Programme and policy perspectives towards a tobacco-free generation in India: findings from a qualitative study.

OBJECTIVE: This study explored multistakeholder perspectives on existing adolescent-specific tobacco control policies and programmes, to advance India's transition towards a tobacco-free generation. DESIGN: Qualitative semi-structured interviews. SETTING: Interviews were conducted with officials involved in tobacco control at the national (India), state (Karnataka), district (Udupi) and village level. Interviews were audio recorded, transcribed verbatim and analysed thematically. PARTICIPANTS: Thirty-eight individuals representing national (n=9), state (n=9), district (n=14) and village (n=6) levels, participated. RESULTS: The study findings highlighted the need to strengthen and amend the existing Tobacco Control Law (2003) provisions, particularly in the vicinity of schools (Sections 6a and 6b). Increasing the minimum legal age to buy tobacco from 18 to 21 years, developing an 'application' for 'compliance and monitoring indicators' in Tobacco-Free Educational Institution guidelines were proposed. Policies to address smokeless tobacco use, stricter enforcement including regular monitoring of existing programmes, and robust evaluation of policies was underscored. Engaging adolescents to co-create interventions was advocated, along with integrating national tobacco control programmes into existing school and adolescent health programmes, using both an intersectoral and whole-societal approach to prevent tobacco use, were recommended. Finally, stakeholders mentioned that when drafting and implementing a comprehensive national tobacco control policy, there is a need to adopt a vision striving toward a tobacco-free generation. CONCLUSION: Strengthening and developing tobacco control programmes and policies are warranted which are monitored and evaluated rigorously, and where adolescents should be involved, accordingly.

Accelerating policy response to curb non-communicable diseases: an imperative to mitigate the dual public health crises of non-communicable diseases and COVID-19 in India.

Non-communicable Diseases (NCDs) are a threat to public health and sustainable development. NCDs were equated to being a 'pandemic' before COVID-19 originated. Globally, NCDs caused approximately 74% of deaths (2019). India accounted for nearly 14.5% of these deaths. NCDs and COVID-19 have a lethal bi-directional relationship with both exacerbating each other's impact. Health systems and populations, particularly in Low- and Middle-Income Countries (LMICs) like India have among the highest burden of COVID-19. This narrative review tracks key policy and programmatic developments on NCD prevention and control in India, with a focus on commercially-driven risk factors (tobacco and alcohol use, unhealthy diet, physical inactivity, and air pollution), and the corresponding NCD targets. It identifies lacunae and recommends urgent policy-focussed multi-dimensional action, to ameliorate the dual impact of NCDs and COVID-19. India's comprehensive response to NCDs can steer national, regional and global progress towards time-bound NCD targets and NCD-related Sustainable Development Goals (SDGs). Funding: This work is supported by the Commonwealth Foundation. None of the authors were paid to write this article by a pharmaceutical company or other agency. The authors were not precluded from accessing data and accept responsibility to submit for publication.

Anxiety and depression among adult tobacco users during the COVID-19 restrictions in India.

Background: The world witnessed a highly contagious and deadly disease, COVID-19, toward the end of 2019. India is one of the worst affected countries. We aimed to assess anxiety and depression levels among adult tobacco users and people who recently quit tobacco during COVID-19 lockdown in India. Materials and methods: The study was conducted across two Indian cities, Delhi and Chennai (July-August, 2020) among adult tobacco users (n = 801). Telephonic interviews were conducted using validated mental health tools (Patient Health Questionnaire-PHQ-9 and Generalized Anxiety Disorder-GAD-7) to assess the anxiety and depression levels of the participants. Descriptive analysis and multiple logistic regression were used to study the prevalence and correlates of depression and anxiety. Results: We found that 20.6% of tobacco users had depression symptoms (3.9% moderate to severe); 20.7% had anxiety symptoms (3.8% moderate to severe). Risk factors associated with depression and anxiety included food, housing, and financial insecurity. Conclusion: During COVID-19 lockdown, mental health of tobacco users (primarily women) was associated with food, housing and financial insecurity. The Indian Government rightly initiated several health, social and economic measures to shield the most vulnerable from COVID-19, including a ban on the sale of tobacco products. It is also necessary to prioritize universal health coverage, expanded social security net, tobacco cessation and mental health services to such vulnerable populations during pandemic situations.

Norms, rules and policy tools: understanding Article 5.3 as an instrument of tobacco control governance.

