Shifting the gaze on implementation: examining the association between the implementation of tobacco control laws and prevalence of tobacco using data from a nationally representative survey.

BACKGROUND: Tobacco use and the associated health burden is a cause of concern in India and globally. Despite several tobacco control policies in place, their sub-optimal and variable implementation across Indian states has remained a concern. Studies evaluating the real-world implementation of policies such as Cigarettes and Other Tobacco Products (COTPA) or National Tobacco Control Program (NTCP) in India and its association with reductions in tobacco use are limited. In this paper, we analyse data from a nationally representative survey to examine how policy implementation is associated with the tobacco use prevalence in India. METHODS: We analysed data from the Global Adult Tobacco Survey (GATS 2016-17) India using multivariable logistic regression. The dependent variables were the use of smoked tobacco, smokeless tobacco, and tobacco in any form. The independent variables were proxies of implementation of the COTPA and the NTCP. We followed a step-wise backward elimination technique to reach the best fit models. RESULTS: People exposed to no-smoking signages had lower odds of using tobacco (OR = 0.70, p < 0.001). People exposed to second-hand smoke (OR = 1.51, p < 0.001) and tobacco product advertisements (OR = 1.23, p < 0.001) had greater odds of using tobacco. Exposure to tobacco advertisements was associated with higher odds of using smokeless tobacco (OR = 1.23, p < 0.001), and smoked (OR = 1.33, p < 0.001) forms of tobacco. CONCLUSION: We find significant association between the implementation of tobacco control laws/programs and tobacco use in India. Our findings highlight the potential that policy implementation holds in reducing population-level tobacco use thus drawing attention towards the implementation phase of policies. The findings have implications on prioritising enforcement of specific tobacco control measures such as smokefree laws, modifying COTPA signages to encompass all tobacco products including against smokeless tobacco use and strengthening indirect advertising restrictions. Future research could focus on developing and validating predictors specific to policy implementation to support policy evaluation efforts.

Strategic and contested use of food laws to ban smokeless tobacco products in India: a qualitative analysis of litigation.

OBJECTIVE: To understand how food laws are used, contested and interpreted to ban certain forms of chewing tobacco in India. METHODS: A qualitative study analysing all the tobacco-related litigation under the food laws in India. We used an inductive thematic analysis of the litigation contents. RESULTS: The tobacco industry systematically deployed litigation to (1) challenge the categorisation of smokeless tobacco products as food, and hence, questioned the use of food laws for regulating these products; (2) challenge the regulatory power of the state government in banning tobacco products via the food laws; and (3) challenge the applicability of the general food laws that enabled stricter regulations beyond what is prescribed under the tobacco-specific law. CONCLUSION: Despite facing several legal challenges from the tobacco industry, Indian states optimised food laws to enable stricter regulations on smokeless tobacco products than were feasible through use of a tobacco-specific law.

How do tobacco control policies work in low-income and middle-income countries? A realist synthesis.

BACKGROUND: The burden of tobacco use is disproportionately high in low- and middle-income countries (LMICs). There is scarce theorisation on what works with respect to implementation of tobacco control policies in these settings. Given the complex nature of tobacco control policy implementation, diversity in outcomes of widely implemented policies and the defining role of the context, we conducted a realist synthesis to examine tobacco control policy implementation in LMICs. METHODS: We conducted a systematic realist literature review to test an initial programme theory developed by the research team. We searched EBSCOHost and Web of Science, containing 19 databases. We included studies on implementation of government tobacco control policies in LMICs. RESULTS: We included 47 studies that described several contextual factors, mechanisms and outcomes related to implementing tobacco control policies to varying depth. Our initial programme theory identified three overarching strategies: awareness, enforcement, and review systems involved in implementation. The refined programme theory identifies the plausible mechanisms through which these strategies could work. We found 30 mechanisms that could lead to varying implementation outcomes including normalisation of smoking in public places, stigmatisation of the smoker, citizen participation in the programme, fear of public opposition, feeling of kinship among violators and the rest of the community, empowerment of authorised officials, friction among different agencies, group identity among staff, shared learning, manipulation, intimidation and feeling left out in the policy-making process. CONCLUSIONS: The synthesis provides an overview of the interplay of several contextual factors and mechanisms leading to varied implementation outcomes in LMICs. Decision-makers and other actors may benefit from examining the role of one or more of these mechanisms in their particular contexts to improve programme implementation. Further research into specific tobacco control policies and testing particular mechanisms will help deepen our understanding of tobacco control implementation in LMICs. PROSPERO REGISTRATION NUMBER: CRD42020191541.

