Understanding the rise in global tobacco consumption, the WHO global action plan for prevention and control of Non-Communicable diseases announced a 30% reduction in the prevalence of tobacco consumption by the year 2025 (baseline 2010).
Global action plan for the prevention and control of NCDs 2013-2020.
If there is any hope of achieving these sustainable developmental goals, controlling tobacco use among adolescents is exceptionally vital. This is especially true for South-East Asian regions (SEAR), known for their high prevalence of tobacco consumption and early initiation. An effective tobacco control program can be formulated by utilizing a multipronged approach that integrates community, interpersonal and individual-level factors (Fig. 1
4.1 Community-level tobacco control
Community-level control emphasizes decreased density of tobacco outlets, especially near EI, which has been demonstrated to effectively reduce adolescent tobacco use.
- Henriksen L.
- Feighery E.C.
- Schleicher N.C.
- Cowling D.W.
- Kline R.S.
- Fortmann S.P.
Is adolescent smoking related to the density and proximity of tobacco outlets and retail cigarette advertising near schools?.
- McCarthy W.J.
- Mistry R.
- Lu Y.
- Patel M.
- Zheng H.
- Dietsch B.
Density of tobacco retailers near schools: effects on tobacco use among students.
Almost 80% of EIs had at least one tobacco outlet within 100 yards of it. The average number of tobacco outlets per EI was found to be 7. This is a clear violation of the COPTA Section 6b
A multi-centre study examining 307 schools from five different states in India found an average 69% violated Section 6b
- Pradhan A.
- Oswal K.
- Padhan A.
- et al.
Cigarettes and Other Tobacco Products Act (COTPA) Implementation in Education Institutions in India: A Cross-Sectional Study.
Mead et al. conducted a two-wave observational study to assess COPTA compliance found that most tobacco vendors had no/low compliance, with little change over time (58%–63%, P = 0.108).
- Mead E.L.
- Rimal R.N.
- Cohen J.E.
- et al.
A two-wave observational study of compliance with youth access and tobacco advertising provisions of the cigarettes and other tobacco products act in India.
Other single centre studies concerning these violations showed a range between 46% and 93%.
- McKay A.J.
- Patel R.K.K.
- Majeed A.
Strategies for tobacco control in India: a systematic review.
We did not find a single “prohibition of tobacco sale/consumption” signage outside any EI (100% violation) we surveyed which violates Section 4
of COPTA. This high rate of non-compliance was also mirrored in the large multi-centric study where an average of 85% of the schools violated the regulatory requirements. The highest was seen in Anantapur and Chittoor districts of Andhra Pradesh, where 100% of the educational institutions violated Section 420
. Similar findings were also observed in other studies, which shows a lack of health communication strategies between the education department and institutions.
- Mistry R.
- Pednekar M.S.
- Gupta P.C.
- et al.
Longitudinal study of adolescent tobacco use and tobacco control policies in India.
- Pimple S.
- Gunjal S.
- Mishra G.A.
- Pednekar M.S.
- Majmudar P.
- Shastri S.S.
Compliance to Gutka ban and other provisons of COTPA in Mumbai.
One-fourth of the tobacco vendors admitted to having sold to a minor, which is alarming. It is most likely an underestimation which is also a clear violation of COPTA section 6a
Additionally, the sale of single sticks of cigarettes is highly detrimental to the already established tobacco control strategies. The availability of single sticks leads to easy affordability of loose cigarettes and acts as an enabling factor for students and minors. Single sticks also lack written/pictorial warning, a clear violation of COPTA section 7
or effective taxation.
- Hall M.G.
- Fleischer N.L.
- Reynales-Shigematsu L.M.
- Arillo-Santillán E.
- Thrasher J.F.
Increasing availability and consumption of single cigarettes: trends and implications for smoking cessation from the ITC Mexico Survey.
As of September 11, 2017, most states, including the one where the study was conducted, issued orders/notifications banning the sale of loose cigarettes under section-7 of COTPA, 2003. Our study shows that this law is not being enforced as the sale of a single stick was seen in more than 80% of the vendor population.
As per the Indian legislature, the advertisement of tobacco products is allowed at the point of sale. But they have to adhere to strict size and number limitations (as per the recent 2006 notification). Unfortunately, there remain loopholes to such laws. Tobacco brands often extend the display size by joining two boards or placing one large display on adjacent shops. This makes the COPTA section 5
regulations futile. In our study, violations of COPTA 5 laws ranged from 35% to 67%. The majority of these violations were seen in the placement of open displays of tobacco products and exhibiting more than two boards at one point of sale.
