Socio-Economic Status Differences in Changing Affordability of Tobacco Products from 2011-2012 to 2018-2019 in India.

INTRODUCTION: We studied the change in affordability of tobacco products, an important determinant of tobacco use, across the different socio-economic status (SES) in India. AIMS AND METHODS: We calculated affordability in the form of relative income price (RIP-cost of tobacco products relative to income) for the years 2011-2012 and 2018-2019 using three different denominators, that is per capita gross domestic product (GDP) and net state domestic product at national and state levels, respectively; monthly per capita consumer expenditure (MPCE); and individual wages. We investigated RIP for cigarettes, bidis, and smokeless tobacco (SLT) across different SES groups (caste groups, type of employment, and education). RESULTS: RIP increased marginally for cigarettes, bidis and remained almost constant for SLT across casual workers. However, when RIP was adjusted with SES variables, there was no significant change (p > .05) in the affordability of products for casual workers in the year 2018-2019 as compared to 2011-2012. For regular workers, cigarettes and bidis became marginally less affordable (ß < 1), whereas affordability remained constant for SLT. All products became more affordable for backward caste groups within regular workers. When RIP was calculated using MPCE all tobacco products became less affordable in the year 2018-2019. However, after adjusting for SES variables SLT reported no change in affordability. There was a marginal increase in affordability for all products when RIP was calculated with GDP. CONCLUSIONS: Although implementation of GST has increased the price of tobacco products, it is still not sufficient to reduce the affordability of tobacco products, particularly SLT and especially for the lower SES group. IMPLICATIONS: Tobacco use and economic disadvantage conditions of the population are intricately linked. Affordability of tobacco products is influenced by socio-economic indicators like age, sex, income, education, etc. The literature measuring the affordability of tobacco products across different SES groups is scant in India. Additionally, existing literature measures affordability of tobacco products based on per capita GDP as a proxy for income. This is the first study in Indian context to report the change in affordability of tobacco products across different SES groups after adjusting for SES indicators, using individual-level income data. We have calculated the change in affordability of tobacco products between the year 2011-2012 and 2018-2019 using GDP, household income, and individual wages as a proxy for income.

Changes in tobacco depictions after implementation of tobacco-free film and TV rules in Bollywood films in India: a trend analysis.

BACKGROUND: India's tobacco-free film and TV rules were implemented from 2012. To assess the effect of the rules, we studied tobacco depictions in top-grossing Bollywood films released between 2006 and 2017 and rule compliance after 2012. METHODS: Tobacco incidents and brand appearances were coded in 240 top-grossing Bollywood films (2006-2017) using the Breathe California method. Trends in number of tobacco incidents per film per year were studied before and after implementation of the rules using Poisson regression analysis. Compliance with rules over the years was studied using Pearson product-moment correlations. RESULTS: Forty-five films were U-rated (all ages), 162 were UA-rated (below age 12 years must be adult-accompanied), and 33 were A-rated (age 18+ years only). Before implementation of the rules, the number of tobacco incidents per film was increasing by a factor of 1.1/year (95% CI 1.0 to 1.2, p=0.002). However, beginning year 2013, the number of incidents per film started falling significantly by a factor of 0.7/year (95% CI 0.6 to 0.9; p=0.012) compared with the previous increasing trend. The percentage of youth-rated (U and UA) films with any tobacco incidents also declined from a peak of 76% in 2012 to 35% in 2017. The percentage of films complying with the rules (audio-visual disclaimers, health spots, static warnings) did not change significantly from 2012 to 2017. CONCLUSION: India's 2012 rules were followed by a reduction in tobacco depictions in Bollywood films. Enhanced monitoring of compliance is needed to ensure the continued effectiveness of the rules.

Potential Risk Factors of Smokeless Tobacco Consumption Among Adolescents in South India.

