Compliance to Online Retail of Electronic Nicotine Delivery Systems (ENDS) in India before and after the 2018 Ban Order of the Government of India.

Since their launch globally in 2012, electronic nicotine delivery systems (ENDS) were positioned as a harm reduction strategy and cessation device but it is yet to be proven to have clinical safety or public health benefits. Instead, recent reports suggest that the tobacco industry targeted youth and sponsored research whose evidence was used to mislead policymaking. On August 28, 2018, Ministry of Health & Family Welfare's advisory banned the sale, purchase, and trade of ENDS. A survey was done in two waves. The first survey was done between August 10 and 25 2018 all websites which sold ENDS product were mapped and documented. The survey was repeated (November 30, 2018) were after the restriction to trade on ENDS was proposed by the Department of Customs. The two waves of survey found that no website, whether comprehensive e-commerce portals or dedicated ENDS marketing platforms fully complied with government orders. National and states government enforcement agencies are currently unaware of internet-based sale of ENDS. Although some states have given specific directions to stop the sale and delivery of ENDS within the state through e-commerce, there is limited monitoring and legal compliance by seller. Public health advocates need to stay vigilant and monitor the online sale and point of sale retail of ENDS to ensure strict compliance of national and state regulations.

Banning Loose Cigarettes and Other Tobacco Products in India: A Policy Analysis.

BACKGROUND: Sale of single cigarettes (also known as singles or loosies) is a key driver for early initiation of smoking and is a leading contributor to the smoking epidemic in India. Sale of singles additionally deter implementation of tobacco control strategies of pictorial health warnings including plain packaging and defeat effective taxation and promote illicit trade. We review India's tobacco control policy responses towards banning singles and other products sold as loose tobacco and identify opportunities for future policy intervention especially in the context of the ongoing COVID-19 pandemic. METHODS: Existing national and sub-national policy documents were analyzed for their content since the inception of the tobacco control laws in the country. RESULTS: There are no effective provisions at national level to ban loose tobacco products in India. However, the implementation of multiple legislative and regulatory measures (Acts/circulars/letters/notifications/orders/court judgements) in 16 Indian states and jurisdictions provide sufficient legal framework to substantiate its complete ban pan India. While the majority of state governments have adopted state level measures, Rajasthan had issued specific directive to all the 33 districts banning loose cigarettes and other tobacco products. Himachal Pradesh introduced the most unique and comprehensive legislation, for banning the sale of cigarettes and beedis (Dated November 7, 2016). The most recent notification in the state of Maharashtra (September 24, 2020) is the first to leverage powers using a mix of national and state legislations including the legislation addressing the rapidly emerging challenge of managing COVID-19. CONCLUSION: A robust national policy which supports strong provision to deter tobacco companies, their distribution network and vendors from selling singles or loose tobacco products is urgently needed. Such policy should be backed by cautionary messaging for consumers as well. Eliminating singles and loose tobacco sale will help in blunting tobacco use prevalence besides curbing spread of infectious diseases like COVID-19 pandemic.

Health Warning Label Compliance for Smokeless Tobacco Products and Bidis in Five Indian States.

BACKGROUND: The burden of tobacco use In India is very high. To inform users of harm, India has a strong health warning label law that applies to all tobacco products. This study examines the extent of compliance of health warning labels on smokeless tobacco (SLT) and bidi products with the Indian law. METHODS: In 2017, a systematic protocol was used to collect unique SLT and bidi packages from five Indian states. To assess compliance, we used three indicators: location, label elements, and warning size. RESULTS: Only 1% of the 133 SLT products and none of the 32 bidi packs were compliant with all three compliance indicators. Other compliance-related issues included non-standardized packaging, incomplete health warning labels, poor printing quality, and old warning labels. CONCLUSION: There is very poor compliance with the health warning label law on bidi and SLT products. India needs to regularly monitor and address implementation to ensure that warning labels are effective.

Tobacco Advertising, Promotion and Sponsorship in India and Indonesia: Present Regime and the Way Forward.