INTRODUCTION: Article 5.3 of the WHO Framework Convention on Tobacco Control, elaborated via its implementation guidelines, can be understood as a policy instrument comprising norms, rules and policy tools designed to shape practices of policy making and minimise tobacco industry interference. METHODS: This qualitative research is based on in-depth interviews with officials from diverse government sectors and non-governmental organisations across countries (Ethiopia, India, Uganda) that have adopted measures to implement Article 5.3. RESULTS: The data highlight varied perceptions and knowledge of Article 5.3 norms between health and non-health sectors. Health officials typically link its core norm of a fundamental conflict between public health and industry interests to the governance norm of protecting public health policies from industry interference. While officials in sectors beyond health broadly endorsed this core norm, they exhibited more limited awareness of Article 5.3 and its model of governance. The results examine how rules to implement Article 5.3 have been codified, but identify the absence of policy tools necessary to operationalise rules and norms. This limitation, alongside restricted awareness beyond health departments, suggests that political commitments to implement Article 5.3 will have limited impact on practices of stakeholder consultation and policy engagement with the tobacco industry. CONCLUSION: Conceptualising Article 5.3 as a policy instrument helps to explain how its rules and policy tools interact with each other and with broader governance processes. This framework has the potential to enhance understanding of Article 5.3 and help identify opportunities and constraints in its implementation.

Understanding the dynamics of notification and implementation of Article 5.3 across India's states and union territories.

INTRODUCTION: In federal systems, state and local governments may offer opportunities for innovation in implementing the WHO Framework Convention on Tobacco Control (FCTC). This paper explores the implementation of WHO FCTC Article 5.3 within India's federal system, examining how its guidelines have been operationalised across states and union territories. METHODS: Interviews with officials from government and civil society organisations across key states, and a document review of state government and district administration notifications adopting Article 5.3 guidelines between 2015 and 2019. RESULTS: The data reveal subnational leadership in formulating intersectoral committees, which are designed to limit interactions with the tobacco industry, and corresponding measures to reject partnership and conflicts of interest for government officials. There are notable omissions across states and union territories in adoption of key Article 5.3 guidelines; only four districts and state governments refer to regulating aspects of 'socially responsible' industry activities, and no notifications include measures to prevent the tobacco industry receiving preferential treatment or requiring that information provided by industry actors be transparent and accountable. Interview data indicate that dynamics of notification across states have been shaped by lesson drawing and the catalytic role of civil society. The adoption of protocols is impacting on the practices of health officials, but there are concerns about engagement by other departments and the regulatory capacity of empowered committees. CONCLUSION: The spread of state- and district-level policies illustrates opportunities federal structures can provide for accelerating tobacco control. Given significant omissions and policy tensions, there remains a need for national action to build on these innovations, including in revisions to India's tobacco control legislation.

Implementation of Article 5.3 of the World Health Organization Framework Convention on Tobacco Control: A Subnational Assessment.

Background: Article 5.3 of the World Health Organization's Framework Convention on Tobacco Control necessitates the governments to take measures to protect health policy from the commercial and other vested interests of the tobacco industry (TI). Considering the vast geographical area and diversity between states within India, it is necessary to evaluate the level of implementation of Article 5.3 at the sub-national level. Hence, this study was conducted to assess the implementation of Article 5.3 in the Karnataka state of southern India. Materials and Method: Southeast Asia Tobacco Control Alliance Tobacco Industry Interference index was adopted and used for the study. A desk review was conducted for 2018. Publicly available evidence of tobacco industry interference was scored based on its frequency, severity, and the government's response to it. Lower the score, effective the level of governance against the TI interference, which predicts well for the state. Results: The study demonstrates a score of 46 out of 95 in the implementation of Article 5.3 in Karnataka, which is lower when compared to the national score of 69 out of 100 for 2018. Corporate social responsibility, conflict of interest, and unnecessary interactions with TI are the major areas that need focus to comply with the provisions of Article 5.3. Conclusion: Overall, Karnataka needs to strengthen the implementation of Article 5.3 and develop a strategy in line with the global best practices. This assessment can help in identifying areas requiring enhanced vigilance to avoid industry interference.

Knowledge, attitude, and behaviours on diet, physical activity, and tobacco use among school students: A cross-sectional study in two Indian states.