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.

Implementing FCTC Article 17 Through Participatory Research With Bidi Workers in Tamil Nadu, India.

INTRODUCTION: The exploitation, poor conditions, and precarity in the bidi (hand-rolled leaf cigarette) industry in India make it ripe for the application of the FCTC's Article 17, "Provision of support for economically viable alternative activities". "Bottom-up", participatory approaches give scope to explore bidi rollers' own circumstances, experiences, and aspirations. METHODS: A team of six community health volunteers using a participatory research orientation developed a questionnaire-based semi-structured interview tool. Forty-six bidi rolling women were interviewed by pairs of volunteers in two northern Tamil Nadu cities. Two follow-up focus groups were also held. A panel of 11 bidi rollers attended a workshop at which the findings from the interviews and focus groups were presented, further significant points were made and possible alternatives to bidi rolling were discussed. RESULTS: Bidi workers are aware of the adverse impact of their occupation on them and their families, as well as the major risks posed by the product itself for the health of consumers. However, they need alternative livelihoods that offer equivalent remuneration, convenience, and (in some cases) dignity. Alternative livelihoods, and campaigns for better rights for bidi workers while they remain in the industry, serve to undercut industry arguments against tobacco control. Responses need to be diverse and specific to local situations, i.e. "bottom-up" as much as "top-down", which can make the issue of scaling up problematic. CONCLUSION: Participatory approaches involving bidi workers themselves in discussions about their circumstances and aspirations have opened up new possibilities for alternative livelihoods to tobacco. IMPLICATIONS: Progress with the FCTC's Article 17 has generally been slow and has focussed on tobacco cultivation rather than later stages in the production process. The bidi industry in India is ripe for the application of an alternative livelihoods approach. This study is one of the first to use participatory methods to investigate the circumstances, experiences, and aspirations of bidi workers themselves.

Using social network analysis to understand multisectoral governance in district-level tobacco control programme implementation in India.

INTRODUCTION: Interest in multisectoral policies has increased, particularly in the context of low-income and middle-income countries and efforts towards Sustainable Development Goals, with greater attention to understand effective strategies for implementation and governance. The study aimed to explore and map the composition and structure of a multisectoral initiative in tobacco control, identifying key factors engaged in policy implementation and their patterns of relationships in local-level networks in two districts in the state of Karnataka, India. METHODS: Social network analysis (SNA) was used to examine the structure of two district tobacco control networks with differences in compliance with the India's national tobacco control law. The survey was administered to 108 respondents (n=51 and 57) in two districts, producing three distinct network maps about interaction, information-seeking and decision-making patterns within each district. The network measures of centrality, density, reciprocity, centralisation and E-I index were used to understand and compare across the two districts. RESULTS: Members from the department of health, especially those in the District Tobacco Control Cell, were the most frequently consulted actors for information as they led district-level networks. The most common departments engaged beyond health were education, police and municipal. District 1's network displayed high centralisation, with a district nodal officer who exercised a central role with the highest in-degree centrality. The district also exhibited greater density and reciprocity. District 2 showed a more dispersed pattern, where subdistrict health managers had higher betweenness centrality and acted as brokers in the network. CONCLUSION: Collaboration and cooperation among sectors and departments are essential components of multisectoral policy. SNA provides a mechanism to uncover the nature of relationships and key actors in collaborative dynamics. It can be used as a visual learning tool for policy planners and implementers to understand the structure of actual implementation and concentrate their efforts to improve and enhance collaboration.

Policy Processes in Multisectoral Tobacco Control in India: The Role of Institutional Architecture, Political Engagement and Legal Interventions.

