Tobacco Cessation

Legislations in India

Dr. Priyanka SharmaIII year MDSDepartment of Public Health Dentistry

CONTENTS• Introduction

• History of Tobacco

• Types of tobacco used in India

• Tobacco in Indian economy

• Prevalence of Tobacco use

• Health effects of tobacco in India

• Origin of Tobacco control in India

• Battle for tobacco control in India

• Land mark events

• Indian Law & Various Acts

• Implementation challenges

• Suggested other measures need to be taken

• FCTC implementation

• Education Approach Strategy

• Conclusion

• References

INTRODUCTION• Caffeine, nicotine and ethyl alcohol are the three most widely

consumed psychoactive agents in the world.• Tobacco, particularly cigarette smoking, has long been recognized

as a health threat.• The tobacco epidemic is one of the biggest public health threats

the world has ever faced, killed nearly 6 million people a year.• Tobacco use is recognized as the single most preventable cause of

premature death worldwide.• Upto half of the current users will die prematurely of a tobacco

related disease.• If current trends continue, tobacco use may cause one billion

deaths in 21st century.• Unchecked, tobacco related deaths will increase to more than 8

million deaths per year by 2030.• Tobacco induced oral diseases contributes significantly to the

global oral disease burden.

• Data reported by cancer patients aid association of India in 2004, reveals the prevalence to be cigarettes (20%), bidis (40%) and the remaining 40% is consumed as chewing tobacco, pan masala, snuff, gutkha, masheri and tobacco toothpaste.

• There is a growing pattern of tobacco users in India.

• 16.6% of the smokers live in India. Sixty-five per cent of all men and 33% of all women use tobacco in some form. 35% of men and 3% of women smoke.

• In India, in 1990, 1.5% of total deaths were tobacco related . Tobacco consumption is growing at a rate of 2-3% per annum. By 2020, it is predicted that it will account for 13% of all deaths in India.

HISTORY OF TOBACCOTobacco cultivation has a history of about 8000 years.

Europeans were introduced to tobacco when Columbus landed in America in 1492.

Portuguese traders introduced tobacco in India during 1600. Tobacco became a valuable commodity in barter trade and its use spread rapidly.

Gradually tobacco got assimilated into the cultural rituals and social fabric due to presumed medicinal and actually addictive properties attributed to it.

Increase in tobacco production during British rule:

Introduced initially in India as a product to be smoked, tobacco

gradually began to be used in several other forms.

The entry of European colonial powers into India spurred the

import of tobacco into India.

Investment in production and export came later during the

British rule.

The policies of strong governmental support for tobacco

agriculture, initiated during British colonial rule, have

continued after Independence.

TYPES OF TOBACCO USE IN INDIASmoked forms of tobacco useBidis, Cigarettes, Cigars, Cheroots, Chuttas, Dhumti, Pipe, Hooklis,

Chillum, Hookah.

Smokeless forms of tobacco usePaan (betel quid) with tobacco, Paan masala with tobacco

Tobacco, areca nut and slaked lime preparations, Mainpuri tobacco, Mawa, Khaini, chewing tobacco, snus, gutkha

Tobacco products for application: Mishri, Gul, Bajjar, Lal dantmanjan, Gudhaku, Creamy snuff, Tobacco water, Nicotine chewing gum.

CONSTITUENTS OF TOBACCO

CONSTITUENTS ADVERSE EFFECTSPoly aromatic hydro carbon Carcinogenesis.Nicotine Potential carcinogenic agentPhenol Ganglionic stimulation

and depressionsTumor promotion.

Benzopyrene Tumor promotionIrritation

Carbon mono oxide Impaired oxygen transport and repair.

Formaldehyde Toxicity to cilia and irritation.Nitrosamine Potential carcinogenic agent.

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Tobacco in Indian Economy

Tobacco cultivation has sustained despite social disapproval because of domestic demand (beedi tobacco) and the international market (flue-cured Virginia tobacco).

Tobacco plays a significant role in the Indian economy as it contributes substantially in terms of excise revenue, export revenue and employment.

India is the world’s second largest producer of tobacco and also the second largest consumer of unmanufactured tobacco. It is a major exporter of unmanufactured tobacco.