Background: Non-communicable diseases (NCDs) are escalating in India and can be attributed to behavioural risk factors such as unhealthy diet, physical inactivity and tobacco use that began in early years. Understanding adolescents' knowledge, attitudes and behaviours (KAB) related to NCD risk factors would inform the development of school-based health programmes to prevent NCDs. Methods: Sixth-grade students (n=1026) in 20 schools (10 private, 10 public) from two Indian cities (n=667 from Pune; n=359 from Bengaluru) participated in a KAB survey in 2019. Differences in KAB by gender, school type within cities were investigated. Results: Knowledge about the harms of tobacco use was higher than knowledge about a healthy diet and the importance of physical activity. Only a small proportion of students did not eat breakfast (8.7%) or fruits (11.3%) daily. Only 33.4% of students read nutrition labels before choosing their food. Moderate-to-vigorous physical activity of less than an hour per day was reported by 42.5% of students. Approximately one-third of students had ever tried smoking tobacco (30.1%), smokeless tobacco (30.5%), and e-cigarettes (32.4%). Differences in these behaviours by gender and school type showed that both boys, girls and students of private and public schools are vulnerable. Conclusions: The findings highlight that knowledge is low for thematic areas like diet and physical activity. Low knowledge can be attributed to unfavourable behaviours like lack of reading nutrition labels and indulgence in sedentary activities. To protect India's young population (adolescents), there is a need to amplify health education activities and context-specific health intervention materials for them by engaging parents and communities. Thus, these programmes should be incorporated into the curriculum as part of the regular teaching, as they may induce positive changes in their knowledge and behaviours. In India, school health programmes should dedicate significant time to health promotion and NCD risk prevention.

Tobacco Industry Interference Index: Implementation of the World Health Organization's Framework Convention on Tobacco Control Article 5.3 in India.

In India, there has been no attempt to measure the implementation of World Health Organization's Framework Convention on Tobacco Control Article 5.3, which provides guidelines to address tobacco industry interference (TII). This study draws on a desk review conducted to assess the frequency and severity of TIIs and the government's response, reported between January and December 2017. This study highlights that the government of India does not allow tobacco industry to participate in policy development. However, the industry interferes by collaborating with the government's allied organizations. The tobacco industry has diversified as food industry in India, and directly or indirectly supports various government programs, by investing through their corporate social responsibility schemes. In addition, there are limited legislative measures to allow transparency in adoption of Article 5.3 guidelines across the country. Hence, the findings of this study underscore an exigent need to adopt and implement Article 5.3 at the national level in India.

School policies, built environment and practices for non-communicable disease (NCD) prevention and control in schools of Delhi, India.

OBJECTIVE: To assess school policies, built environment and practices for prevention and control of non-communicable diseases in schools of Delhi, India. METHODS: School built environments and policies were assessed using a structured observation checklist in 10 private and 9 government schools which were randomly selected from all 184 co-educational schools with primary to senior secondary level education in Delhi, India. A self-administered questionnaire was also completed by teachers from each school (n = 19) to capture information specific to school policies. Surveys were also conducted with parent of students in class II (aged 6-7 years; n = 574) and student in class XI (aged 15-16 years, n = 755) to understand school practices. RESULTS: The majority of government (88.9%; n = 8) and private (80%; n = 8) schools reported having comprehensive school health policy. In terms of specific health behaviours, policies related to diet and nutrition in government schools were mostly restricted to primary levels with provision of the mid-day meal programme. All schools had two physical education periods per week of about 45-50 minutes. Most schools were compliant with tobacco-free school guidelines (n = 15 out of 19) and had alcohol control policies (n = 13 out of 19). Parent and student reports of practices indicated that school policies were not consistently implemented. CONCLUSION: Most schools in Delhi have policies that address health behaviours in students, but there was considerable variation in the types and number of policies and school environments. Government schools are more likely to have policies in place than private schools. Further work is needed to evaluate how these policies are implemented and to assess their impact on health outcomes.

School environment assessment tools to address behavioural risk factors of non-communicable diseases: A scoping review.

We aimed to identify, describe and analyse school environment assessment (SEA) tools that address behavioural risk factors (unhealthy diet, physical inactivity, tobacco and alcohol consumption) for non-communicable diseases (NCD). We searched in MEDLINE and Web of Science, hand-searched reference lists and contacted experts. Basic characteristics, measures assessed and measurement properties (validity, reliability, usability) of identified tools were extracted. We narratively synthesized the data and used content analysis to develop a list of measures used in the SEA tools. Twenty-four SEA tools were identified, mostly from developed countries. Out of these, 15 were questionnaire based, 8 were checklists or observation based tools and one tool used a combined checklist/observation based and telephonic questionnaire approach. Only 1 SEA tool had components related to all the four NCD risk factors, 2 SEA tools has assessed three NCD risk factors (diet/nutrition, physical activity, tobacco), 10 SEA tools has assessed two NCD risk factors (diet/nutrition and physical activity) and 11 SEA tools has assessed only one of the NCD risk factor. Several measures were used in the tools to assess the four NCD risk factors, but tobacco and alcohol was sparingly included. Measurement properties were reported for 14 tools. The review provides a comprehensive list of measures used in SEA tools which could be a valuable resource to guide future development of such tools. A valid and reliable SEA tool which could simultaneously evaluate all NCD risk factors, that has been tested in different settings with varying resource availability is needed.

