Editor’s Note:Tobacco use is a major public health challenge in India with 275 million adults consuming different tobacco products. Government of India has taken various initiatives for tobacco control in the country. Besides enacting comprehensive tobacco control legislation (COTPA, 2003), India was among the first few countries to ratify WHO the Framework Convention on Tobacco Control (WHO FCTC) in 2004. The National Tobacco Control Programme was piloted during the 11 th Five Year Plan which is under implementation in 42 districts of 21 states in the country. The advocacy for tobacco control by the civil society and community led initiatives has acted in synergy with tobacco control policies of the Government. Although different levels of success have been achieved by the states, non prioritization of tobacco control at the sub national level still exists and effective implementation of tobacco control policies remains largely a challenge.
Tobacco was introduced in India by Portuguese barely 400 years ago during the Mughal era. Mainly due to a potpourri of different cultures in the country, tobacco rapidly became a part of socio cultural milieu in various communities, especially in the eastern, north eastern and southern parts of the country. India is the second largest producer of tobacco in the world after China. 
India is also the second largest consumer of tobacco in the world, second only to China.  The prevalence of tobacco use among adults (15 years and above) is 35%. The prevalence of overall tobacco use among males is 48 percent and that among females is 20 percent. Nearly two in five (38%) adults in rural areas and one in four (25%) adults in urban areas use tobacco in some form. 
The challenge posed by tobacco has been countered by different countries with various levels of success. While economically advanced democracies share a broad commitment to liberal political values and demonstrate an interesting range of beliefs and practices with respect to privacy, autonomy, and paternalism, there are examples of developing countries with liberal political values and autonomy such as India, the world’s largest democracy, South Africa, and the Philippines which go unmentioned. 
In South East Asia, Bhutan (2004), Thailand (2006) and India (2008) are some of the countries that have successfully enforced a smoking ban in public places. Bhutan is the first country in the world to impose a total ban on tobacco products-sale and use.  China introduced a smoking ban in public buildings in Beijing from May 2008 as a run-up to the Olympic Games  and a ban on smoking in public places came into effect from 1 st May 2011. Singapore has had smoke-free legislation since 1970, but has strengthened it recently.  Hong Kong enacted the smoking ban law in 1982 but could enforce it only since 2007.  Countries like Indonesia (2006), Kazakhstan 2003), Malaysia (2004), Bangladesh (2006), Pakistan (2003), Philippines (2002), Vietnam (2005), Brunei Darussalam (1988) have banned smoking in public places, but implementation is far from complete. 
Tobacco control legislation in India
India has played a leadership role in global tobacco control. With the growing evidence of harmful and hazardous effects of tobacco, the Government of India enacted various legislations and comprehensive tobacco control measures.  The Government enacted the Cigarettes Act (Regulation of Production, Supply and Distribution) in 1975.  The statutory warning “cigarette smoking is injurious to health” was mandatorily displayed on all cigarette packages, cartons and advertisements of cigarettes. Some states like Maharashtra and Karnataka restricted smoking in public places. In the case of Maharashtra, specification of the size of boards in English and Marathi were prescribed, declaring certain premises as smokefree.  Tobacco smoking was prohibited in all health care establishments, educational institutions, domestic flights, air-conditioned coaches in trains, suburban trains and air-conditioned buses, through a Memorandum issued by the Cabinet Secretariat in 1990.  Since these were mainly Government or administrative orders, they lacked the power of a legal instrument. Without clear enforcement guidelines and awareness of the citizens to their right to smoke-free air, the implementation of this directive remained largely ineffective.
Under the Prevention of Food Adulteration Act (PFA) (Amendment) 1990, statutory warnings regarding harmful health effects were made mandatory for paan masala and chewing tobacco. 
In 1992, under the Drugs and Cosmetics Act 1940 (Amendment), use of tobacco in all dental products was banned.  The Cable Television Networks (Amendment) Act 2000 prohibited tobacco advertising in state controlled electronic media and publications including cable television.  Under the Chairmanship of Shri Amal Datta, the 22 nd Committee on Subordinate Legislation in November 1995 recommended to the Ministry of Health to enact legislation to protect non-smokers from second hand smoke. In addition, the committee recommended stronger warnings for tobacco users, stricter regulation of the electronic media and creating mass awareness programmes to warn people about the harms of tobacco. In a way, this Committee’s recommendation laid the foundation of developing the existing tobacco control legislation in the country.