One of the important factors contributing to tobacco epidemic is tobacco advertising, promotion, and sponsorship (TAPS). TAPS is employed by tobacco industry to increase demand for its products, often through targeting specific groups or market segments. The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) recommends implementation of comprehensive bans on TAPS as part of an effective set of tobacco control policies. Article 13 of the WHO FCTC and its guidelines mandate a comprehensive ban on all TAPS. Besides, TAPS ban is one of the MPOWER strategy and is included in the 'Best Buys' for effective tobacco control. However, many countries, especially low-income and middle-income countries, primarily implement only partial TAPS bans, allowing the tobacco industry to directly or indirectly advertise and promote its products via multiple media. This review article analyzes the current state of affairs in respect of TAPS in India and Indonesia, the two of the largest countries in the WHO South-East Asia Region of the world, and discusses the way forward to address the identified gaps in TAPS ban policy formulation and implementation focusing on strengthening its compliance and enforcement at the country level.

A Legal and Epidemiological Consideration of the Causal Relationship between Tobacco and Lung Cancer.

This study reviewed issues including causality among tobacco companies' illegal acts, smoking, and lung cancer occurrence. In tobacco lawsuits so far, the burden of proof regarding negligence and a causal relationship has fallen on plaintiffs, who are the injured party. However, since the legislation of the Product Liability Act, the possibility of mitigating plaintiffs' burden of proof has opened up. Nevertheless, this alone cannot prevent the immense socioeconomic cost incurred due to smoking. It is legislatively necessary to enact a tobacco management law so that the no-fault liability of tobacco companies, which are the defendants, for compensation can be acknowledged. However, it is necessary to take supplementary measures through the social security system such as establishing the upper limits for liquidated damages in lawsuits and creating a relief fund for the victims of smoking. In addition, it is fundamentally necessary for courts to accept the methods for inferring causality that are based on the natural sciences and epidemiology in situations such as tobacco lawsuits, where a causal relationship cannot be proven easily. In particular, jurists, too, must consider the application of population-based evidence presented by epidemiologists to lawsuits in a forward-looking manner for redressing damages to individuals with diseases; thus, bridging the gap between normative adjudication and scientific judgment to draw a conclusion about a causal relationship.

Tobacco control policies in the 21st century: achievements and open challenges.

Noncommunicable diseases (NCDs), including cancer, are responsible for almost 70% of all deaths worldwide. Tobacco use is a risk factor common to most NCDs. This article discusses tobacco control policies and highlights major achievements and open challenges to reduce smoking prevalence and attributable morbidity and mortality in the 21st century. The introduction of the WHO Framework Convention on Tobacco Control in 2005 has been a key achievement in the field and has already facilitated a drop in both smoking prevalence and exposure to secondhand smoke. Indicatively, the size of the worldwide population benefiting from at least one cost-effective tobacco control policy has quadrupled since 2007. In addition, plain cigarette packaging has been successfully introduced as a tobacco control policy, surmounting efforts of the tobacco industry to challenge this based on trade and investment law. Nevertheless, tobacco control still faces major challenges. Smoking prevalence needs to be further reduced in a rather expedited manner. Smoke-free environments should be extended, and the use of plain tobacco packaging with large pictorial health warnings for all tobacco products should be further promoted in some parts of the world. Some of these measures will require prompt determination and diligence. For example, bold political decisions are needed to significantly increase real prices of tobacco products through excise taxes, ban added ingredients that are currently used to increase the attractiveness of tobacco products and ban the tobacco industry's corporate social responsibility initiatives. Finally, the debate on harm reduction strategies for tobacco control still needs to be resolved.

The Application of Philip Morris' Litigation Prevention Program in South Korea.

This article is aimed to identify the strategies of Philip Morris (PM, before its spin-off in 2003) and its affiliates in the intervention and prevention of tobacco litigation in South Korea. We analyzed 193 documents obtained from the Truth Tobacco Industry Documents. We found that PM organized and operated the "Litigation Prevention Program (LPP)" to create legal environments making tobacco litigation difficult to initiate and legal networks with local lawyers, media, and even competitors to effectively respond to such litigations. PM developed the LPP based on its legal strategies in the United States against tobacco litigation and disseminated them all around the world including South Korea. In 1999, the first joint action against Korea Tobacco and Ginseng Corporate (KTGC, today known as KT&G), a state-owned tobacco company, began. KTGC asked PM to support their litigation, and PM provided its legal strategies, such as sources to counter the plaintiffs' arguments, through the LPP to KTGC. In front of legal threats, tobacco companies, competitors in markets, jointly fought back the litigation in Korea. Any litigation against a single local tobacco company may confront legal networks of tobacco companies. As a result, no litigation against tobacco companies in South Korea has been able to win over tobacco companies. International legal support including the development of guidelines of Article 19 of the Framework Convention on Tobacco Control is vital for an effective legal fight against tobacco companies around the world.