The total social costs of tobacco products exceed the direct outlay on them, owing to morbidity, mortality and negative externalities associated with the consumption of tobacco products.

Tobacco economy in the post-Independence period

YearArea

(x1000 hectare)Production(million kg)

Excise revenue (Rs in million)

Export revenue

(Rs in million)

Tobacco consumption (million kg)

1950–19511960–19611970–19711980–19811990–19912000–20012001–2002

360400450450410290-

260310360480560490601

258540228475532,69578,1824-

1501603201400263090348885

245328367360474470-

Source: Tobacco Board 2002; Directorate of Tobacco Development 1997

The costs inflicted by tobacco consumption extend much beyond the direct users to cover secondary smokers as well as non-users, and are spread over a period much beyond the period of actual consumption of tobacco.

The recognition of the costs of tobacco has been obfuscated and made opaque by the unethical tactics and practices of the tobacco lobbies.

Total cost entailed by three major tobacco-related diseases is estimated to be about USD 7.2 billion for the year 2001-02.

Prevalence of Tobacco Use

Tobacco use prevalence : 51.3% males & 10.3% females (1995 -1996) and 46.5% males and 13.8% females (1998 -1999)

National Sample Survey 52nd Round and National Family Health Survey-2

55.8% of males currently use tobacco (12 - 60 years of age)

National Household Survey of Drug and Alcohol Abuse, 2002

Tobacco use prevalence among males is higher compared to females and among older age groups compared to the younger age groups. The scenario is shifting to middle and younger age groups at present.

The prevalence of tobacco use is higher in rural population compared to that in urban areas.

India has a huge problem of widespread smokeless tobacco use among women, particularly among disadvantaged women.

The prevalence of tobacco use in pregnant women is similar to that in non-pregnant women of the same age.

Tobacco is used by the youth all over India with a wide range of variation among states.

Two in every ten boys and one in every ten girls use a tobacco product.

Initiation to tobacco products before the age of 10 years is increasing.

There are currently about 240 million tobacco users aged 15 years and above (195 million male users and 45 million female users) in India.

Tobacco Use Among Youth in India

Tobacco Toll in India

7,00, 000 deaths per year due to smoking

8,00, 000 to 9,00, 000 per year due to all forms of tobacco use/ exposure

Fastest trajectory of rise in tobacco related deaths forecast for the next 20 years.

Many of the deaths (>50%) occur below 70 years of age

Health effects of tobacco in India

The relative risk for death due to tobacco use in cohort studies from rural India is:

40%-80% higher for any type of tobacco use;50%-60% higher for smoking;90% higher for reverse smoking;15% and 30% higher for tobacco chewing in men and women, respectively;

40% higher for chewing and smoking combined.Overall, smoking alone currently causes about 700,000 deaths per year in India.

BEEDI SMOKING IS EVEN MORE DANGEROUS

Cohort of 52568 individuals (> 35 years); follow-up of 5-6 years

Ratios of excess deaths in tobacco users

100 male non-smoker deaths : 139 male cigarette smoker deaths

100 male non-smoker deaths : 178 male beedi smoker deaths

100 female non-tobacco user deaths : 135 female oral tobacco user deaths

- Mumbai Cohort Study; Gupta et al, WHO Bulletin, 2000

Studies in India have shown that tobacco use in its various forms is directly responsible for increase in cardiovascular diseases, cancers of the oral cavity, espohagus, pharynx etc, and chronic obstructive lung disease, TB, poor reproductive health outcomes, oral precancerous lesions and green tobacco sickness.

Tobacco Use and Related Diseases

TOBACCO AND TUBERCULOSIS

Prevalence of TB is about 3 times as great among the ever-smokers as among the never-smokers.

The heavier the smoking, either cigarettes or bidis, the greater the prevalence of TB among smokers.

Mortality from TB is 3 to 4 times as great in ever-smokers as in never-smokers.

Smoking contributes to half the male deaths from TB in India and a quarter of all male deaths in the middle age (25-69 years); of these 200,000 deaths, half occur in men who are in 30’s, 40’s or early 50’s.