Between 1997 and 2001, several litigations e.g K Ramakrishnan and Anr. Vs State of Kerala and others (AIR 1999 Ker 385) and Murli Deora vs Union of India (2001 8 SCC 765) were filed for individual’s right to smoke-free air and five states responding with smoke-free and tobacco control legislations, clearly gave the signal for the Government of India to propose a comprehensive law for tobacco control. The Government enacted the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act (COTPA), in 2003.  The provisions under the act included prohibition of smoking in public places, prohibition of advertisements of tobacco products, prohibition on sale of tobacco products to and by minors (persons below 18 years), ban on sale of tobacco products within 100 yards of all educational institutions and mandatory display of pictorial health warnings on tobacco products packages. The law also mandates testing all tobacco products for their tar and nicotine content. Although the Rules pertaining to various provisions under the law were notified during 2004 to 2006, there were many legal challenges which the Government had to face in view of the tobacco industry countering most of these Rules in the court of law. However after a long legal battle and interventions by the civil society, Revised Smoke-free Rules came into effect from 2 nd October, 2008.  The ban on smoking in public places, which included work places also, was a remarkable achievement in terms of political will and national commitment. Subsequently the law pertaining to pictorial warnings on tobacco products packages was implemented with effect from 31 st May 2009. After getting positive and supportive judgments in other court cases, the Government was forthcoming in notifying laws pertaining to ban on sale to and by minors and sale of tobacco products within 100 yards of educational institutions.
In 2004, the Government ratified the WHO Framework Convention on Tobacco Control (WHO FCTC), which enlists key strategies for reduction in demand and reduction in supply of tobacco. Some of the demand reduction strategies include price and tax measures and non price measures (statutory warnings, comprehensive ban on advertisements, promotion and sponsorship, tobacco product regulation etc). The supply reduction strategies include combating illicit trade, providing alternative livelihood to tobacco farmers and workers and regulating sale to and by minors.  India has been in the forefront of negotiations under various Working Groups of the WHO FCTC and also played a leadership role in bringing region specific issues e.g smokeless tobacco to the global attention. India has actively contributed to drafting of guidelines as a member of the Inter Government Negotiating Body (INB) to curb the illicit trade of tobacco products. India provided valuable contribution to development of guidelines for Article 9 and 10, 12, 13, 14, 17 & 18 of WHO FCTC.
National Tobacco Control Programme
As the implementation of various provisions under COTPA lies mainly with the State Governments, effective enforcement of tobacco control law remains a big challenge. To strengthen implementation of the tobacco control provisions under COTPA and policies of tobacco control mandated under the WHO FCTC, the Government of the India piloted National Tobacco Control Programme (NTCP) in 2007-2008.  The programme is under implementation in 21 out of 35 States/Union territories in the country. In total, 42 districts are covered by NTCP at present. This was a major leap forward for the tobacco control initiatives in the country as for the first time dedicated funds were made available to implement tobacco control strategies at the central state and substate levels.
The main components of the NTCP were:
i. Public awareness/mass media campaigns for awareness building and behavior change.
ii. Establishment of tobacco product testing laboratories, to build regulatory capacity, as mandated under COTPA, 2003.
iii. Mainstreaming the program components as part of the health care delivery mechanism under the National Rural Health Mission framework.
iv. Mainstream Research and Training on alternate crops and livelihoods in collaboration with other nodal Ministries.
v. Monitoring and Evaluation including surveillance e.g. Global Adult Tobacco Survey (GATS) India.
i. Tobacco control cells with dedicated manpower for effective implementation and monitoring of anti tobacco laws and initiatives.
i. Training of health and social workers, SHGs, NGOs, school teachers etc.
ii. Local IEC activities.
iii. Setting up tobacco cessation facilities.
iv. School Programme.
v. Monitoring tobacco control laws.
