the project states of Meghalaya, Odisha, Puducherry and Telangana using purposive sampling technique. The characteristics of tobacco vendors and the status of loose cigarettes sale were collected using a structured and pre-tested checklist. Proportion for prevalence estimate, bivariate and multivariable log binomial regression analysis were done. RESULTS: The prevalence of loose cigarette sale was 93.05% [95% CI: 91.89-94.1]. Sale of loose cigarette showed a significant association with area (aPR 1.03; 95% CI: 1-1.06; p = 0.025), sale of tobacco products to minors (aPR 1.07; 95% CI: 1.04-1.11; p < 0.001), sale of smoking aids to customers (aPR 1.05; 95% CI: 1.01-1.09; p = 0.02), sale of flavored chewable tobacco (aPR 1.08; 95% CI: 1.03-1.12; p = 0.001) and presence of pack warning (aPR 1.18; 95% CI: 1.11-1.25; p < 0.001). CONCLUSION: Our findings infer an open disregard for the laws specific to sale of loose cigarettes at PoS. The factors associated with the sale of loose cigarette needs to be addressed through prompt implementation of the tobacco control laws and suitable policy formulation.

Communicating risk: Status of health warning labels on various tobacco products in Indian market.

BACKGROUND: Owing to the role of tobacco packaging as a strong medium of communication, display of health warnings on tobacco packs effectively impart health risks of tobacco consumption to those currently using or contemplating the use of tobacco. METHODS: This community based cross-sectional analytical study was conducted among 2044 tobacco product packs, each collected from a different PoS, to estimate the non-compliance of section 7, 8 & 9 of COTPA among various tobacco products and its association with the PoS characteristics. Data were collected by observation of PoS by field investigators and then purchase of a unique product from each vendor followed by a brief interview of the tobacco vendor. RESULTS: The study documented an absence of health warning label on 15.51% [95% CI: 13.99-17.13] of the total 2044 tobacco products collected. The non-compliance to 'quality of health warning picture' was lowest 5.96% [95% CI: 4.91-7.16] among the tobacco products with a health warning label. The multivariate regression model revealed that absence of health warning on tobacco product packs were higher among the PoS in rural area (aPR 1.38; 95% CI: 1.16-1.65; p < 0.001) and among street/mobile vendors (aPR 1.65; 95% CI: 1.22-2.24; p = 0.001). The PoS not displaying tobacco products (aPR 1.36; 95% CI: 1.08-1.72; p = 0.01), selling flavored chewable tobacco (aPR 1.67; 95% CI: 1.24-2.27; p = 0.001), not selling loose cigarettes (aPR 2.93; 95% CI: 1.94-4.43; p < 0.001) and with vendors not enquiring age proof (aPR 10.69; 95% CI: 1.59-72.09; p < 0.001) had higher proportion of tobacco products without health warning labels. A greater proportion of smokeless/local variety tobacco products (aPR 18.06; 95% CI: 12.31-26.51; p < 0.001) had absence of health warning label. CONCLUSION: The data provided by us have clear policy implications. We recommend regular enforcement activities to monitor the presence of health warning labels on tobacco product packs along and accurate printing of the same with adherence to the Ministry of Health and Family Welfare templates.