Awareness to action through multi-channel advocacy for effective tobacco control in India: a case study from Bihar.

Developing a synergistic relationship between the government machinery and civil society is crucial for advancing the tobacco control movement in India. With diverse patterns of tobacco use and far reach of the tobacco industry, stringent enforcement mechanisms along with innovative and culturally appropriate advocacy efforts are imperative. In this paper, we evaluate multi- level tobacco control interventions undertaken in the Indian state of Bihar and the subsequent success achieved in strengthening government-non-government partnerships and commitment towards tobacco control in the state. Our experience shows that sustained advocacy at the policy and grassroots levels, along with willingness of the administrative machinery, can present result- oriented tobacco control initiatives at the state and grassroots levels.

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.

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).

Weight-related concerns and weight-control behaviors among overweight adolescents in Delhi, India: a cross-sectional study.

BACKGROUND: Obesity is emerging as a public health problem among adolescents in India. The aim of this study was to describe specific weight-related concerns among school-going youth in Delhi, India and to assess the prevalence of weight control behaviors, including healthy and unhealthy ones. Differences by weight status, gender, grade level, and school-type (a proxy for SES in this setting) are considered. METHODS: This study is cross-sectional by design. A sample of eighth and tenth graders (n=1818) enrolled in Private (middle-high SES) and Government (low SES) schools (n=8) in Delhi, India participated. All students' height and weight were measured. Students participated in a survey of weight-related concerns and weight-control behaviors, as well. Mixed-effects regression models were used to test for differences in weight-related concerns and weight-control behaviors across key factors of interest (i.e., weight status, gender, grade level, and SES). RESULTS: The combined prevalence of obesity and overweight was 16.6%, overall. Controlling one's weight was important to overweight and non-overweight youth, alike (94.2% v. 84.8%, p<0.001). Significantly more overweight or obese youth reported trying to control their weight last year, compared to those who were not overweight (68.1% v. 18.0%, p<0.001). Healthy weight control behaviors were more common than unhealthy or extreme practices, although the latter were still prevalent. Half of the overweight or obese students misclassified their weight status, while about 1 in 10 non-overweight youth did the same. Body dissatisfaction was highest among overweight youth and girls. CONCLUSIONS: Interventions to promote healthy weight control should be pertinent to and well-received by school-going youth in India. Healthy weight control practices need to be explicitly encouraged and unhealthy practices reduced. Future interventions should address issues specific to body image, too, as body dissatisfaction was not uncommon among youth.

Tobacco-use psychosocial risk profiles of girls and boys in urban India: implications for gender-specific tobacco intervention development.

INTRODUCTION: This study examined the distribution of psychosocial risk factors and prevalence of tobacco use among youth in urban India by gender. METHODS: Data were obtained from a cross-sectional baseline survey of a group-randomized tobacco intervention trial involving 6th and 8th graders from 32 schools in Delhi and Chennai (N = 11,642). Mixed-effects regression models were used to examine differences in the prevalence of tobacco use by gender, to determine how the relationship between current tobacco use and related psychosocial risk factors varied by gender, to compare the distribution of risk factors by gender, and to determine if any of these relationships varied by grade level or school type. RESULTS: 14.7% of girls and 21.1% of boys reported ever-use of tobacco. The psychosocial risk profile for tobacco use was remarkably similar for boys and girls, though some differences were apparent. For example, exposure to advertising and beliefs about social effects of use were significant risk factors for girls but not for boys. Across the board, girls showed lower risk for all psychosocial risk factors, except for perceived prevalence of chewing and smoking, for which girls had higher risk compared with boys. DISCUSSION: While the psychosocial risk profile for boys suggests a more vulnerable population for tobacco use, the closing gap in tobacco use between boys and girls indicates a need to examine possible differences in psychosocial risk factors. This study reports that there are subtle, but important, differences in risk factors between genders, having implications for gender-specific intervention development.