Furthermore, compliance with the simple requirement to display a sign about the ban on tobacco sale to minors shows a clear anti-tobacco message deterring underage purchases, thereby reducing student tobacco use risk.
- Frick R.G.
- Klein E.G.
- Ferketich A.K.
- Wewers M.E.
Tobacco advertising and sales practices in licensed retail outlets after the Food and Drug Administration regulations.
Compliance with COPTA 5 reduces exposure to pro-tobacco messages and correlates to lower tobacco use
- Shang C.
- Huang J.
- Cheng K.-W.
- Li Q.
- Chaloupka F.J.
Global evidence on the association between POS advertising bans and youth smoking participation.
An alarming one-third of the school adjacent communities showed low levels of compliance with COPTA regulations. Our study, along with similar others,
- Banandur P.
- Kumar M.
- Gopalakrishna G.
Awareness and Compliance to Anti-smoking Law in South Bengaluru, India.
was consistent with the hypotheses that higher compliance with tobacco COPTA laws would be associated with a protective effect on tobacco use in adolescents. Moreover, our study also shows a direct relationship with higher community compliance scores having higher AOIs (Table 4
Table 4Correlation Matrix assessing different factors influencing adolescent tobacco use.
Note. *p < 0.05, **p < 0.01, ***p < 0.001.
FTE=Family education against tobacco use; AOI = Age of initiation of tobacco use in adolescents.
Table 5Multivariable Binomial Logistic regression analysing odds of tobacco consumption among students.
Since tobacco vendor compliance plays such a critical role in hindering adolescent tobacco use, we need to design better interventions to improve adherence to point-of-sale compliance laws, which are now lacking.
- Robertson L.
- McGee R.
- Marsh L.
- Hoek J.
A systematic review on the impact of point-of-sale tobacco promotion on smoking.
Almost 40% of the vendors said that they had not had a visit by law-enforcing authorities to their shop. To overcome barriers, tobacco vendors may benefit from explicit instruction and training. This will help tobacco vendors understand that enforcement of the tobacco control policies would not jeopardize their business and express support to these regulations.
- Rose S.W.
- Emery S.L.
- Ennett S.
- Reyes H.L.M.
- Scott J.C.
- Ribisl K.M.
Retailer opinions about and compliance with family smoking prevention and tobacco control act point of sale provisions: a survey of tobacco retailers.
4.2 Interpersonal influence in tobacco control
Interpersonal influence is moderated by family, friends, and close acquaintances. A nurturing interpersonal environment where tobacco use is discouraged was found to reduce adolescent tobacco and helped negate the effects of the community tobacco environment (CTE).
- Mistry R.
- McCarthy W.J.
- Yancey A.K.
- Lu Y.
- Patel M.
Resilience and patterns of health risk behaviors in California adolescents.
The key interpersonal predictor of our study was found to be tobacco use among the peers and family in both students studying in government and private EI. Peer pressure likely modifies adolescents’ behaviour as they tend to copy their peers to avoid being alienated. In a similar study, peer pressure was a stronger determinant for tobacco use than parental use or formal education.
- Bhojani U.M.
- Elias M.A.
- Devadasan N.
Adolescents' perceptions about smokers in Karnataka, India.
Likewise, having had a parent/teacher explain the harmful effects of tobacco use was protective. We found that students from government EI were taught significantly less about the detrimental effects of tobacco use by either parents or teachers. Previous studies suggest a strong association between tobacco in family members and adolescent tobacco use
Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General.
but there is a paucity of data on how different parenting styles may affect adolescent tobacco use and how it interacts with the community-level tobacco environment.
4.3 Individual factors of tobacco control
The individual factors of tobacco control (biological/personality stream) of the conceptual framework detail personality traits and individual characteristics providing internal motivation to use tobacco or increase susceptibility to tobacco addiction. Our study found that the male gender was more susceptible to tobacco use than females. It is well established that the prevalence of tobacco consumption in males was higher than in females.
- Rahmanian S.D.
- Diaz P.T.
- Wewers M.E.
Tobacco use and cessation among women: research and treatment-related issues.
Additionally, there is evidence that poor self-image can be a crucial factor of smoking initiation among youth.
- McCool J.
- Freeman B.
- Tanielu H.
Perceived social and media influences on tobacco use among Samoan youth.
Almost 60% of the students in our study felt more comfortable in a social gathering, while one-third of the participants were likely to accept a cigarette if their friends offer it.
One major challenge for new smokers is the harsh effect of cigarette smoke on the throat. In our study, more than half the study population preferred the use of flavoured cigarettes. Smoking flavoured cigarettes may help establish regular smoking among young people and reduce the likelihood of quitting.