How Coca-Cola Shaped the International Congress on Physical Activity and Public Health: An Analysis of Email Exchanges between 2012 and 2014.

There is currently limited direct evidence of how sponsorship of scientific conferences fits within the food industry's strategy to shape public policy and opinion in its favour. This paper provides an analysis of emails between a vice-president of The Coca-Cola Company (Coke) and prominent public health figures in relation to the 2012 and 2014 International Congresses of Physical Activity and Public Health (ICPAPH). Contrary to Coke's prepared public statements, the findings show that Coke deliberated with its sponsored researchers on topics to present at ICPAPH in an effort to shift blame for the rising incidence of obesity and diet-related diseases away from its products onto physical activity and individual choice. The emails also show how Coke used ICPAPH to promote its front groups and sponsored research networks and foster relationships with public health leaders in order to use their authority to deliver Coke's message. The study questions whether current protocols about food industry sponsorship of scientific conferences are adequate to safeguard public health interests from corporate influence. A safer approach could be to apply the same provisions that are stipulated in the Framework Convention on Tobacco Control on eliminating all tobacco industry sponsorship to the food industry.

Raising Tobacco Taxes: The Philippine Experience.

The 2012 Philippine Sin Tax Reform Law or Republic Act No. 10351 (RA10351) offers important lessons on tobacco taxation and tobacco control. In a span of five years, it increased the excise tax rate on cigarettes to as high as 1000% for low-priced brands. It is recognized by the international community not only because of the magnitude of the tobacco tax increase that it stipulated but also because of the challenging context within which it was achieved. This article presents the Philippine experience as a case study in pursuing bold reforms in tobacco taxation and tobacco control amidst strong opposition by the tobacco industry. It considers: 1) the key events and factors that led to successful reform of the Philippine tobacco tax system; 2) the impact of higher tobacco taxes on health and the economy; and 3) the emerging challenges in tobacco taxation in the Philippines.
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Tobacco Industry Fingerprints on Delaying Implementation of Pictorial Health Warnings in the Western Pacific.

OBJECTIVE: This case series describes tobacco industry tactics and strategies used to interfere, derail, delay, and weaken the development of effective health warning regulations in Malaysia, Cambodia, the Philippines, and Hong Kong. METHODS: A historical review of official reports, news articles, and gray literature was undertaken to identify tobacco industry tactics and strategies to hamper government efforts in implementing stronger pictorial health warning regulations in four Asian jurisdictions (Cambodia, Hong Kong, Malaysia, and the Philippines). RESULTS: Nineteen countries/jurisdictions in the WHO Western Pacific region currently require pictorial health warnings on cigarette packs, including some of the world's largest, in line with the WHO Framework Convention on Tobacco Control Article 11 Guidelines. In the four jurisdictions examined, tobacco industry interference consisted of lobbying and misinformation of high-level government officers and policy-makers, distributing industry-friendly legislative drafts, taking government to court, challenging government timelines for law implementation, and mobilizing third parties. Strong political leadership and strategic advocacy enabled governments to successfully overcome this industry interference. CONCLUSION: The tobacco industry uses similar tactics in different jurisdictions to derail, delay, and weaken the implementation of effective health warning policies. Identifying and learning from international experiences can help anticipate and defeat such challenges.

Comparison of tobacco import and tobacco control in five countries: lessons learned for Indonesia.

BACKGROUND: With a 264 million population and the second highest male smoking prevalence in the world, Indonesia hosted over 60 million smokers in 2018. However, the government still has not ratified the Framework Convention on Tobacco Control. In the meantime, tobacco import increases rapidly in Indonesia. These create a double, public health and economic burden for Indonesia's welfare. OBJECTIVE: Our study analyzed the trend of tobacco import in five countries: Indonesia, Pakistan, Bangladesh, Zimbabwe, and Mozambique. Also, we analyze the tobacco control policies implemented in these countries and determine some lessons learn for Indonesia. METHODS: We conducted quantitative analyses on tobacco production, consumption, export, and import during 1990-2016 in the five countries. Data were analyzed using simple ordinary least square regressions, correcting for time series autocorrelation. We also conducted a desk review on the tobacco control policies implemented in the five countries. RESULTS: While local production decreased by almost 20% during 1990-2016, the proportion of tobacco imports out of domestic production quadrupled from 17 to 65%. Similarly, the ratio of tobacco imports to exports reversed from 0.7 (i.e., exports were higher) to 2.9 (i.e., import were 2.9 times higher than export) in 1990 and 2016, respectively. This condition is quite different from the other four respective countries in the observation where their tobacco export is higher than the import. From the tobacco control point of view, the four other countries have ratified the Framework Convention on Tobacco Control (FCTC). CONCLUSION: The situation is unlikely for Indonesia to either reduce tobacco consumption or improve the local tobacco farmer's welfare, considering that the number of imports continued to increase. Emulating from the four countries, Indonesia must ratify the FCTC and implement stricter tobacco control policies to decrease tobacco consumption and import.