BACKGROUND: The development and implementation of health policy have become more overt in the era of Sustainable Development Goals, with expectations for greater inclusivity and comprehensiveness in addressing health holistically. Such challenges are more marked in low- and middle-income countries (LMICs), where policy contexts, actor interests and participation mechanisms are not always well-researched. In this analysis of a multisectoral policy, the Tobacco Control Program in India, our objective was to understand the processes involved in policy formulation and adoption, describing context, enablers, and key drivers, as well as highlight the challenges of policy. METHODS: We used a qualitative case study methodology, drawing on the health policy triangle, and a deliberative policy analysis approach. We conducted document review and in-depth interviews with diverse stakeholders (n = 17) and anlayzed the data thematically. RESULTS: The policy context was framed by national law in India, the signing of a global treaty, and the adoption of a dedicated national program. Key actors included the national Ministry of Health and Family Welfare (MoHFW), State Health Departments, technical support organizations, research organizations, non-governmental bodies, citizenry and media, engaged in collaborative and, at times, overlapping roles. Lobbying groups, in particular the tobacco industry, were strong opponents with negative implications for policy adoption. The state-level implementation relied on creating an enabling politico-administrative framework and providing institutional structure and resources to take concrete action. CONCLUSION: Key drivers in this collaborative governance process were institutional mechanisms for collaboration, multi-level and effective cross-sectoral leadership, as well as political prioritization and social mobilization. A stronger legal framework, continued engagement, and action to address policy incoherence issues can lead to better uptake of multisectoral policies. As the impetus for multisectoral policy grows, research needs to map, understand stakeholders' incentives and interests to engage with policy, and inform systems design for joint action.

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.

Decoding the black box of health policy implementation: A case of regulating private healthcare establishments in southern India.

Background: . Implementation of healthcare regulatory policies, especially in low- and middle-income countries where the private health sector is predominant, is challenging. Karnataka, a southern state in India, enacted the Karnataka Private Medical Establishments Act (KPMEA) with an aim to ensure quality of care in the private healthcare establishments. After more than a decade the implementation of KPMEA is suboptimal. Methods: . We used a case study design. The case was 'implementation of KPMEA'. The case study site was Bengaluru Urban district in Karnataka. Data from key informant interviews, focus group discussions held at the state, district and subdistrict levels and key policy documents, minutes of the meetings, data from the State Department of Health and Family Welfare, district level KPMEA data and litigations at the High Court of Karnataka were analysed using a framework. Results: . The policy (KPMEA) content is inadequate and requires clarity in certain provisions of the Act. There was a lack of coordination between the implementing agencies. Workforce shortages were evident. Factors that impede the enforcement of the Act include poor knowledge and lack of competency of the officials on the content and the implementation mechanics of the policy, insufficient policy oversight from the state on the districts, corruption, political interference and lack of support from the local public, especially during raids on illegal establishments. Conclusions: . A regulatory policy such as KPMEA needs a clear, comprehensive content and directions for operationalization. However, improving the content of the policy is not easy as some aspects of the policy remain contentious with the private healthcare providers/ establishments. Addressing health governance issues at all levels is key to effective enforcement.

Improving access to medicines for non-communicable diseases in rural primary care: results from a quasi-randomized cluster trial in a district in South India.

BACKGROUND: A large proportion of non-communicable diseases (NCDs) are treatable within primary health care (PHC) settings in a cost-effective manner. However, the utilization of PHCs for NCD care is comparatively low in India. The Access-to-Medicines (ATM) study examined whether (and how) interventions aimed at health service optimization alone or combined with community platform strengthening improve access to medicines at the primary health care level within the context of a local health system. METHOD: A quasi-randomized cluster trial was used to assess the effectiveness of the intervention (18 months) implemented across 39 rural PHCs (clusters) of three sub-districts of Tumkur in southern India. The intervention was allocated randomly in a 1:1:1 sequence across PHCs and consisted of three arms: Arm A with a package of interventions aimed at health service delivery optimization; B for strengthening community platforms in addition to A; and the control arm. Group allocation was not blinded to providers and those who assessed outcomes. A household survey was used to understand health-seeking behaviour, access and out-of-pocket expenditure (OOP) on key anti-diabetic and anti-hypertension medicines among patients; facility surveys were used to assess the availability of medicines at PHCs. Primary outcomes of the study are the mean number of days of availability of antidiabetic and antihypertensive medicines at PHCs, the mean number of patients obtaining medicines from PHC and OOP expenses. RESULT: The difference-in-difference estimate shows a statistically insignificant increase of 31.5 and 11.9 in mean days for diabetes and hypertension medicines availability respectively in the study arm A PHCs beyond the increase in the control arm. We further found that there was a statistically insignificant increase of 2.2 and 3.8 percentage points in the mean proportion of patients obtaining medicines from PHC in arm A and arm B respectively, beyond the increase in the control arm. CONCLUSION: There were improvements in NCD medicine availability across PHCs, the number of patients accessing PHCs and reduction in OOP expenditure among patients, across the study arms as compared to the control arm; however, these differences were not statistically significant. TRIAL REGISTRATION: Trial registration number CTRI/2015/03/005640 . This trial was registered on 17/03/2015 in the Clinical Trial Registry of India (CTRI) after PHCs were enrolled in the study (retrospectively registered). The CTRI is the nodal agency of the Indian Council of Medical Research for registration of all clinical, experimental, field intervention and observation studies.