Improving the school experience of children with diabetes: Evaluation of the KiDS project.

BACKGROUND: The International Diabetes Federation (IDF) launched the Kids and Diabetes in School (KiDS) project in collaboration with the International Society for Paediatric and Adolescent Diabetes (ISPAD) and Sanofi Diabetes to inform and teach school staff, children and parents on the management of diabetes in school. Brazil and India were chosen as pilot countries. METHODS: The evaluation was conducted using a qualitative methodology using semi-structured face to face in-depth interviews. Five out of fifteen schools were selected, where teachers and parents of children with and without diabetes were interviewed. Interviews took place one and three months after the implementation of KiDS. FINDINGS: Diabetes knowledge among the school staff and parents of children without diabetes was very limited prior to the KiDS Project in both countries. After introducing the KiDS information pack both groups mentioned increased knowledge on the management of diabetes. This was reflected through healthier food choices at school and the encouragement of physical activities. Increased awareness and understanding in the school staff were observed by parents of children with diabetes. INTERPRETATION: The KiDS project received positive feedback on the educational materials. The pack was deemed informative, interesting and engaging, creating increased awareness and understanding among school staff, parents and children. The project has created a demand for diabetes intervention in schools. The pack has been translated into fourteen languages and was downloaded over 17,000 times by November 2018.

Intermediate outcomes from Project MYTRI: mobilizing youth for tobacco-related initiatives in India.

The purpose of this article is to present the intermediate results for Project MYTRI, a school-based, multiple component intervention designed to prevent and reduce many forms of tobacco use (chewing tobacco, cigarettes, and bidis) among youth in India. The intervention is based on effective models in the United States "translated" for use in this context. The intervention targets two cohorts of students who were in the 6th and 8th grade when the study started. Thirty-two schools in Delhi (north India) and Chennai (south India) were randomized to receive the intervention (n = 16) or serve as a delayed intervention control (n = 16). Students in these schools were surveyed before the intervention began and at an intermediate point, 1 year into this 2-year intervention (n = 8,369). A test of the changes in risk factors for tobacco use between the baseline and intermediate surveys revealed that, compared with the control, students in the intervention condition (a) had better knowledge about the health effects of tobacco (P < 0.01); (b) believed that there were more negative social consequences to using tobacco (P = 0.04); (c) had fewer reasons to use tobacco (P < 0.01); (d) had more reasons not to use tobacco (P = 0.03); (e) were less socially susceptible to chewing (P = 0.04) and smoking (P = 0.03) tobacco; (f) perceived fewer peers and adults around them smoked (P < 0.01) or chewed (P < 0.01) tobacco; (g) felt that tobacco use was not acceptable, especially among their peers (P < 0.01); (h) were more confident in their ability to advocate for tobacco control (P = 0.03); (i) were more knowledgeable about tobacco control policies (P < 0.01); and (j) supported these policies, too (P = 0.04). Fewer students in the intervention condition reported having intentions to smoke tobacco in the next year (P = 0.02) or chew tobacco when they reached college (P < 0.01). No changes in actual tobacco use were observed at this stage of the study.

Health promotion for primordial prevention of tobacco use.

Prevention of tobacco use is critical for primordial prevention of cardiovascular diseases. Low- and middle-income countries such as India face a burgeoning burden of tobacco-related cardiovascular diseases. A focus on adolescents and young people is consistent with a primordial approach to cardiovascular disease prevention and appropriate given the natural history of tobacco use, in regards to its onset and progression. The primordial prevention approach is feasible, because it attempts to bring about behavior change (sustained abstinence for nonusers) at the population level. This paper reviews effective strategies for population-based tobacco control among adolescents including settings-based interventions at school, at home, and in the community, as well as policy and media interventions. It goes on to briefly touch on the pivotal role that medical professionals, particularly cardiologists, play in fortifying such interventions and summarizes some key recommendations based on review of evidence on the effectiveness of these interventions.

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).