INTRODUCTION: Although most of the disease burden internationally is due to tobacco smoking, smokeless tobacco (SLT) use contributed to an estimated 76 000 deaths in 2017. We have studied the potential risk factors for SLT use among adolescents in South India. METHODS: A cross-sectional questionnaire survey of all students in grades 6-8 in schools in the Udupi district of Karnataka State ascertained SLT use status and potential determinants of SLT uptake. Ever SLT use was defined as any reported consumption of any SLT products, currently or at any time in the past. Independent effects on ever SLT use status were estimated using multiple logistic regression. RESULTS: Of 46 706 students from 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever SLT use was reported by 775 (2.0%) participants and in a mutually adjusted model was significantly related to age, male sex, family use, or friend's use of SLT, low socioeconomic status, high rebelliousness, and low self-esteem. After controlling for these effects, the odds of ever-SLT use were significantly higher among students who had least awareness of the harmful effects of tobacco use (odds ratio 3.7, 95% confidence interval [2.9, 4.7]) and significantly lower among those not exposed to tobacco advertising (odds ratio 0.7, 95% confidence interval [0.5, 0.8]). CONCLUSIONS: The prevalence of SLT use among children in Karnataka is relatively low when compared with other studies in India. The significant potential risk factors of SLT use include low awareness of the harmful effects of tobacco and tobacco control policies and exposure to tobacco advertising. IMPLICATIONS: The prevalence of SLT use among school going adolescents in South India is relatively low. The potential risk factors for SLT use among adolescents in southern India are similar to those for smoked tobacco. It includes age, male gender, family or friend's use of SLT, low socioeconomic status, high rebelliousness, low self-esteem, exposure to tobacco advertisement and least awareness about the harmful effects of tobacco and of tobacco control policies. The present study lays emphasis regarding creating awareness about tobacco harms and control policies for further reducing tobacco use among adolescents.

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.

Tobacco imagery in on-demand streaming content popular among adolescents and young adults in India: implications for global tobacco control.

BACKGROUND: India implemented tobacco-free film and TV rules (Rules) to protect adolescents and young adults from tobacco exposure. OBJECTIVE: To assess tobacco imagery in online series popular among adolescents and young adults. METHODS: Ten popular online series on streaming platforms were identified after discussions with participants (aged 15-24 years) in New Delhi, and content-coded for tobacco imagery following the Breathe California protocol. Incidents of tobacco use and brand appearances in each series episode were counted, and compliance with Indian Rules was recorded. RESULTS: 188 episodes across 10 series on Netflix and Amazon Prime Video were coded. Seven series were rated age 16+, two were 18+ and one was 13+. The median number of tobacco incidents per episode in foreign productions was as follows: Amazon's 'The Marvellous Mrs Maisel' (87.5, IQR 62.0-116.0) and Netflix's 'The Crown' (29.0, 18.0-36.0) were higher than Indian productions: Netflix's 'Sacred Games' (9.0, 0.5-14.5) and Amazon's 'Mirzapur' (7.0, 4.0-11.0) (p=0.84). Tobacco incidents per hour ranged from 0 (Bodyguard, Riverdale, 13 Reasons Why) to 106.1 (The Marvellous Mrs Maisel). Seven of 10 series had tobacco imagery and none were compliant with the Rules. CONCLUSION: Contrary to Section 5 of India's Cigarettes and Other Tobacco Products Act, its Rules are not being complied with by the streaming platforms. US-produced streaming media contains more tobacco incidents than Indian-produced media. There is an urgent need for better enforcement of existing Rules on streaming platforms in India, and modernisation of the WHO Framework Convention on Tobacco Control, Article 13 guidelines to account for new streaming platforms to protect youth from tobacco imagery globally.

Exposure to tobacco imagery in popular films and the risk of ever smoking among children in southern India.