- Villanti A.C.
- Collins L.K.
- Niaura R.S.
- Gagosian S.Y.
- Abrams D.B.
Menthol cigarettes and the public health standard: a systematic review.
Menthol cigarettes are also more commonly used by less-established or ‘novice’ smokers and those experimenting with smoking.
- Hersey J.C.
- Ng S.W.
- Nonnemaker J.M.
- et al.
Are menthol cigarettes a starter product for youth?.
Research shows that the tobacco industry has manipulated the menthol content of cigarettes to promote smoking initiation and sustain tobacco use. Countries such as Canada, the EU, Chile, brazil have already taken steps to ban flavoured and mentholated cigarettes. Health policymakers in India should consider taking similar steps as banning menthol cigarettes can discourage sustained tobacco use among adolescents. Finally, ease of access to tobacco plays a significant role as an individual factor. More than 40% of the study population bought their tobacco from vendors, and 60% said it would be easy to get tobacco products. These influences may be associated with an upshift in the prevalence of adolescent tobacco use, lowering the age of initiation, intention to use, and ease of access.
4.4 The interaction effect
The conceptual design of our study centred around treating the issue of adolescent tobacco use as a sum effect of community, interpersonal and individual factors. This was further substantiated when we calculated a correlation matrix compiling the impact of community, family, and peer factors (Table 4
This further substantiates our conceptual design, which is based on three crucial behavioural theories that have been used to understand the initiation and maintenance of smoking in adolescents. They are the “Bronfenbrenner's theory of the ecology of human development,” “the social learning theory,” and “the social control theory.” The ecology of human development theory considers that youth behaviour develops within critical nested environments (family, peers, school, neighbourhood) that constantly interact with one another.
Social learning theory describes the facilitating effect of a role model who uses tobacco and has on impressionable youth. Social control theory describes the constraining impact of social relationships (for example, a close bonding with the parents who discourage smoking) on the initiation of tobacco among the youth. Ennett et al. reported the importance of all these three theories with significant interaction between them and that neighbourhood of residence was also substantial.
- Ennett S.T.
- Foshee V.A.
- Bauman K.E.
- et al.
A Social Contextual Analysis of Youth Cigarette Smoking Development.
For tobacco control policies to be effective, we need to first understand that the problem of adolescent tobacco use is multifactorial. We need large-scale tobacco control campaigns which focus on merging community compliance enforcement with interpersonal and individual education. There are examples of such successful national campaigns. “True initiative,” a campaign done in the USA, is said to have prevented about 450,000 youths from tobacco initiation in the USA.
- Richardson A.K.
- Green M.
- Xiao H.
- Sokol N.
- Vallone D.
Evidence for truth®: the young adult response to a youth-focused anti-smoking media campaign.
LMICs such as India could build on successful experiences when developing their national anti-tobacco campaigns to reduce tobacco use among adolescents.
A summary of compliance to various COPTA policies and community level compliance from Indian studies are presented in Supplementary Table S1
. Violation of Section 4
ranged from 27 to 85%, Section 5
ranged from 16 to 85%, Section 6a
ranged from 39 to 73.1%, Section 6b
ranged from 19 to 69%, Section 7 and 8
, 7 and 8
ranged from 21.7 to 53.6%. Only one study previously evaluated community compliance and observed 27% high compliance, 49% moderate compliance and 24% low compliance. A summary of recent studies from India on adolescent tobacco smoking, their sample size, prevalence of tobacco smoking and the various determinants evaluated in each study are presented in Supplementary Table S2
. The studies with the large sample sizes over 1000 were 2 studies from Kerala (n = 7350 & n = 1114), followed by Delhi (n = 4786) and Mumbai (n = 1317). The highest prevalence of adolescent smoking was observed in Chhattisgarh (25%), followed by Karnataka (20.4%). Only two studies from Delhi and Mumbai evaluated more than 5 determinants.
We adopted a systematic approach to the selection of colleges wherein both private and government colleges were accounted for and equally represented. A major strength of the study is that we are assessing a combination of the influence of individual, interpersonal and community level factors together. Additionally we also assessed how these factors correlate and interact with each other. This gives us a better understanding of variables involved in adolescent tobacco use. Tobacco vendors were also interviewed to assess their understanding of the COPTA laws. The primary limitation was that it was a single city study and is not representative of India. Confounding factors such as stress, depression and risk-taking behaviour were not accounted for. The law enforcement agency and the school management were not interviewed, which would have given a more comprehensive view.