Policy strictness, enforcement and public health effectiveness of tobacco control in India: integrating world health organization framework convention on tobacco control compliance and public perceptions
DOI:
https://doi.org/10.18203/2394-6040.ijcmph20261437Keywords:
Tobacco control, WHO, FCTC, Enforcement, Public health impact, India, Smoking, CigaretteAbstract
The objective of this study is to examine the extent to which India's tobacco control policies have been implemented in practice and to analyse public perceptions of their effectiveness and alignment with WHO-FCTC provisions. A mixed-method design was adopted. A systematic review of national tobacco control policies was conducted to examine their alignment with selected world health organization framework convention on tobacco control (WHO-FCTC) provisions. Concurrently, a cross-sectional survey involving 95 participants was administered using the policy perception scale. The instrument measured policy strictness, enforcement rigidity, effectiveness of tobacco control initiatives, and policy alignment with international standards. Structural equation modelling (SEM) was performed to test hypothesized relationships among latent constructs and to determine predictors of perceived policy effectiveness. Our review of the policies showed that India is doing well with smoke free rules and warnings on packages but there are still problems with taxes and indirect promotion controls. When we asked people what they thought we found that they believe tougher policies lead to enforcement and good enforcement leads to better effectiveness of anti-tobacco initiatives, which in turn make people think the WHO-FCTC is being followed. For India to be successful in controlling tobacco use it needs to make sure the laws are enforced properly not just passed. India needs to make its enforcement stronger and fix the problems with how the laws are being implemented so that the laws can actually lead to better effectiveness of anti-tobacco initiatives.
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References
World Health Organization. WHO report on the global tobacco epidemic 2019: Offer help to quit tobacco use. Geneva: World Health Organization, 2019. Available at: https://www.who.int/publications/i/item/9789241516204. Accessed on 1 February 2026.
World Health Organization. WHO global report on trends in prevalence of tobacco use 2000-2030. 4th ed. Geneva: World Health Organization, 2023. Available at: https://www.who.int/publications/i/item/9789240088283. Accessed on 1 February 2026.
World Health Organization. WHO framework convention on tobacco control. Geneva: World Health Organization, 2005. Available at: https://www.who.int/europe/teams/tobacco/who-framework-convention-on-tobacco-control-(who-fctc). Accessed on 1 February 2026.
Government of India. The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003. New Delhi: Ministry of Health and Family Welfare. 2003.
Ministry of Health and Family Welfare, Government of India. Global Adult Tobacco Survey GATS 2 India 2016-17: Report. New Delhi: Ministry of Health and Family Welfare. 2017.
Gravely S, Giovino GA, Craig L, Commar A, D'Espaignet ET, Schotte K, et al. Implementation of key demand-reduction measures of the WHO Framework Convention on Tobacco Control. Tob Control. 2017;26(2):S2-S8.
Studlar DT. Tobacco control policy instruments in a shrinking world: How much policy learning? Tob Control. 2015;24(3):243-50.
Agaku IT, Ayo-Yusuf OA, Vardavas CI, Connolly GN. Enforcement of tobacco control laws and public compliance: Evidence from low- and middle-income countries. Tob Control. 2019;28(3):305-12.
World Health Organization. WHO technical manual on tobacco tax administration. Geneva: World Health Organization, 2010. Available at: https://www.who.int/publications/i/item/9789240019188. Accessed on 1 February 2026.
Goodchild M, Nargis N, Tursan d'Espaignet E. Global economic cost of smoking-attributable diseases. Tob Control. 2018;27(1):58-64. DOI: https://doi.org/10.1136/tobaccocontrol-2016-053305
Tata Institute of Social Sciences, Ministry of Health and Family Welfare. Global Adult Tobacco Survey GATS 2 India 2016-2017. Mumbai: International Institute for Population Sciences. 2017.
John RM, Dauchy E, Goodchild M. Cigarette and bidi taxes in India: Estimates of consumption and revenue impacts. Nicotine Tob Res. 2019;21(7):920-7.
John RM, Sung HY, Max W. Economic cost of tobacco use in India, 2004. Tob Control. 2009;18(2):138-43. DOI: https://doi.org/10.1136/tc.2008.027466
Shang C, Chaloupka FJ, Fong GT, Thompson M, O'Connor RJ. The association between tax structure and cigarette price variability: Evidence from the ITC Project. Tob Control. 2015;24(3):iii88-iii93. DOI: https://doi.org/10.1136/tobaccocontrol-2014-051771
Ministry of Health and Family Welfare. The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Rules, 2004. New Delhi: Government of India. 2004.