Origin Of Tobacco Control Efforts In India

• India’s Journey from appreciating potential of tobacco production to emerging as a leader in global tobacco control efforts:

Increasing scientific evidence about mortality and morbidity attributable to tobacco use provided impetus for legislative action in India for tobacco control (Mid 1970s)

Cigarettes (Regulation of Production, Supply and Distribution) Act, 1975

• Health Warning on Packages and Advertisements of Cigarettes : “Cigarette Smoking is Injurious to Health”

Origin Of Tobacco Control Efforts In IndiaTobacco Board Act of 1975 brought tobacco under a single Jurisdiction

(The Central Government)Civil society groups, media and other agencies played a vital role in

raising public awareness of tobacco-related health issues (1980s and 1990s)This led to:- Civil litigation and favorable verdicts by courts- Demands for tobacco control in Indian Parliament - Increased pressure on government to impose restrictions

Resolutions of World Health Assembly in 1986 and 1990 urged member states to impose stronger legislative measures to protect people from dangers of tobacco

Regional and national consultations on “Tobacco or Health”, convened by government of India (Ministry of Health) and WHO in 1991

Battle for Tobacco Control in India

- Activism and advocacy efforts by civil society organization in India

- Strong role played by Indian judiciary

- Role of media in building positive public opinion on tobacco control

- Commitment by the Government of India (Ministry of Health and Family Welfare) towards effective tobacco control efforts

- Support of well informed Parliamentarians and Policy-makers

- Tobacco industry’s continuous resistance to strong tobacco control laws or regulations- Violation of regulations by the

industry (e.g. ad ban)- Economic issues related to

tobacco production and tobacco control, distorted by the industry.- Over emphasizing employment

issues in connection with tobacco control- Industry’s efforts to create fears

of adverse impact of tobacco control on poor

Anti-Tobacco Influences Pro-Tobacco Influences

Land Mark Events

1975: Cigarettes (Regulation of Production, Supply and Distribution) Act

1980: Central and State Governments imposed restrictions on tobacco trade and initiated efforts for comprehensive legislation for tobacco control

1990: Central Government issued directive for prohibiting smoking in public places, banned tobacco advertisements on National Radio and T.V. channels, advised State Governments to discourage sale of tobacco around educational institutions and mandated display of statutory health warning on chewing tobacco products.

1991: Regional and National Consultations on “Tobacco or Health”

1991: Central Government directed the Central Board of Film Certification to comply with the Cinematograph Act of 1952

1995: The Parliamentary Committee on Subordinate legislation of the Tenth Lok Sabha examined the rules framed under Cigarette (Regulation of Production, Supply and Distribution) Act, 1975 and made specific suggestions for stronger provisions to achieve better results in tobacco control

1995: Expert Committee on the economics of tobacco use constituted by the Central Ministry of Health.

1996: Delhi anti-smoking amd mom-smoker’s health protection act

1999: High Court of Kerala announced ban on smoking in public places

1999: Ministry of Railways banned sale of cigarettes and beedis on railway platforms and in trains

2000: Central Government banned tobacco advertisements on cable television

2001: Supreme Court of India mandated a ban on smoking in public places.

2001: Ministry of Railways imposed ban on sale of gutkha on railway station, concourses, reservation centres and in trains

2001: The National Human Rights Commission of India (NHRC) convened a South-East Asia Regional consultation on ‘Public Health and Human Rights”, and advocated tobacco control as an essential measure to protect human rights.

2001-2003: Ban on Gutkha production and sale of gutkha and paan masala containing tobacco or not containing tobacco in states of Tamil Nadu, Andhra Pradesh, Maharashtra, Madhya Pradesh, Bihar and Goa using the provision of the Prevention of Food Adulteration Act.