BACKGROUND: Exposure to smoking in films is a recognised cause of smoking uptake among children. In India, in an attempt to protect children, films containing smoking are required to include tobacco control messaging including audiovisual disclaimers, on-screen health warnings when tobacco imagery is displayed and antitobacco 'health spots' before and during the film. We report a study of the association between ever smoking and exposure to tobacco imagery in locally popular films among children in Udupi district of Karnataka state in southern India. METHODS: A cross-sectional questionnaire survey of all students in grades 6-8 in schools in the Udupi district ascertained smoking status and potential confounders of smoking uptake, and whether children had seen any of 27 locally popular films we had coded and found to contain imagery of actual or implied tobacco use. Ever-smoking status was defined as any reported smoking of cigarettes, beedis or other tobacco products currently or at any time in the past. Independent effects on ever-smoking status were estimated using multiple logistic regression. RESULTS: Of 46 706 students enrolled in grades 6-8 in 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever smoking was reported by 914 (2.3%) participants and in a mutually adjusted model was significantly related to age, male sex, living in a home where smoking is allowed, having parents or siblings who smoke, low paternal education, low levels of family wealth, low self-esteem, rebelliousness and poor school performance. After allowing for these effects, the odds of ever smoking were not increased among students who had seen any of the listed films containing tobacco imagery when included in the analysis as a binary exposure (OR 0.9, 95% CI 0.4 to 2.0), and decreased in relation to level of exposure graded into tertiles of tobacco intervals seen. CONCLUSIONS: In this cross-sectional study, children in southern India who had seen films containing tobacco imagery are no more likely to smoke than those who had not, indicating that the tobacco control messaging mandated by Indian law may be attenuating the effect of tobacco imagery in films on smoking uptake.

Impact of India's National Tobacco Control Programme on bidi and cigarette consumption: a difference-in-differences analysis.

BACKGROUND: Despite the importance of decreasing tobacco use to achieve mortality reduction targets of the Sustainable Development Goals in low-income and middle-income countries (LMICs), evaluations of tobacco control programmes in these settings are scarce. We assessed the impacts of India's National Tobacco Control Programme (NTCP), as implemented in 42 districts during 2007-2009, on household-reported consumption of bidis and cigarettes. METHODS: Secondary analysis of cross-sectional data from nationally representative Household Consumer Expenditure Surveys (1999-2000; 2004-2005 and 2011-2012). Outcomes were: any bidi/cigarette consumption in the household and monthly consumption of bidi/cigarette sticks per person. A difference-in-differences two-part model was used to compare changes in bidi/cigarette consumption between NTCP intervention and control districts, adjusting for sociodemographic characteristics and time-based heterogeneity. FINDINGS: There was an overall decline in household-reported bidi and cigarette consumption between 1999-2000 and 2011-2012. However, compared with control districts, NTCP districts had no significantly different reductions in the proportions of households reporting bidi (adjusted OR (AOR): 1.03, 95% CI: 0.84 to 1.28) or cigarette (AOR: 1.01 to 95% CI: 0.82 to 1.26) consumption, or for the monthly per person consumption of bidi (adjusted coefficient: 0.07, 95% CI: -0.13 to 0.28) or cigarette (adjusted coefficient: -0.002, 95% CI: -0.26 to 0.26) sticks among bidi/cigarette consuming households. INTERPRETATION: Our findings indicate that early implementation of the NTCP may not have produced reductions in tobacco use reflecting generally poor performance against the Framework Convention for Tobacco Control objectives in India. This study highlights the importance of strengthening the implementation and enforcement of tobacco control policies in LMICs to achieve national and international child health and premature NCD mortality reduction targets.

Assessment of tobacco imagery and compliance with tobacco-free rules in popular Indian films.

BACKGROUND: Exposure to smoking in films causes smoking uptake among adolescents. Investigation of the extent to which tobacco imagery appears, or tobacco control laws are complied with in Indian films is limited, and especially so for films in regional languages. This study presents an analysis of tobacco content and compliance with tobacco control laws in popular films in several languages from the Karnataka state of India. METHODS: We used 5 min interval coding to measure actual tobacco use, implied tobacco use, tobacco paraphernalia and tobacco branding in the top 10 films identified from national box office ratings and regional distributor reports in Karnataka in 2015 and 2016. We also assessed compliance with tobacco-free film rules in India. FINDINGS: A total of 47 films, in English, Hindi, Malayalam, Tamil, Telugu and Tulu languages were coded. Any tobacco imagery was observed in 72% of films, and actual tobacco use in 50%. Tobacco imagery was equally prevalent in films classified as suitable for universal viewing (U category) or at age 12 or more (U/A category) films; and significantly more common in films made in regional than national language (Hindi). None of the films were fully compliant with legal requirements on health spots, audiovisual disclaimers and health warnings. CONCLUSIONS: Tobacco content was common in films classified as suitable for viewing by children, more among regional than national languages. Compliance with tobacco control laws was low. Stricter enforcement of tobacco-free film rules will protect children and adolescents from exposure to tobacco use on screen.