Ministry of Health and Family Welfare. Notification on prohibition of smoking in public places. New Delhi: Government of India. 2008.
Nagler RH, Viswanath K. Implementation and research priorities for FCTC Articles 13 and 16: Tobacco advertising, promotion, and sponsorship and sales to minors. Nicotine Tob Res. 2013;15(4):832-46. DOI: https://doi.org/10.1093/ntr/nts331
Mishra S, Joseph RA, Gupta PC, Pezzack B, Ram F, Sinha DN, et al. Trends in bidi and cigarette smoking in India from 1998 to 2015, by age, gender and education. BMJ Glob Health. 2016;1(1):e000005. DOI: https://doi.org/10.1136/bmjgh-2015-000005
Kaur J, Jain DC. Tobacco control policies in India: Implementation and challenges. Indian J Public Health. 2011;55(3):220-7. DOI: https://doi.org/10.4103/0019-557X.89941
Hammond D. Health warning messages on tobacco products: A review. Tob Control. 2011;20(5):327-37. DOI: https://doi.org/10.1136/tc.2010.037630
Arora M, Yadav A. Pictorial health warnings on tobacco products in India: Sociological and legal examinations. Indian J Med Res. 2010;132(3):366-71.
Rao SR, Aslam SK, Jha P. Trends in cigarette smoking in India. BMC Public Health. 2015;15:1309.
Noar SM, Hall MG, Francis DB, Ribisl KM, Pepper JK, Brewer NT. Pictorial cigarette pack warnings: A meta-analysis of experimental studies. Tob Control. 2016;25(3):341-54. DOI: https://doi.org/10.1136/tobaccocontrol-2014-051978
Bhawna G. Burden of smoked and smokeless tobacco consumption in India - results from the Global Adult Tobacco Survey India (GATS-India) 2009-2010. Asian Pac J Cancer Prev. 2013;14(5):3323-9. DOI: https://doi.org/10.7314/APJCP.2013.14.5.3323
Mehrotra R, Yadav A, Sinha DN, Parascandola M, John RM, Ayo-Yusuf O, et al. Smokeless tobacco control in 180 countries across the globe: Call to action for full implementation of WHO FCTC measures. Lancet Oncol. 2019;20(4):e208-e217. DOI: https://doi.org/10.1016/S1470-2045(19)30084-1
Kumar R. Tobacco control in India: Present status and way forward. J Indian Med Assoc. 2010;108(10):659-64.
da Costa e Silva VL, Koifman S. Smoking in Latin America: A major public health problem. Cad Saude Publica. 1998;14 Suppl 3:99-108. DOI: https://doi.org/10.1590/S0102-311X1998000700010
Reddy KS, Gupta PC, editors. Report on tobacco control in India. New Delhi: Ministry of Health and Family Welfare, Government of India. 2004.
WHO. The tobacco atlas. Geneva: World Health Organization, 2002. Available at: https://iris.who.int/items/25b88eaa-3dfb-4d7b-b69c-712667bd7241. Accessed on 1 February 2026.
Government of National Capital Territory of Delhi. The Delhi Prohibition of Smoking and Non-Smokers' Health Protection Act, 1996. Delhi: Delhi Gazette. 1996.
Chokshi M, Patil B, Khanna R, Neogi SB, Sharma J, Paul VK, et al. Health systems in India. J Perinatol. 2016;36(3):S9-S12. DOI: https://doi.org/10.1038/jp.2016.184
Fong GT, Hammond D, Hitchman SC. The impact of pictures on the effectiveness of tobacco warnings. Bull World Health Organ. 2009;87(8):640-3. DOI: https://doi.org/10.2471/BLT.09.069575
World Health Organization. WHO report on the global tobacco epidemic, 2013: Enforcing bans on tobacco advertising, promotion and sponsorship. Geneva: World Health Organization, 2013. Available at: https://www.who.int/publications/i/item/9789241505871. Accessed on 1 February 2026.
Cummings KM, Proctor RN. The changing public image of smoking in the United States: 1964-2014. Cancer Epidemiol Biomarkers Prev. 2014;23(1):32-6. DOI: https://doi.org/10.1158/1055-9965.EPI-13-0798
May PJ. Implementation failures revisited: Policy regime perspectives. Public Policy Adm. 2014;29(4):277-99. DOI: https://doi.org/10.1177/0952076714561505
Agaku IT, King BA, Dube SR. Current cigarette smoking among adults - United States, 2005-2012. MMWR Morb Mortal Wkly Rep. 2014;63(2):29-34.