Inspite of a comprehensive legislation being in place and implementation of NTCP by the Government, many of the states are not able to initiate effective measures for tobacco control. The internal monitoring of implementation of COTPA in 21 States, where the National Tobacco Control Programme is under implementation has revealed that only about half of the states (52%) have mechanisms for monitoring provisions under the law. Although 15 states have established challenging mechanism for enforcement of smoke-free rules, only 11 states collected fines for violations of bans on smoking in public places. Similarly, a steering committee for implementation of section-5 (ban on Tobacco advertisements, promotion and sponsorship) has been constituted in 21 states but only 3 states collected fines for the violation of this provision. Similarly, enforcement of a ban on the sale of tobacco products to minors and bans on the sale of tobacco products within 100 yards of educational institutions also remains largely ineffective in many states. Less than half of the states under the programme have established tobacco cessation facilities at the district level. It is largely because of the failure of the states to recruit manpower under the programme. To facilitate the implementation of NTCP at state and sub state level, the Government developed various Training modules, guides, IEC and advocacy materials. ,,,,
A well designed public education campaign that is integrated with community and school based programmes, strong enforcement efforts, and help for tobacco users who want to quit, can successfully counter the tobacco industry. Such integrated programmes have been demonstrated to lower smoking among young people by as much as 40%.  An intensive national level mass media campaign for awareness generation on harmful health effects of tobacco and provisions under COTPA has been a major initiative under NTCP for the last three years. The anti tobacco TV/radio messages were translated into 18 languages for the national campaign. The World Lung Foundation provided technical support for development of well tested and good quality TV/radio spots.
The global Adult Tobacco Survey (GATS) was also undertaken as part of NTCP, which was the first ever dedicated household survey to study the prevalence of tobacco use among adults, exposure to second hand smoke, cessation and other tobacco related indicators in the country.
The Ministry of Health & Family Welfare led a research project on alternate crops to tobacco (chewing, bidi and hukkah tobacco), which was undertaken in collaboration with Ministry of Agriculture through the Central Tobacco Research Institute (CTRI), Rajahmundry, Andhra Pradesh. The preliminary results submitted by the institute have encouraging findings in terms of the possibility of economically viable options for alternate crops.
WHO Tobacco Free Initiative in India
Setting up of Tobacco Cessation Clinics in India has been one of the major highlights of WHO/Ministry of Health and Family Welfare collaborative programme in the area of tobacco control. Tobacco cessation is one of the important links of tobacco control as it helps current users to quit tobacco use in a scientific manner. Article 14 of the WHO Framework Convention on Tobacco Control (FCTC) also requires countries to take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence. During 2001-02, a series of 13 Tobacco Cessation Clinics were set-up in 12 states across the country in diverse settings such as cancer treatment hospitals, psychiatric hospitals, medical colleges, NGOs and community settings to help users to quit tobacco use. This network of Tobacco Cessation Clinics was further expanded in 2005 to cover five new clinics in Regional Cancer Centers (RCCs) in 5 states of which two centers were in the North-Eastern States of Mizoram and Assam, having high prevalence of tobacco use. The Tobacco Cessation Clinics were renamed as Tobacco Cessation Centres (TCCs) and their role was expanded to include trainings on cessation and developing awareness generation on tobacco cessation. In 2009, two new TCC’s were set up in Rajasthan and Delhi. A model for Workplace TCC was also set up in Nirman Bhawan in Delhi, where the Ministry of Health and Family Welfare is housed.
The role of TCCs was further expanded in 2009 and they were designated as ‘Resource Centre for Tobacco Control (RCTC)’. Besides providing tobacco cessation services, these RCTCs helped in capacity building of other institutes to develop tobacco cessation facilities. Many of them have developed outreach programs for the community and are regularly doing awareness programs at schools, colleges, slums and workplaces.
Taking into consideration the definite felt need for tobacco cessation both in rural and urban areas, as revealed by the GATS India, 2010, the Government is looking at further capacity building initiatives to expand the tobacco cessation facilities in the country. The emphasis is now being laid on mainstreaming tobacco cessation in the health care delivery system by encouraging health care institutes to set up tobacco cessation facilities in their respective premises utilizing their existing infrastructure, where the Government and WHO will provide the requisite technical support. With this approach, many medical, dental colleges, general and TB hospitals have set up tobacco cessation clinics in their respective institutes. The Indian Dental Association, a professional organization has also initiated Tobacco Intervention Initiative (TII) to train the dental professionals in tobacco cessation and help set up cessation clinics.