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.

Socioeconomic Inequalities in Secondhand Smoke Exposure at Home and at Work in 15 Low- and Middle-Income Countries.

INTRODUCTION: In high-income countries, secondhand smoke (SHS) exposure is higher among disadvantaged groups. We examine socioeconomic inequalities in SHS exposure at home and at workplace in 15 low- and middle-income countries (LMICs). METHODS: Secondary analyses of cross-sectional data from 15 LMICs participating in Global Adult Tobacco Survey (participants ≥ 15 years; 2008-2011) were used. Country-specific analyses using regression-based methods were used to estimate the magnitude of socioeconomic inequalities in SHS exposure: (1) Relative Index of Inequality and (2) Slope Index of Inequality. RESULTS: SHS exposure at home ranged from 17.4% in Mexico to 73.1% in Vietnam; exposure at workplace ranged from 16.9% in Uruguay to 65.8% in Bangladesh. In India, Bangladesh, Thailand, Malaysia, Philippines, Vietnam, Uruguay, Poland, Turkey, Ukraine, and Egypt, SHS exposure at home reduced with increasing wealth (Relative Index of Inequality range: 1.13 [95% confidence interval [CI] 1.04-1.22] in Turkey to 3.31 [95% CI 2.91-3.77] in Thailand; Slope Index of Inequality range: 0.06 [95% CI 0.02-0.11] in Turkey to 0.43 [95% CI 0.38-0.48] in Philippines). In these 11 countries, and in China, SHS exposure at home reduced with increasing education. In India, Bangladesh, Thailand, and Philippines, SHS exposure at workplace reduced with increasing wealth. In India, Bangladesh, Thailand, Philippines, Vietnam, Poland, Russian Federation, Turkey, Ukraine, and Egypt, SHS exposure at workplace reduced with increasing education. CONCLUSION: SHS exposure at homes is higher among the socioeconomically disadvantaged in the majority of LMICs studied; at workplaces, exposure is higher among the less educated. Pro-equity tobacco control interventions alongside targeted efforts in these groups are recommended to reduce inequalities in SHS exposure. IMPLICATIONS: SHS exposure is higher among the socioeconomically disadvantaged groups in high-income countries. Comprehensive smoke-free policies are pro-equity for certain health outcomes that are strongly influenced by SHS exposure. Using nationally representative Global Adult Tobacco Survey (2008-2011) data from 15 LMICs, we studied socioeconomic inequalities in SHS exposure at homes and at workplaces. The study showed that in most LMICs, SHS exposure at homes is higher among the poor and the less educated. At workplaces, SHS exposure is higher among the less educated groups. Accelerating implementation of pro-equity tobacco control interventions and strengthening of efforts targeted at the socioeconomically disadvantaged groups are needed to reduce inequalities in SHS exposure in LMICs.

Association between being employed in a smoke-free workplace and living in a smoke-free home: evidence from 15 low and middle income countries.

OBJECTIVE: To assess whether being employed in a smoke-free workplace is associated with living in a smoke-free home in 15 low and middle income countries (LMICs). METHODS: Country-specific individual level analyses of cross-sectional Global Adult Tobacco Survey data (2008-2011) from 15 LMICs was conducted using multiple logistic regression. The dependent variable was living in a smoke-free home; the independent variable was being employed in a smoke-free workplace. Analyses were adjusted for age, gender, residence, region, education, occupation, current smoking, current smokeless tobacco use and number of household members. Individual country results were combined in a random effects meta-analysis. RESULTS: In each country, the percentage of participants employed in a smoke-free workplace who reported living in a smoke-free home was higher than those employed in a workplace not smoke-free. The adjusted odds ratios (AORs) of living in a smoke-free home among participants employed in a smoke-free workplace (vs. those employed where smoking occurred) were statistically significant in 13 of the 15 countries, ranging from 1.12 [95% CI 0.79-1.58] in Uruguay to 2.29 [1.37-3.83] in China. The pooled AOR was 1.61 [1.46-1.79]. CONCLUSION: In LMICs, employment in a smoke-free workplace is associated with living in a smoke-free home. Accelerated implementation of comprehensive smoke-free policies is likely to result in substantial population health benefits in these settings.