2003: The Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003

Indian Law- At a GlanceKey Provision of cigarettes and other tobacco product Act,

2003 Ban on smoking in public places (including indoor workplaces)

Ban on direct and indirect advertising of tobacco products- Point-of-sale advertising is permitted

Ban on sales to minors- Tobacco products cannot be sold to children <18 years- Tobacco products cannot be sold within a radius of 100 yards of

educational institutions

Pictorial health warnings

English and one or more Indian languages to be used for health warnings on tobacco packs

Testing and Regulation: Ingredients to be declared on tobacco product packages (Tar and Nicotine)

Implementation of Indian Law

Prohibition of smoking in public places- mandates display of board containing the warning ”No Smoking Area-

Smoking Here is an Offence”- Hotels & Restaurants should ensure:

• physical segregation of smoking and non-smoking areas• these areas should be labeled as ”Smoking Area/Non-smoking Area”• proper location of smoking and non-smoking areas

Prohibition of advertisement of cigarettes and other tobacco products

- Point of sale advertisement not to exceed two boards- This board should contain health warnings “Tobacco Kills or Tobacco

Causes Cancer”

Prohibition of Sale to Minors- Display board containing the warning “Sale of tobacco products to a person

under the age of 18 yrs is a punishable offence” to be put at point of sale

Rules Notified and Enforced from May 1, 2004

Rules notified and enforced from December 1, 2004

Prohibition on Sale of Cigarettes and other Tobacco Products around Educational Institutions

· Board outside the premises to be displayed stating that sale of cigarettes and other tobacco products in an area within a radius of 100 yards of educational institution is strictly prohibited

· Distance of 100 yards shall be measured radically starting from the outer limit of boundary wall or fence of the institution.

• 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.

Proposed Indian Health Warning on Gutkha Pack

Proposed Indian Health Warning on Cigarette Pack

 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.

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: 

National level

Public awareness/mass media campaigns for awareness building and behavior change.

• Establishment of tobacco product testing laboratories, to build regulatory capacity, as mandated under COTPA, 2003.

• Mainstreaming the program components as part of the health care delivery mechanism under the National Rural Health Mission framework.

• Mainstream Research and Training on alternate crops and livelihoods in collaboration with other nodal Ministries.

• Monitoring and Evaluation including surveillance e.g. Global Adult Tobacco Survey (GATS) India.

State level

Tobacco control cells with dedicated manpower for effective implementation and monitoring of anti tobacco laws and initiatives.

• District level

Training of health and social workers, SHGs, NGOs, school teachers etc.

• Local IEC activities.

• Setting up tobacco cessation facilities.

• School Programme.

• Monitoring tobacco control laws.

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.

• 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.

• 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.

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 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.

• 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.

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.

• 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.

• 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.

• 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.

• 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. [33] 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.

• 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.

• 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.

• 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.

In 2015 amendments COTPA

• The Union Ministry of Health and Family Welfare on 13 January 2015 proposed the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) (Amendment) Bill 2015 (COTPA).

• Provisions of the COTPA (Amendment) Bill 2015• The bill proposes to ban on-site advertising of tobacco products and shops selling cigarettes and other tobacco products will no longer be able to display the brand names.• It proposed scrapping of designated smoking areas from hotels, restaurants and airports making an exception only for international airports to prevent exposure of non-smokers to harmful emissions.• The penalty for smoking in restricted areas has been raised from 200 to 1000 rupees. 

• Anyone found producing tobacco products without the specified warning will be liable for imprisonment for up to two years for the first offence or fine up to 50000 rupees or both. • For the second and subsequent offences, the imprisonment can be up to five years with a fine of up to 1 lakh rupees.• Selling products without warning will incur a fine of up to 10000 rupees or a jail term of up to one year or both and subsequent offence will draw a fine of up to 25000 rupees and a jail term of two years.• Tobacco products and cigarettes in approved packaging will now be sold only to those above 21 years of age. The proposed age limit will be revised after evaluating the impact of raising the minimum age.

• The draft Bill also proposes a ban on spitting of tobacco products, pointing it out as the biggest cause of spread of diseases like Tuberculosis, Avian Flu and H1N1 virus.• It has also been proposed to extend the ban on sale of cigarettes and tobacco products from 100 yards of an educational institution to 100 metres.• The bill proposes to set up a National Tobacco Control Organisation (NTCO) that will implement and monitor the provisions of COTPA, 2003.