Impact of tobacco industry pricing and marketing strategy on brand choice, loyalty and cessation in global south countries: a systematic review.

OBJECTIVES: We undertook this review to assess the impact of pricing strategies on brand choice, loyalty and quitting behaviour in Global South countries. METHODS: We systematically retrieved articles from Medline, CENTRAL, ScienceDirect, Google Scholar from inception up to January 2020. Studies which reported tobacco industry's pricing strategies were eligible. We summarized the data as themes and codes using the principles of inductive qualitative thematic analysis within structured rational constructivist framework. RESULTS: In total, 13 studies met inclusion criteria were included. Major strategies adopted by tobacco industries to tackle the pricing and taxation changes were increased tax absorption, differential taxation based on price, cigarette length/size which ensures modest increase in the net price of cigarettes. This in turn influences the tobacco users in terms of brand loyalty and switching as they prefer to stay with factory-made cigarettes or shift to a cheaper alternative or illegal product rather than decreasing/quitting tobacco use. CONCLUSIONS: Absorption of excise tax and differential taxation are the common pricing strategies adopted by tobacco industries in Global South. These strategies together with external determinants impact the price-related tobacco control interventions.

Estimating the Magnitude of Illicit Cigarette Trade in Bangladesh: Protocol for a Mixed-Methods Study.

The illicit tobacco trade undermines the effectiveness of tobacco tax policies; increases the availability of cheap cigarettes, which, in turn, increases tobacco use and tobacco related deaths; and causes huge revenue losses to governments. There is limited evidence on the extent of illicit tobacco trade particularly cigarettes in Bangladesh. The paper presents the protocol for a mixed-methods study to estimate the extent of illicit cigarette trade in Bangladesh. The study will address three research questions: (a) What proportion of cigarettes sold as retail are illicit? (b) What are the common types of tax avoidance and tax evasion? (c) Can pack examination from the trash recycle market be considered as a new method to assess illicit trade in comparison to that from retailers and streets? Following an observational research method, data will be collected utilizing empty cigarette packs from three sources: (a) retailers; (b) streets; and (c) trash recycle market. In addition, a structured questionnaire will be used to collect information from retailers selling cigarettes. We will select post codes as Primary Sampling Unit (PSU) using a multi-stage random sampling technique. We will randomly select eight districts from eight divisions stratified by those with land border and non-land border; and within each district, we will randomly select ten postcodes, stratified by rural (five) and urban (five) PSU to ensure maximum geographical variation, leading to a total of eighty post codes from eight districts. The analysis will report the proportions of packs that do not comply with the study definition of illicit. Independent estimates of illicit tobacco are rare in low- and middle-income countries such as Bangladesh. Findings will inform efforts by revenue authorities and others to address the effects of illicit trade and counter tobacco industry claims.

Characteristics of proposed and enacted state tobacco control legislation in the United States, 2010-2015.

This study documents all tobacco control proposals (bills) introduced in the United States into all 50 state legislatures from the start of 2010 through 2015 and assesses associations between tobacco-related strategies and tobacco product types with enactment of the bills into law. In total, members of state legislatures introduced 2801 tobacco control bills, and state legislatures enacted 17.4%. Bills most introduced addressed clean air (n = 696) and tax or price bills (n = 582), yet both had lower likelihood of enactment (each OR, 0.51; 95% CI 0.38-0.69) compared to bills on any other tobacco control strategy. Legislators introduced only 147 product manufacturing bills, but these had the highest odds of enactment (OR, 3.70, 95% CI 2.52-5.44) compared to any other intended strategy, followed by tax evasion (OR, 3.08; 95% CI 2.33-4.08) and retailer licensing or location (OR, 1.73; 95 CI 1.24-2.41). Compared to other products, bills regulating e-cigarettes had the highest enactment rate (21.2%). Despite introduction of many bills promoting traditional, evidence-based tobacco control strategies, these had less likelihood of enactment than others.