Workplace wellness programming in low-and middle-income countries: a qualitative study of corporate key informants in Mexico and India.

BACKGROUND: A qualitative study of key informant semi-structured interviews were conducted between March and July 2016 in Mexico and India to achieve the following aims: to explore corporations' and stakeholders' views, attitudes and expectations in relation to health, wellness and cancer prevention in two middle-income countries, and to determine options for health professions to advance their approach to workplace wellness programming globally, including identifying return-on-investment incentives for corporations to implement wellness programming. RESULTS: There is an unmet demand for workplace wellness resources that can be used by corporations in an international context. Corporations in India and Mexico are already implementing a range of health-related wellness programs, most often focused on disease prevention and management. A number of companies indicated interest is collecting return on investment data but lacked the knowledge and tools to carry out return-on-investment analyses. There was widespread interest in partnership with international non-governmental organizations (public health organizations) and a strong desire for follow-up among corporations interviewed, particularly in Mexico. CONCLUSIONS: As low-and middle-income countries continue to undergo economic transitions, the workforce and disease burden continue to evolve as well. Evidence suggests a there is a growing need for workplace wellness initiatives in low-and middle-income countries. Results from this study suggest that while corporations in India and Mexico are implementing wellness programming in some capacity, there are three areas where corporations could greatly benefit from assistance in improving wellness programming in the workplace: 1) innovative toolkits for workplace wellness initiatives and technical support for adaptation, 2) assistance with building partnerships to help implement wellness initiatives and build capacity, and 3) tools and training to collect data for surveillance as well as monitoring and evaluation of wellness programs.

Impact of school policies on non-communicable disease risk factors - a systematic review.

BACKGROUND: Globally, non-communicable diseases (NCDs) are identified as one of the leading causes of mortality. NCDs have several modifiable risk factors including unhealthy diet, physical inactivity, tobacco use and alcohol abuse. Schools provide ideal settings for health promotion, but the effectiveness of school policies in the reduction of risk factors for NCD is not clear. This study reviewed the literature on the impact of school policies on major NCD risk factors. METHODS: A systematic review was conducted to identify, collate and synthesize evidence on the effectiveness of school policies on reduction of NCD risk factors. A search strategy was developed to identify the relevant studies on effectiveness of NCD policies in schools for children between the age of 6 to 18 years in Ovid Medline, EMBASE, and Web of Science. Data extraction was conducted using pre-piloted forms. Studies included in the review were assessed for methodological quality using the Effective Public Health Practice Project (EPHPP) quality assessment tool. A narrative synthesis according to the types of outcomes was conducted to present the evidence on the effectiveness of school policies. RESULTS: Overall, 27 out of 2633 identified studies were included in the review. School policies were comparatively more effective in reducing unhealthy diet, tobacco use, physical inactivity and inflammatory biomarkers as opposed to anthropometric measures, overweight/obesity, and alcohol use. In total, for 103 outcomes independently evaluated within these studies, 48 outcomes (46%) had significant desirable changes when exposed to the school policies. Based on the quality assessment, 18 studies were categorized as weak, six as moderate and three as having strong methodological quality. CONCLUSION: Mixed findings were observed concerning effectiveness of school policies in reducing NCD risk factors. The findings demonstrate that schools can be a good setting for initiating positive changes in reducing NCD risk factors, but more research is required with long-term follow up to study the sustainability of such changes.

Reducing tobacco use among low socio-economic status youth in Delhi, India: outcomes from project ACTIVITY, a cluster randomized trial.