With support from WHO, the following training and IEC material has been developed for facilitating tobacco cessation in the country. ,National Guidelines for Treatment of Tobacco Dependence have also been developed and disseminated by the Government in 2011, to facilitate training of health professionals in tobacco cessation.  Various intervention and research studies were also supported to develop community based tobacco cessation models. These included, “An Intervention study on tobacco use practices and impact of cessation strategies among women of Jodhpur districts of Rajasthan’ undertaken by Dr. S.N. Medical College, Jodhpur, Rajasthan, “An Intervention study on community based tobacco cessation among women in Varanasi district’ undertaken by Banaras Hindu University, UP and a “Community based Tobacco Cessation Interventions project” in 4 states (Bihar, Assam, Tamil Nadu and Goa), coordinated by RCTC Goa (WHO India supported projects, unpublished).
Under GOI-WHO collaborative Tobacco Free Initiative, consultants have been provided in 12 out of 21 NTCP states to support state governments in implementation of the programme. WHO has also been supporting activities on World No Tobacco Day (WNTD), every year on 31 st May. The tobacco control policies furthered by WHO are highlighted on this day and are marked by celebrations at various levels. These activities were led by the TCCs and civil society earlier. After the onset of National Tobacco Control Programme, the State Tobacco Control cells have been in the forefront by organizing activities on the theme of WNTD, reiterating commitment of the state for tobacco control initiatives.
Other initiatives for tobacco control
Advocacy for tobacco control – low awareness regarding the anti tobacco law and its provisions at all levels of governance and policy making has been an important impeding factor for effective implementation of tobacco control policies. The states had not trained enforcement officials from various departments e.g. police, food, drug, health, labor, transport, railways etc. who have been authorized to enforce provisions under COTPA, resulting in failure to initiate action for violations and the implementation of the law suffered. Moreover many of the States lacked the capacity and the mechanism for implementation of COTPA.
The Government of India organized a series of advocacy workshops in the country with the following objectives:
Sensitization and awareness building of policy makers, law enforcers at various levels of governance and civil society groups;
Capacity building of the states.
Preparation of National and State-wise enforcement action plans for effective implementation of COTPA and WHO FCTC.
Many advocacy materials were developed with support from WHO to accomplish the realization of the objectives. ,,,,,Between August 2008 and January 2009, one national and five regional workshops were organized to cover all regions of the country. At the end of these workshops, nearly 2000 key personnel in the Government(s) and civil society groups were duly sensitized on the provisions under COTPA and the WHO FCTC with related enforcement strategies.
i. National Inter ministerial Taskforce for Tobacco Control – an inter ministerial taskforce has been constituted under the chairmanship of union health secretary to reiterate the role of other departments and ministries in tobacco control and to bring them on board for performing their respective roles to reduce the demand and supply of tobacco in the country.
ii. Steering Committee on Section 5 of COTPA- as mandated under COTPA, a Steering committee has been constituted under the chairmanship of union health secretary and notified in the Gazette of India.  On the direction of the national committee, state and district level Steering committees were constituted to look into the matters of violations under Section 5 of COTPA.
iii. Alternate livelihood initiatives by Ministry of Labor – a series of training programmes were undertaken in bidi rolling areas to train women bidi rollers in alternate vocations by the Ministry of Labor.
iv. The Ministry of Health and Family Welfare has collaborated with Ministries of Rural Development and Women and Child Development for providing alternate economically viable livelihood options to bidi rollers under their ongoing schemes.
v. Integration of TB and Tobacco Project- As per available evidence, smoking contributes to half the male deaths, (200,000) in the 25-69 age group, from TB in India.  For the first time, tobacco cessation was included in the training module of doctors under RNTCP (Revised National Tuberculosis Control Programme). A pilot project to integrate TB and Tobacco control initiatives, incorporating brief advice for tobacco cessation to tobacco using TB patients was initiated in two districts (Kamrup in Assam and Vadodara in Gujarat) in 2010.