Prospective study of exposure to smoking imagery in films and changes in susceptibility to smoking in a cohort of school students in Southern India.

INTRODUCTION: India has unique tobacco-free film and TV rules designed to prevent tobacco uptake. In this study, we examined the potential influence of exposure to smoking imagery in regionally famous films, on susceptibility to smoke in teenagers enrolled in schools in a district in Southern India. METHODS: A longitudinal survey of students, in grades 6 to 8 at baseline in 2017 and grades 7 to 9 one year later in 2018, ascertained prospective incident susceptibility to smoking during the study period in relation to baseline exposure to 27 locally popular films with actual or implied smoking imagery. RESULTS: We analyzed linked data from 33676 participants, and 3973 (11.8%) of the adolescents reported incident susceptibility. There was a significant increase in susceptibility to smoking with increasing exposure at baseline to smoking imagery in films on univariable analysis, highest tertile of exposure relative to no exposure (OR=1.4; 95% CI: 1.0 -2.1, ptrend<0.001), and this trend remained significant (p=0.022) after mutual adjustment for recognized confounders, highest vs no exposure (AOR=1.3; 95% CI: 0.9-1.8). We found no statistically significant association between exposure to tobacco-free film rules and change in susceptibility. CONCLUSIONS: Prospectively, watching films featuring smoking imagery increases adolescents' vulnerability to smoking. Further research revealed no difference in susceptibility change between youth who saw partially compliant films and those who watched non-compliant films. Our findings, thus, underscore the need to incorporate comprehensive approaches to prevent the inclusion of smoking imagery in films.

Discussions with adults and youth to inform the development of a community-based tobacco control programme.

Project Advancing Cessation of Tobacco in Vulnerable Indian Tobacco Consuming Youth (ACTIVITY) is a community-based group randomized intervention trial focused on disadvantaged youth (aged 10-19 years) residing in 14 low-income communities (slums and resettlement colonies) in Delhi, India. This article discusses the findings of Focus Group Discussions (FGDs) conducted to inform the development and test the appropriateness of Project ACTIVITY's intervention model. The findings of the FGDs facilitated the understanding of factors contributing to increased tobacco uptake and cessation (both smoking and smokeless tobacco) among youth in this setting. Twenty-two FGDs were conducted with youth (10-19 years) and adults in two urban slums in Delhi. Key findings revealed: (i) youth and adults had limited knowledge about long-term health consequences of tobacco use; (ii) socio-environmental determinants and peer pressure were important variables influencing initiation of tobacco use; (iii) lack of motivation, support and sufficient skills hinder tobacco cessation and (iv) active involvement of community, family, religious leaders, local policy makers and health professionals is important in creating and reinforcing tobacco-free norms. The results of these FGDs aided in finalizing the intervention model for Project ACTIVITY and guided its intervention development.

Corrigendum: Impact of a tobacco sales ban on the frequency of tobacco consumption in India during the COVID-19 pandemic.

[This corrects the article DOI: 10.18332/tid/161855.].

Impact of a tobacco sales ban on the frequency of tobacco consumption in India during the COVID-19 pandemic.

INTRODUCTION: Measures to address the COVID-19 pandemic in India included a ban on the sale and use of tobacco products during 2020 when stay at home guidance (lockdown) was in place. In this study we examined the extent of reduction in frequency of tobacco consumption across all products. METHODS: Telephone survey was conducted between July and August 2020 across an existing cohort of tobacco users (n=801) residing in Delhi (55.4%) and Chennai (44.6%), India. The participants were recruited irrespective of their gender and use of any kind of tobacco product(s). The survey questionnaire was based on the STOP (Studying Tobacco users Of Pakistan) survey and adapted to the context of smoking and smokeless tobacco use in India. RESULTS: Cigarette consumption declined from a median value of 5.0 (IQR: 2-10) sticks in the pre-lockdown period to 2.0 (IQR: 0.4-5) sticks during the lockdown period. Reductions were reported in the daily use of bidis, from 8 (IQR: 4-12) sticks to 5 (IQR: 2-10) sticks and for smokeless tobacco users from 3.5 (IQR: 2-5) packs to 2 (IQR: 1-4) packs during the lockdown. Furthermore, the number of daily cigarette smokers in our cohort decreased from 32.6% (n=261) in the pre-lockdown period to 27.5% (n=220) during lockdown and smokeless tobacco users decreased from 35.8% (n=287) in pre-lockdown period to 30.3% (n=243) during the lockdown period. CONCLUSIONS: The decrease in tobacco use can be attributed to various societal and environmental factors. However, the pandemic-linked lockdown provided an opportune condition to reduce the use of tobacco products, which could be due to restricted access and increase in health awareness during the COVID-19 lockdown.