Breton E, Richard L, Gagnon F, Jacques M, Bergeron P. Health promotion research and practice require sound policy analysis models: The case of Quebec's Tobacco Act. Soc Sci Med. 2008;67(11):1679-89. DOI: https://doi.org/10.1016/j.socscimed.2008.07.028
Schneider A, Ingram H. Behavioral assumptions of policy tools. J Politics. 1990;52(2):510-29. DOI: https://doi.org/10.2307/2131904
Mazmanian DA, Sabatier PA. Implementation and public policy. Glenview: Scott Foresman. 1983.
Hyland A, Higbee C, Borland R, Travers M, Hastings G, Fong GT, et al. Attitudes and beliefs about secondhand smoke and smoke-free policies in four countries: Findings from the International Tobacco Control Four Country Survey. Nicotine Tob Res. 2009;11(6):642-9. DOI: https://doi.org/10.1093/ntr/ntp063
Studlar DT, Christensen K, Sitasari A. Tobacco control and public policy: A comparison across six developed democracies. J Comp Policy Anal. 2011;13(3):329-43.
Wipfli H, Fujimoto K, Valente TW. Global tobacco control diffusion: The case of the Framework Convention on Tobacco Control. Am J Public Health. 2010;100(7):1260-6. DOI: https://doi.org/10.2105/AJPH.2009.167833
Sinha DN, Palipudi KM, Rolle I, Asma S, Rinchen S. Tobacco use among youth and adults in member countries of South-East Asia region: Review of findings from surveys under the Global Tobacco Surveillance System. Indian J Public Health. 2011;55(3):169-76. DOI: https://doi.org/10.4103/0019-557X.89946
Bump JB, Reich MR. Political economy analysis for tobacco control in low- and middle-income countries. Health Policy Plan. 2013;28(2):123-33. DOI: https://doi.org/10.1093/heapol/czs049
Gravely S, Giovino GA, Craig L, Commar A, D'Espaignet ET, Schotte K, et al. Implementation of key demand-reduction measures of the WHO Framework Convention on Tobacco Control and change in smoking prevalence in 126 countries: An association study. Lancet Public Health. 2017;2(4):e166-e174. DOI: https://doi.org/10.1016/S2468-2667(17)30045-2
Blecher E. Targeting the affordability of cigarettes: A new benchmark for taxation policy in low-income and middle-income countries. Tob Control. 2010;19(4):325-30. DOI: https://doi.org/10.1136/tc.2009.030155
Hammond D, Fong GT, Zanna MP, Thrasher JF, Borland R. Tobacco denormalization and industry beliefs among smokers from four countries. Am J Prev Med. 2006;31(3):225-32. DOI: https://doi.org/10.1016/j.amepre.2006.04.004
Chapman S, Freeman B. Markers of the denormalisation of smoking and the tobacco industry. Tob Control. 2008;17(1):25-31. DOI: https://doi.org/10.1136/tc.2007.021386
Yong HH, Borland R, Thrasher JF, Thompson ME, Nagelhout GE, Fong GT, et al. Prevalence and correlates of self-exempting beliefs about smoking: Findings from the International Tobacco Control Four Country Survey. Tob Control. 2014;23(1):i17-i25.
Siahpush M, McNeill A, Borland R, Fong GT. Socioeconomic variations in nicotine dependence, self-efficacy, and intention to quit across four countries: Findings from the International Tobacco Control (ITC) Four Country Survey. Tob Control. 2006;15(3):iii71-5. DOI: https://doi.org/10.1136/tc.2004.008763
Brown A, Moodie C, Hastings G. A longitudinal study of policy effect (smoke-free legislation) on smoking norms: ITC Scotland/United Kingdom. Nicotine Tob Res. 2009;11(8):924-32. DOI: https://doi.org/10.1093/ntr/ntp087
Sabatier PA, Mazmanian DA. The implementation of public policy: A framework of analysis. Policy Stud J. 1980;8(4):538-60. DOI: https://doi.org/10.1111/j.1541-0072.1980.tb01266.x
Hill M, Hupe P. Implementing public policy: An introduction to the study of operational governance. 3rd ed. London: Sage. 2014.
MacKinnon DP, Fairchild AJ, Fritz MS. Mediation analysis. Annu Rev Psychol. 2007;58:593-614. DOI: https://doi.org/10.1146/annurev.psych.58.110405.085542
Matland RE. Synthesizing the implementation literature: The ambiguity-conflict model of policy implementation. J Public Adm Res Theory. 1995;5(2):145-74.
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