vi. Mainstreaming tobacco control in medical and dental education in the country- steps have been taken to incorporate tobacco control in the curriculum of undergraduate medical and dental curriculum to equip medical and dental graduates with skills for tobacco control, especially tobacco cessation.
vii. National Tobacco Control Helpline- a national level 24×7 toll free helpline has been set up for reporting violations of provisions under COTPA. On an average 1000 calls are received every month from all over the country. The same are then forwarded to respective state governments for taking action. This has facilitated the implementation of provisions under COTPA and monitoring of the same by sensitizing the state governments on the issue.
viii. National Consultation on Smokeless Tobacco – The Government is seriously concerned about the high prevalence of smokeless tobacco in the country and its growing use among the youth. The Supreme Court of India has also expressed its concern over the high prevalence of tobacco use and its hazardous effects on health and environment. A national consultation was organized by the Ministry of Health and Family Welfare to deliberate the modalities for control and regulation of smokeless tobacco under the existing legislation in the country. The recommendations of this consultation were shared with concerned stakeholders and the matter will also be highlighted in the next meeting of the Conference of Parties of the WHO FCTC
Challenges and Opportunities
India is a major stakeholder in global tobacco control efforts and has always played a leadership role on various forums to bring the challenge posed by tobacco to the forefront. The country has taken many initiatives for tobacco control including legislative measures, ratification of the WHO FCTC and implementation of the National Tobacco Control Programme. The Indian anti tobacco law is reasonably strong to comply with most of the provisions in the WHO FCTC.  The Government is committed to face the challenge posed by high prevalence of tobacco use in the country and has tried mainstreaming tobacco control by integrating it into the ongoing national health programmes and National Rural Health Mission. As the implementation of the law and programme mainly lies with the state governments, much depends on prioritization of tobacco control by the states in view of the huge burden of tobacco related diseases, deaths and disability and resulting health cost burden. This is particularly relevant as the country is now facing the rising burden of non communicable diseases for which tobacco is a major risk factor. One of the areas needing attention is tobacco taxation. Taxation as a tool for price policy is at a very low level and even the low level of taxes are not effectively collected for all tobacco products except perhaps for cigarettes, rendering tobacco products quite inexpensive and affordable even by school children through their pocket money.  Taxes have traditionally been raised targeting cigarettes. Bidis got more or less exempted from taxation for various reasons. There are reported incidences of huge tax evasion in the smokeless tobacco sector. Globally raising the tobacco taxes on tobacco products has been effective in reducing the prevalence of tobacco use. Recently some of the state governments have come forward and raised VAT on bidis and smokeless tobacco products to the levels comparable to taxes on cigarettes.
Surrogate advertisements of tobacco products, brand stretching and brand extension by the tobacco industry amounts to gross violation of Section 5 of COTPA. Article 13 of the WHO FCTC also prohibits the same. With the Cable Television Networks (Amendment) Act 2009, which actually never came into force, there was a spurt of surrogate advertisements of paan masala in mass media. The Ministry of Health and Family Welfare took strong exception to these developments and the matter was taken up with the Ministry of Information and Broadcasting at the highest level to withdraw this amendment.
On a positive note, the country has also witnessed examples of community level initiatives for tobacco control e.g. tobacco free villages and educational institutions being reported from many states. Even before the revised smoke-free rules came into effect, Chandigarh was the first city to be declared smoke-free in 2007. This is an excellent example of partnership of state administration and civil society for tobacco control in the country. Sikkim was the first state in the country to be declared smoke-free in 2010.
In view of tobacco control being a major public health challenge in India, the Government has enacted and implemented various tobacco control policies at national and sub national level. The states have implemented the tobacco control policies and programmes with various levels of success. Effective tobacco control is dependent on balanced implementation of demand and supply reduction strategies by the Government and intersectoral coordination involving stakeholder departments and ministries. The implementation of the Government policies, synergized with tobacco control initiatives by the civil society and community are pivotal in reducing prevalence of tobacco use in the country.
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