LifeFirst: Impact of a school-based tobacco and supari cessation intervention among adolescent students in Mumbai, India.

INTRODUCTION: The youth are a vulnerable population-group for tobacco-related harms. Schools are an excellent setting for health promotion; yet there is a dearth of school-based cessation interventions, rarely evaluated for their impact. Here, we assess the impact of the LifeFirst program: an ongoing tobacco and supari (areca nut) cessation intervention delivered to students from corporation schools in Mumbai city. METHODS: We used a prospective quasi-experimental design with an intervention and a control arm embedded within an ongoing LifeFirst program in select schools. We used a difference-in-difference analysis with baseline and end-line surveys to assess the program's impact on students' knowledge about harms, students' refusal skills, and prevalence of tobacco/supari use. We report our work using the TREND statement checklist. RESULTS: A total of 959 students registered in the LifeFirst program. In our analysis, we included 827 students who completed both the baseline and end-line surveys. Postintervention, we found both tobacco and supari use reduced substantially among the intervention group while tobacco use increased among the control group. The difference-in-difference estimates show a statistically significant reduction of 17.9 and 38.1 percentage points in the intervention group for tobacco and supari use respectively, beyond the reduction in the control group. CONCLUSIONS: The LifeFirst program was successful in reducing tobacco and supari use among the study participants and protected students in the intervention group against new uptake of tobacco. It helped improve knowledge score and refusal skills among students. Implementation and evaluation of similar school-based programs should be considered as part of a multi-strategy approach to reducing tobacco use among young people.

Implementation research for taking tobacco control policies to scale in India: a realist evaluation study protocol.

INTRODUCTION: There are ongoing policies and programs to reduce tobacco use and minimise the associated health burden in India. However, there are several challenges in practice leading to different outcomes across Indian states. Inadequate understanding of how national tobacco control policies achieve their results under varied circumstances obstruct the implementation and scaling up of effective strategies. This study is a realist evaluation using largely qualitative methods to understand the implementation process of India's tobacco control policies. It will do so by evaluating India's Cigarettes and Other Tobacco Products Act (COTPA) and the National Tobacco Control Program (NTCP). The study aims to examine how, why, for whom and under which circumstances COTPA and NTCP are implemented in India. METHODS AND ANALYSIS: A realist synthesis on implementation of tobacco control policies in low-income and middle-income countries is conducted. This is followed by qualitative data collection and analysis in three Indian states selected based on data from two rounds of the Global Adult Tobacco Survey. The study comprises of three steps (1): development of initial programme theories, (2) testing and refinement of initial programme theories and (3) testing and validation of refined programme theories. We will interview policy-makers, programme managers and implementers to identify facilitators and barriers of implementation. The purpose is to identify context-specific evidence-based strategies to gain insights into the implementation process of COTPA and NTCP. Further we aim to contribute to tobacco control research by establishing communities of practice to engage with cross-cutting issues. ETHICS AND DISSEMINATION: The Institutional Ethics Committee, at the Institute of Public Health (Bengaluru), has approved the protocol. Written informed consent forms will be obtained from all the participants. Dissemination has been planned for researchers, policy-makers and implementers as well as the public through peer-reviewed publications, conference presentation, webinars and social media updates. PROSPERO REGISTRATION NUMBER: CRD42020191541.

Diverse and competing interests around tobacco: qualitative analysis of two decades of parliamentary questions in India.