To test the efficacy of an intervention to reduce tobacco use among youth (10-19 years old) in slum communities in Delhi, India. This community-based cluster-randomized trial included 14 slums composed of purposely built resettlement colonies and adjacent inhabitant-built Jhuggi Jhopris. Youth in the intervention received a 2 year multiple-component intervention: (a) youth and adult leader training; (b) peer-led interactive activities and outreach; (c) tobacco cessation camps; and (d) enforcement of India's Tobacco Control Law (smoke-free environments and youth access). Overall, no differences between the intervention and control conditions were observed over time; self-reported tobacco use declined in both groups. However, when stratified by type of residence, a significant decrease was observed among youth in the resettlement colonies in the intervention group for overall tobacco use (slope = -0.69) and cigarette and bidi smoking (slope = -0.66), compared to an increase in the control group (slope = 0.24 and 0.12, respectively) (P < 0.001). No differences in smokeless tobacco (SLT) use were observed for either group. Comprehensive community-based interventions that engage youth can be effective in reducing smoking among disadvantaged youth in India. More intensive interventions, like tax increases or large-scale media campaigns, appear warranted for the most marginalized in this context and for SLT products.

Project EX-India: A classroom-based tobacco use prevention and cessation intervention program.

Tobacco use experimentation is most frequent between the ages of 15­24 in India. Therefore, programming to counteract tobacco use among adolescents is needed. There is a lack of evidence-based teen tobacco use prevention and cessation programs. The current study provides an outcome evaluation of the Project EX tobacco use prevention and cessation program among Indian adolescents (16­18 years). An eight-session classroom-based curriculum was adapted to the Indian context and translated from English to Hindi (local language). Next, it was tested using a quasi-experimental design with 624 Indian students at baseline, involving two program and two control schools, with a three-month post-program follow-up. Project EX involves motivation enhancement (e.g., talk shows and games) and coping skills (e.g., complementary and alternative medicine) components. Program participants rated complementary and alternative medicine (CAM) activities like meditation, yoga and healthy breathing higher than talk shows and games. Compared to the standard care control condition, the program condition revealed a prevention effect, but not a cessation effect. Implications for prevention/cessation programming among Indian teens are discussed. This study was approved by the Independent Ethics Committee, Mumbai.

Using salivary cotinine to validate self-reports of tobacco use by Indian youth living in low-income neighborhoods.

BACKGROUND: Self-reported tobacco use among young people can underestimate the actual prevalence of tobacco use. Biochemical validation of self-reports is particularly recommended for intervention studies where cessation outcomes are to be measured. Literature on biochemical validation of self-reports of multiple forms of tobacco use in India is sparse, particularly among young people. METHODS: The study was conducted during the baseline household survey of a community-based tobacco prevention and cessation intervention trial for youth (10-19 years old) residing in slum communities in Delhi, India in 2009. Salivary cotinine measurement on 1,224 samples showed that youth were under-reporting use of chewing and smoking tobacco. RESULTS: Self-reports had a low sensitivity (36.3%) and a positive predictive value of 72.6%. No statistically significant difference in under- reporting was found between youth in the control and intervention conditions of the trial, which will be taken into consideration in assessing intervention outcomes at a later time point. CONCLUSION: Biochemical validation of self-reported tobacco use should be considered during prevention and cessation studies among youth living in low-income settings in developing countries like India. IMPACT: The future results of biochemical validation from Project ACTIVITY (Advancing Cessation of Tobacco in Vulnerable Indian Tobacco Consuming Youth) will be useful to design validation studies in resource-poor settings.

Tobacco control among disadvantaged youth living in low-income communities in India: introducing Project ACTIVITY.

OBJECTIVE: To provide an overview of Project ACTIVITY, a group randomized intervention trial designed to test the efficacy of a community-based, comprehensive approach to tobacco control for youth (10-19 years) living in low- income communities in India. In doing so, details regarding baseline characteristics of the study sample are provided. METHODS: Fourteen slum communities in Delhi, India were matched and randomized to intervention (n=7) and control (n=7) conditions. The intervention included multiple strategies to promote prevention and cessation of tobacco use among youth. A census was conducted in selected blocks in all study communities (n=78,133), as well as a baseline survey of eligible youth (n=6,023). Main outcomes measures on the survey included ever use, past six months use and current use of multiple forms of tobacco. Mixed effects regression models were used to examine differences between study conditions in (a) demographic characteristics and (b) the prevalence of tobacco consumption. RESULTS: Census data revealed that 31.9% of sampled population was in the age group of 10-19 years. No differences between study conditions in demographic characteristics (e.g. age, gender, religion, education, and occupation) among either adults or youth were noted (p> 0.05). The baseline survey data revealed the prevalence of ever tobacco use among youth was 7.99%, past six months use was 5.70%, and current use was 4.88%. No differences between study conditions in these prevalence rates were observed, either (p>0.05). CONCLUSION: The two study conditions in Project ACTIVITY are comparable. The evaluation should provide a robust test of this intervention's efficacy.