Integrating tobacco control into health and development agendas.

Tobacco use is one of the major risk factors for non-communicable diseases, with a profound impact on resource-poor low-income and middle-income countries such as India, where tobacco use is high and where socioeconomic as well as health inequalities are rampant. Effective implementation of the Framework Convention on Tobacco Control requires multisectoral efforts that can fructify through integration of tobacco control into broader health and development agendas such as food and water security, environment, the right to education and human rights. The global tobacco control community will need to explore innovative partnerships beyond its traditional confines and build a global coalition that supports tobacco control by partnering with others having convergent concerns on common determinants. A firm political commitment and intersectoral coordination between government and non-government agencies is paramount in order to implement effective tobacco control programmes. Integration of tobacco control into other health and development agendas as described in this paper has the potential to contribute to the achievement of all the eight United Nations Millennium Development Goals. This paper explores why the whole of government should accord a high priority to tobacco control, and how this integration could be achieved.

Tobacco use in Bollywood movies, tobacco promotional activities and their association with tobacco use among Indian adolescents.

BACKGROUND: Smoking in Hollywood movies is a known risk factor for teen smoking in the USA and Europe, but little is known about the association between exposure to tobacco use in Bollywood movies and teen tobacco use in India. METHODS: A cross-sectional sample of 3956 adolescents (eighth and ninth grades, ages 12-16 years) from 12 randomly selected New Delhi schools was surveyed in 2009, assessing tobacco use status, receptivity to tobacco promotions (based on owning or being willing to wear tobacco-branded merchandise) and exposure to tobacco use in movies. Quartiles of exposure to tobacco use in popular Bollywood movies released from 2006 to 2008 (n=59) were determined by content coding them for tobacco use and querying the adolescents whether they had seen each one. Logistic regression was used to control for covariates including age, gender, parent education, school performance, sensation-seeking propensity, family and peer tobacco use, and authoritative parenting. RESULTS: Altogether, the 59 movies contained 412 tobacco use occurrences. The prevalence of ever tobacco use among adolescents was 5.3%. Compared with low-exposure adolescents (quartile 1), the adjusted odds of ever tobacco use among high-exposure adolescents (quartile 4) was 2.3 (95% CI 1.3 to 3.9). Being receptive to tobacco promotions was also associated with higher adjusted odds of ever tobacco use, 2.0 (95% CI 1.4 to 3.0). CONCLUSION: Watching tobacco use in Bollywood movies and receptivity to tobacco promotional activities were both independently associated with ever tobacco use among adolescents in India, with ORs being similar to the studies of adolescents elsewhere.

Impact of tobacco advertisements on tobacco use among urban adolescents in India: results from a longitudinal study.