INTRODUCTION: India continues to enhance tobacco control regulations protecting the public health while housing a widespread tobacco industry. This implies complexities in regulating tobacco. As part of a broader inquiry on the political economy of tobacco, we aimed to understand the concerns of Indian parliamentarians around tobacco. METHODS: We sourced transcripts of tobacco-related questions asked by parliamentarians between the years 1999 and 2019 from the electronic archives of both the houses of Indian parliament. We analysed the frequency of questions during different regimens, segregated by the states and the political parties that parliamentarians belonged to, as well as by the government ministries to which these questions were posed. We also conducted thematic content analysis of these questions, identifying specific themes defining parliamentarians' concerns. RESULTS: 729 unique parliamentarians asked 1315 questions about tobacco, conveying varied concerns related to health, commerce, labour and agriculture sectors. Over time, the focus of the questions shifted from majorly trade to majorly health-related concerns. We show how the tobacco regulations in India are multi-institutional and are a result of negotiations of several legitimate and competing, interests. We found important state-level differences in the number and nature of these questions. CONCLUSION: Parliamentary questions constitute a useful resource in studying tobacco politics. Tobacco regulations are a product of complex negotiation of varied and competing concerns. We identify core arguments in favour and against tobacco control that would help tobacco control advocates and agencies to better prepare and engage with diverse political voices around tobacco.

The community health impasse: What can family physicians learn about integration of social determinants of health from the challenges, diversity, and worldview of primary healthcare practices located in Southern India?

CONTEXT: As social position rises, health improves. Alma Ata set the stage for community-oriented primary care (COPC), and family medicine is perfectly positioned to integrate Social Determinants of Health. India presents a unique environment for innovations in family medicine. AIMS: This study aimed to (1) assess the ability of different primary care practices to address the social determinants of health (SDoH); (2) identify key obstacles and supports; and (3) provide practical insights to family physicians and other primary care providers (PCPs) for the integration of SDoH and clinical primary care. SETTINGS AND DESIGN: A diverse sample of primary healthcare practices were selected in southern India for investigation. Data collection involved observation and informal interviews. METHODS AND MATERIAL: The researchers used general observation and informal interviews to collect data. Investigators used a basic interview guide to structure conversations and formal journal entries were recorded immediately following each visit. STATISTICAL ANALYSIS USED: Thematic analysis was conducted with NVIVO software to categorize major themes. RESULTS: Seventeen primary healthcare practices were observed; eleven were formally enrolled for interviews. Four inputs and three outputs of socially oriented primary care practices were identified. The inputs include leadership style, appropriate staffing, funding structures, and patient panels. Social interventions, community contact, and treasuring community empowerment were the major outputs. CONCLUSIONS: Community health lies at the heart of strengthening primary healthcare. Establishing practices that bridge the gap between clinical primary care and SDoH initiatives need to be prioritized. This study fosters agency for family physicians and PCPs to engage with local communities and lead the path toward this integration.

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.

Affirmative action, minorities, and public services in India: Charting a future research and practice agenda.

The National Health Policy in India mentions equity as a key policy principle and emphasises the role of affirmative action in achieving health equity for a range of excluded groups. We conducted a scoping review of literature and three multi-stakeholder workshops to better understand the available evidence on the impact of affirmative action policies in enhancing the inclusion of ethnic and religious minorities in health, education and governance in India. We consider these public services an important mechanism to enhance the social inclusion of many excluded groups. On the whole, the available empirical evidence regarding the uptake and impact of affirmative action policies is limited. Reservation policies in higher education and electoral constituencies have had a limited positive impact in enhancing the access and representation of minorities. However, reservations in government jobs remain poorly implemented. In general, class, gender and location intersect, creating inter- and intra-group differentials in the impact of these policies. Several government initiatives aimed at enhancing the access of religious minorities to public services/institutions remain poorly evaluated. Future research and practice need to focus on neglected but relevant research themes such as the role of private sector providers in supporting the inclusion of minorities, the political aspects of policy development and implementation, and the role of social mobilisation and movements. Evidence gaps also need to be filled in relation to information systems for monitoring and assessment of social disadvantage, implementation and evaluative research on inclusive policies and understanding how the pathways to inequities can be effectively addressed.

Integrating tobacco cessation into routine dental practice: protocol for a qualitative study.

