Tobacco Control Scale (TCS) for Tobacco Control Policy Analysis of India

Dear Editor

The recently published article by Chengappa et al., titled “Tobacco Control Policy in India: Progress and Challenges Quantified Using the Tobacco Control Scale” (TCS), offers a quantitative perspective of India’s policies to curb tobacco use [1]. While the article does a commendable job by adapting the Tobacco Control Scale to quantify progress, there are a few key aspects that could be further refined to provide a more balanced and complete picture.

India has been a global leader in tobacco control, adopting the World Health Organization’s Framework Convention on Tobacco Control (WHO-FCTC) in 2004 [2] and implementing national laws like the Cigarettes and Other Tobacco Products Act (COTPA) [3]. More recently, the WHO 2023 report on the global tobacco epidemic, [4] highlighted India’s significant achievements, particularly in areas like tobacco dependence treatment, health warnings, and the National Tobacco Control Program implementation. Despite this progress, the authors’ reliance on the WHO 2021 report for their analysis may have inadvertently overlooked more recent achievements.

The authors’ heavy dependence on government and WHO data sources is understandable but creates a narrow lens. For instance, India’s innovative Tobacco Enforcement and Reporting Movement (TERM), which uses digital platforms to monitor and enforce advertising bans, wasn’t mentioned in the analysis. The TERM has been a game-changer, enabling real-time detection and resolution of tobacco violations, including advancements like this would have painted a fuller picture of India’s ongoing efforts [5].

According to studies, India has well-crafted rules, but their effectiveness may be compromised by regional variations in enforcement, regional disparities in enforcement are another critical aspect that deserved more attention [6]. While some states strictly implement tobacco bans, others lag behind. Each state has also been empowered to introduce their own tobacco control laws and enforcement of any law heavily dependence on state machinery. Therefore, there is wide regional variation in presence and implementation of tobacco control laws as the country level data has very possibility of introducing ecological fallacy [7].

India’s score of 14 out of 30 in the TCS reflects ongoing affordability issues with tobacco products [8]. While taxes on cigarettes have increased over the years, bidis widely consumed among lower-income groups still remain cheap and accessible. As Bidis,account for a significant portion of tobacco use in India, it is necessary to tackle it’s pricing at which it is sold. India’s smoke-free laws have been a strong point, earning a score of 19 out of 22. However, the provision for designated smoking areas in hotels, restaurants, and airports undermines the intent of these laws. Countries like the UK and Ireland, which have completely banned indoor smoking, show how eliminating exceptions can lead to significant health gains [9]. India should follow suit, ensuring all public spaces are truly smoke-free.

One of the weakest areas in India’s tobacco control efforts is public information campaigns, which scored only 2 out of 10. This low score highlights the lack of adequate investment in mass media outreach. India’s campaigns have largely relied on traditional media. A shift toward social media and mobile platforms could amplify their reach and effectiveness, particularly among tech-savvy youth.Evidence from countries like Australia shows that well-funded campaigns can be powerful tools for behaviour change, especially when tailored to target younger audiences on digital platforms [10].

Countries like Mexico have demonstrated the value of comprehensive advertising bans, including sponsorships and indirect promotions. India’s restrictions on tobacco advertising are robust in many respects but still have gaps, particularly around point-of-sale advertising and surrogate marketing. India’s laws should evolve to close these loopholes, ensuring that tobacco companies cannot use creative strategies to bypass restrictions.

On the positive side, India scores a perfect 10 out of 10 for its large pictorial health warnings, which cover 85% of tobacco packaging. These warnings are among the most effective globally and have proven to deter new smokers while encouraging existing ones to quit [11]. While India’s policies are commendable, countries like Timor-Leste, which enforce even larger warning sizes (92.5%), set an aspirational benchmark.

India has made notable progress in tobacco cessation support, earning a score of 9 out of 10. The services like the national quitline and the inclusion of nicotine replacement therapy in public health programs are steps in the right direction. However, accessibility remains a challenge, particularly in rural areas [12]. Expanding cessation services through primary healthcare centers and training healthcare workers to offer brief interventions could make these services more inclusive. India scores 1/2 in tobacco industry interference, while the Ministry of Health and Family Welfare has introduced a code of conduct to limit industry interactions, enforcement is inconsistent [13]. There is a need for greater transparency and stronger regulations are to curb industry interference effectively. While the article mentions India’s accession to the WHO FCTC Protocol, it does not provide concrete measures being taken to curb illicit trade. The lack of a track-and-trace system, as described in the TCS methodology [6]. India lacks in the track-and-trace system for tobacco products which depicts a significant gap. The illicit trade undermines public health policies and creates economic losses. The Countries which have implemented robust track-and-trace systems, as recommended by the WHO FCTC Illicit Trade Protocol, have seen marked improvements in curbing this problem. India should prioritize the development of such systems.

Based on the above analysis, India must substantially raise cigarette prices to make them unaffordable, particularly for young smokers. Evidence indicates that elevated prices discourage initiation and assist current smokers in cessation [8]. An increase in the investment of mass media campaigns, targeted messages on social media platforms and community-focused initiatives can enhance effectiveness [10]. The elimination of designated smoking areas would align India’s legislation with WHO guidelines and diminish secondhand smoke exposure [14]. An integration of cessation services into all primary healthcare centers will enable India to provide essential support for smokers seeking to quit [15]. A nationwide policy restricting tobacco industry interactions is critical for unbiased policymaking [16].

In conclusion, India’s score of 65 on the Tobacco Control Scale highlights its significant achievements, but also areas where there is room for improvement. With stronger policies and more effective enforcement, India has the potential to lead by example in the global fight against tobacco. By focusing on higher taxes, comprehensive advertising bans, smoke-free public spaces, and robust cessation support, India can accelerate progress toward its goal of a tobacco-free nation. This journey requires commitment, collaboration, and a willingness to adapt strategies based on evidence and best practices worldwide. Lastly, future evaluations should be incorporated for qualitative insights from policymakers, enforcement officials, and even tobacco users. Understanding their perspectives would provide a more holistic view of the challenges and successes of tobacco control in India.

Manuscript Details

This letter is in response to the article by Chengappa et al., titled “ Tobacco Control Policy in India: Progress and Challenges Quantified Using the Tobacco Control Scale”, published in Asian Pacific Journal of Cancer Prevention, Volume 25, Issue 9, Pages 3209-3217 DOI:10.31557/APJCP.2024.25.9.3209