Bridging the Divide in India's Tobacco Epidemic: A Review of the Effectiveness of Four Core Policy Interventions.

Introduction: Tobacco is one of the major risk factors for non-communicable diseases (NCDs) in the Indian population. The decreasing trend of tobacco use reflects significant progress in tobacco control, which can be attributed to key policies like price rise, smoke-free areas, ban on advertising and promotion and pictorial warnings on tobacco products. This narrative review was undertaken to assess effectiveness of these four policies in reducing tobacco burden in India. Materials and Methods: Articles were obtained by searching through all major databases. Peer-reviewed articles published in the last 20 years, reports of the Government of India and nationally representative surveys focusing on at least one intervention were included. Selected publications and reports went through two-stage screening process before inclusion. Findings were grouped according to the four policies under evaluation. Main Text: Twenty-three articles and reports were selected to derive the results. Inverse association was found between product price and consumption/affordability. Smoke-free laws in public spaces were associated with reduced second-hand smoke (SHS) exposure at home. Point of sale (POS) advertising remains prominent in India, which is a cause for concern. Awareness about pictorial warnings was significantly high among both consumers and non-consumers who believed they heightened awareness about health hazards and assisted in reducing or quitting use. However, high-dependence users were not influenced by statutory warnings or price increases. Conclusions: To achieve full compliance with COTPA (The Cigarettes and Other Tobacco Products [Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution] Act), 2003, multisectoral interventions will require partnership of government agencies, civil society organisations and the community. While tobacco products are taxed heavily to make them less affordable and smoke-free legislation have reduced SHS exposure, advertising in all forms should be prohibited and pictorial warnings mandated on cigarette sticks. Implementing tobacco endgame strategies may provide the critical breakthrough.