Implementation challenges being faced

Violation of Ad ban through:- Surrogate methods (Red & White Bravery Awards-GPI)- Brand stretching (Wills Life Style Apparel-ITC)- Sponsorship of events (Formula 1 news in print media-Marlboro)

Violation of ban on smoking in public places due to:- Lack of awareness among stakeholders (managers of restaurants, hotels etc.)- Low compliance levels among the management of public places- Low motivation at Health Ministries at State Level

Violation of provision allowing point-of-sale advertisement- Display board specifications being violated- Health warning area specified on this board has been reduced by the industry

Other measures that need to be taken to strengthen tobacco controlTax Net to be Uniform- Current financial budget (2005-06) increased specific (excise) rate on

cigarettes by about 10% and a surcharge of 10% ad valorem duties on other tobacco products (gutkha, chewing tobacco, snuff and pan masala)

- Bidis to be brought under similar tax regime to avoid cost influenced product choice by youth and poor

Ban on Gutkha by Centre- State governments to request the Centre to impose such a ban (as per

Supreme Court judgment)

Framework Convention on Tobacco Control (FCTC) Implementation in India

The Indian Act enactment preceded the adoption and enforcement of the FCTC

Indian Legislation needs to be upscale to comply with the provisions of FCTC- Tax and price measures to be implemented to reduce tobacco consumption- Duty free sales to be tackled by Ministry of Finance- Prohibiting use of misleading terms to label tobacco products- Mobilize stakeholders, engage civil society to promote and strengthen education,

communication, training and public awareness on tobacco control issues- Promote effective measure for tobacco use cessation- Elimination of all forms of illicit trade in tobacco products including smuggling,

illicit manufacturing and counterfeiting- Sale to and by minors- Curb cross-border advertising- Promote economically viable alternatives for tobacco workers, growers and

individual sellers (as appropriate)

EDUCATIONAL APPROACH STRATEGY

• Evidence for Effectiveness of Health Professional Intervention• A Cochrane review of 16 RCTs found simple advice from doctors had a

significant effect on cessation rates (OR for quitting 1.69; 95% confidence interval 1.45–1.98).

• When trained providers are routinely prompted to intervene with people who smoke, they achieve significant reductions in smoking prevalence (up to 15 percent cessation rates compared with 5 to 10 percent in non-intervention sites).

• Doctors and other health professionals using multiple types of intervention to deliver individualized advice on multiple occasions produce the best results. Frequent and consistent interventions over time are more important than the type of intervention

Smoking Cessation Program• The only way any country can substantially reduce smoking

and other tobacco use within its borders is to establish a well-funded and sustained comprehensive tobacco prevention program that employs a variety of effective approaches. • Nothing else will successfully compete against the addictive

power of nicotine and the tobacco industry's aggressive marketing tactics.

ESSENTIAL COMPONENTS The following elements must all be included to maximize the success of any program to reduce tobacco use. Conducted in isolation, each of these elements can reduce tobacco use, but done together they have a much more powerful impact:

• Public Education Efforts • Community-Based Programs•Helping Smokers Quit (Cessation)• School-Based Programs• Enforcement•Monitoring and Evaluation•Related Policy Efforts

Public Education Efforts:

Research has demonstrated that tobacco industry marketing increases the number of kids who try smoking and become regular smokers. Not surprisingly, one of the best ways to reduce the power of tobacco marketing is an intense campaign to counter these pro-smoking messages.

Public Education Efforts (cont.):• These efforts must include multiple paid media (TV,

radio, print, etc.), public relations, special events and promotions, and other efforts.

• Counter-marketing efforts should target both youth and adults with prevention and cessation messages.

Community-Based Programs:• Because community involvement is essential to

reducing tobacco use, a portion of the tobacco control funding should be provided to local government entities, community organizations, local businesses, and other community partners.

Community-Based Programs (cont.):

•These groups can effectively engage in a number of tobacco prevention activities right where people live, work, play, and worship, including: –direct counseling for prevention and to help people quit, –youth tobacco education programs, –interventions for special populations, –worksite programs, and –training for health professionals.

Helping Smokers Quit (Cessation):•A comprehensive tobacco control program should not only encourage smokers to quit but also help them do it. In fact, most smokers want to quit but have a very difficult time because nicotine is so powerfully addictive.