INTRODUCTION: Combined efforts to encompass different aspects of tobacco control have been in place for some time. Despite the recognition of the need to offer support to tobacco users to quit tobacco use, such support remains highly inadequate in India. However, little is known about the practice of oral health professionals (OHP) and the experiences and expectations of dental patients in the context of tobacco cessation (TC) services. In this article, we describe the protocol of a doctoral research project that explores OHPs and their patients in an Indian city. The aims are (A) to understand the functioning of the oral healthcare system towards TC and what changes to it will be needed to benefit TC and (B) to capture the views of dental patients on TC services provided by OHPs. METHODS AND ANALYSIS: A cross-sectional qualitative study based on individual interviews with OHPs and dental patients will be carried out in the city of Ahmedabad, Gujarat, India. The OHP will be purposively selected from two major organisation types: (1) single-doctor dental clinics and (2) dental hospital attached to teaching institutions. The sample population will be divided into two subgroups: general OHP (dentists practising general dentistry irrespective of their qualification) and prosthodontists (dentists with a specialisation in prosthodontics). We will sample dental patients through convenient sampling from a public teaching hospital and select private dental care facilities. The sampling of OHPs and dental patients will continue until we reach data saturation. Interviews will be audio recorded, transcribed verbatim and coded by hand. The interview transcript will subsequently be analysed using thematic content analysis. ETHICS AND DISSEMINATION: The study received ethical approval from the Institutional Ethical Committee of the Government Dental College and Hospital, Ahmedabad. The findings will be disseminated through conference presentations, peer-reviewed publications and to the study participants.

From Policy to Practice: Lessons from Karnataka about Implementation of Tobacco Control Laws.

BACKGROUND: Tobacco use accounts for eight to nine lakh adult deaths annually in India. India enacted a national legislation "Cigarettes and Other Tobacco Products Act, 2003" (COTPA) to protect health of non-smokers and reduce tobacco consumption. However, even a decade after enacting this law, its implementation remains suboptimal and variable across the Indian states. Karnataka has shown leadership on this front by enacting a state law and implementing COTPA at (sub-) district levels. We, therefore, aim to analyze COTPA implementation processes in Karnataka to understand how COTPA can be effectively implemented. METHODS: We developed a case study of COTPA implementation in Karnataka using reports from health, police, education, and transport departments as well as government orders and media reports related to COTPA. We analyzed these data to map and understand the role played by the government agencies in COTPA implementation. We used the proportion of the districts reporting COTPA violations, the number of COTPA violations cases reported, and the proportion of schools reporting compliance with COTPA as proxy measures for COTPA implementation. RESULTS: We found that five government agencies (police, education, health, transport, and urban development) played a major role in COTPA implementation. All the police districts reported COTPA violations with 59,594 cases in a year (April 2013-March 2014). Three of the district anti-tobacco cells and two of the transport divisions reported 1130 and 14,543 cases of COTPA violations, respectively, in the same year. In addition, 84.7% of schools complied with signage requirements of COTPA. COTPA reporting was made part of the reporting systems within health, police, and education departments. The health department created awareness on tobacco harms and COTPA. CONCLUSIONS: COTPA implementation in Karnataka was made possible through integrating COTPA implementation within structure/functions of five government agencies.

Conflicts of interest in tobacco control in India: an exploratory study.

INTRODUCTION: The government of India introduced a tobacco control legislation in 2003 and is a party to the WHO Framework Convention on Tobacco Control. However, anecdotal evidence points to the government's conflicting interests in tobacco control and trade. This research seeks to scope instances of conflicts of interests within the government and analyse how they operate in the Indian context. METHODS: We conducted an exploratory study analysing documents over a 2-year period. We scanned media reports related to tobacco, documents of the tobacco industry, information retrieved from governments using the Right to Information Act and relevant websites. The data were analysed through thematic coding. RESULTS: 100 instances of conflicts of interest were found and classified under six categories: public support for the tobacco industry by government institutions or individuals; stakeholding or ownership of tobacco companies by government functionaries; individuals holding positions both in tobacco companies and the government; formal partnerships between the tobacco industry and public agencies; conflicting policies; and incentives available for the tobacco industry. These instances occur at all three levels of government: the individual, institutional and policy levels. CONCLUSIONS: Conflicts of interest are rampant in India and operate in many different ways. These conflicts can lead to negative consequences for tobacco control with far-reaching effects. Varied strategies using legal, administrative and legislative tools need to be adopted to manage conflicts of interest.