OBJECTIVES: To examine the longitudinal relationship between exposure and receptivity to tobacco advertisements and progression towards tobacco use among adolescents in India. DESIGN AND SETTING: A 2-year longitudinal group-randomised trial, Mobilizing Youth for Tobacco Related Initiatives (MYTRI), was undertaken from 2004 to 2006 in 32 schools in Delhi and Chennai. Among the control schools (n=16), mixed-effects regression models were used to assess the objectives. Subjects Students who were non-susceptible, never users of tobacco (n=2782) at baseline (2004) in the control schools of Project MYTRI, who progressed academically and were followed up at endline (2006). MAIN OUTCOME MEASURES: Progression towards tobacco use (on tobacco uptake continuum). RESULTS: Bivariate results suggest that exposure to tobacco advertisements at baseline was associated in a dose-dependent manner with progression at endline. Students exposed at more than four places were 1.5 times (95% CI 1.12 to 1.94; p<0.05) more likely to progress towards tobacco use at endline versus those not exposed. Among boys, those exposed at more than four places were 1.7 times more likely to progress (95% CI 1.14 to 2.62; p<0.05). These significant results disappeared in multivariate analysis, when other psychosocial risk factors for tobacco use were controlled. In both bivariate and multivariate analyses, the risk of progression at endline was more than two times higher (95% CI 1.28 to 4.32; p<0.05) among boys who were highly receptive versus non-receptive boys. The same relationship did not hold among girls. CONCLUSION: High receptivity to tobacco advertising predicts future progression to tobacco use among boys in India. Suggestive evidence exists of a causal relationship between tobacco marketing and adolescent tobacco use.

Association of breakfast intake with obesity, dietary and physical activity behavior among urban school-aged adolescents in Delhi, India: results of a cross-sectional study.

BACKGROUND: In developed countries, regular breakfast consumption is inversely associated with excess weight and directly associated with better dietary and improved physical activity behaviors. Our objective was to describe the frequency of breakfast consumption among school-going adolescents in Delhi and evaluate its association with overweight and obesity as well as other dietary, physical activity, and sedentary behaviors. DESIGN: Cross-sectional study. SETTING: Eight schools (Private and Government) of Delhi in the year 2006. PARTICIPANTS: 1814 students from 8th and 10th grades; response rate was 87.2%; 55% were 8th graders, 60% were boys and 52% attended Private schools. MAIN OUTCOME MEASURES: Body mass index, self-reported breakfast consumption, diet and physical activity related behaviors, and psychosocial factors. DATA ANALYSIS: Mixed effects regression models were employed, adjusting for age, gender, grade level and school type (SES). RESULTS: Significantly more Government school (lower SES) students consumed breakfast daily as compared to Private school (higher SES) students (73.8% vs. 66.3%; p<0.01). More 8th graders consumed breakfast daily vs.10th graders (72.3% vs. 67.0%; p<0.05). A dose-response relationship was observed such that overall prevalence of overweight and obesity among adolescents who consumed breakfast daily (14.6%) was significantly lower vs. those who only sometimes (15.2%) or never (22.9%) consumed breakfast (p<0.05 for trend). This relationship was statistically significant for boys (15.4 % vs. 16.5% vs. 26.0; p<0.05 for trend) but not for girls. Intake of dairy products, fruits and vegetables was 5.5 (95% CI 2.4-12.5), 1.7 (95% CI 1.1-2.5) and 2.2 (95% CI 1.3-3.5) times higher among those who consumed breakfast daily vs. those who never consumed breakfast. Breakfast consumption was associated with greater physical activity vs. those who never consumed breakfast. Positive values and beliefs about healthy eating; body image satisfaction; and positive peer and parental influence were positively associated with daily breakfast consumption, while depression was negatively associated. CONCLUSION: Daily breakfast consumption is associated with less overweight and obesity and with healthier dietary- and physical activity-related behaviors among urban Indian students. Although prospective studies should confirm the present results, intervention programs to prevent or treat childhood obesity in India should consider emphasizing regular breakfast consumption.

Ineffective pictorial health warnings on tobacco products: lessons learnt from India.

Pictorial warnings are effective in promoting smoking cessation as shown by research in the developed countries. This study aims to determine perceptions of Indians about the effectiveness of pictorial health warnings on tobacco packs which existed from May 31, 2009, to December 1, 2011. A cross-sectional survey was undertaken in five states of India with 1897 participants (56% males; 54% tobacco users). More tobacco users expressed that the pictorial warnings are inadequate to convey the health impact of tobacco use when compared with nonusers (71.50% vs. 62.75%; P < 0.001). More illiterates when compared with literates expressed their concern that the current pictorial warnings will not motivate them to quit (61.17% vs. 51.01%; P < 0.001). The new warnings implemented from December 1, 2011, in India are also not field-tested. Field testing and assessment of effectiveness of health warnings should be a mandatory requirement for Parties reporting on Article 11 of Framework Convention on Tobacco Control (FCTC).