• To help these smokers, cessation products and services should be made more readily available and more affordable.

•Moreover, treatment programs are most effective when they utilize multiple interventions, including pharmacological treatments, clinician provided social support, and skills training.

Helping Smokers Quit (Cessation) (cont.):

• Cessation services can be provided through primary health care providers, schools, government agencies, community organizations, and telephone "quit lines.“

• Staff training and technical assistance should be a part

of all programs to treat tobacco addiction; and following the cessation guidelines from the Agency for Health Care Policy and Research will increase the effectiveness of any cessation efforts in clinical settings.

School-Based Programs:•School-based programs offer a useful way to prevent and reduce tobacco use among kids, especially when based on the CDC’s Guidelines for School Health Programs to Prevent Tobacco Use and Addiction.

• To operate most effectively, school-based programs must include curricula that have been shown to be effective, as well as tobacco-free policies, training for teachers, programs for parents, and cessation services.

School-Based Programs (cont.):•Students must learn not only the dangers of tobacco use but life skills, refusal skills, and media literacy in order to resist the influence of peers and tobacco marketers.

• It is critical that the school programs be integrated with other community-based programs and with counter-marketing efforts.

Enforcement:• Rigorously enforcing laws prohibiting tobacco sales to

youth and limiting exposure to secondhand smoke is an essential element of creating an environment conducive to reducing tobacco use.

• These enforcement efforts should include penalties for violators, and compliance enhancing education.

Enforcement (cont.):•To increase tobacco control enforcement, funds must be provided to enforcement agencies to make sure other enforcement efforts are not compromised.

•Other agencies and organizations should also be supported to provide related educational efforts to raise awareness of the laws and their enforcement and to promote compliance.

Monitoring and Evaluation:• Every element of a comprehensive tobacco control

program should be rigorously evaluated throughout its existence.

• Careful monitoring and evaluation methods should be built-into the programs to provide the data necessary for continual improvement.

Monitoring and Evaluation (cont.):

•Process measures should be developed to monitor the activities conducted under the program from the outside, as well, in order to block the misuse of funds and promote their most efficient and effective use.

•Regular measurements of key outcomes should also be conducted to assess progress and further improve their performance.

Related Policy Efforts:

•Additional policy initiatives have been proven effective in reducing tobacco use -- especially as part of a comprehensive strategy. •These policies include:–increases in cigarette excise taxes, –restrictions on tobacco marketing to kids, –increased penalties for selling tobacco to kids, –new restrictions on environmental tobacco smoke in public places.

GUIDING PRINCIPLES

Past experience with tobacco control efforts indicates that five principles should guide the development of a successful state program to prevent and reduce tobacco use:

•1. It must be comprehensive. Stopgap or partial measures will meet with only partial success. Elements work most effectively when they are combined in complementary fashion.

GUIDING PRINCIPLES (cont.)2. It must be well funded. – Unless properly financed, tobacco prevention will

have little effect against the marketing efforts of the tobacco industry (over $8 billion each year).

– CDC has issued funding guidelines for state tobacco control programs, which can serve as a basis for planning.

GUIDING PRINCIPLES (cont.)3. It must be sustained over a long period of time. –While short-term attitudinal changes can occur relatively early, it will take years to achieve the significant behavioral and cultural changes necessary to reduce tobacco use substantially and maintain low levels.

–If tobacco control programs are not sustained over many years, the chances for success will be diminished, and any early gains may be lost in subsequent years.

GUIDING PRINCIPLES (cont.)4. It must operate free and clear of political and tobacco industry influence. –History warns us that the tobacco industry will employ every manner of tactics to divert money from tobacco prevention and to interfere with any tobacco prevention efforts that are undertaken.

–To avoid this tobacco industry sabotage, new tobacco control programs must be set up to be independent of these influences and insulated from them.

GUIDING PRINCIPLES (cont.)

5. It must address high-risk and diverse populations. –The needs of special populations can and must be taken into account in designing and disseminating the various elements of the tobacco control program (e.g. youth, and women).

CONCLUSION• 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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