Tobacco Control Policies in India Implementationand Challenges
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Review Article
Tobacco Control Policies in India: Implementation and Challenges
*Jagdish Kaur1, D. C. Jain1
1
Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India
Summary
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 11th 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.
Key words: Anti tobacco law, Advocacy, Smoke-free, Tobacco control
Introduction
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.1
India is also the second largest consumer of tobacco
in the world, second only to China.2 The prevalence of
tobacco use among adults (15 years and above) is 35%.
The prevalence of overall tobacco use among males is
*Corresponding Author: Dr. Jagdish Kaur,
Chief Medical Officer, Directorate General of Health Services,
Ministry of Health & Family Welfare, Government of India, India.
E-mail: [email protected]
Access this article online
Website: www.ijph.in
DOI: 10.4103/0019-557X.89941
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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.3
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.4
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.5 China
introduced a smoking ban in public buildings in Beijing
from May 2008 as a run-up to the Olympic Games6 and
a ban on smoking in public places came into effect from
1st May 2011. Singapore has had smoke-free legislation
since 1970, but has strengthened it recently.4 Hong Kong
enacted the smoking ban law in 1982 but could enforce
it only since 2007.7 Countries like Indonesia (2006),
Kazakhstan 2003), Malaysia (2004), Bangladesh (2006),
Pakistan (2003), Philippines (2002), Vietnam (2005),
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Kaur J and Jain DC: Tobacco Control Policies in India
Brunei Darussalam (1988) have banned smoking in
public places, but implementation is far from complete.7
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.8 The Government enacted the
Cigarettes Act (Regulation of Production, Supply and
Distribution) in 1975.9 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.10 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 1990.11 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.12
In 1992, under the Drugs and Cosmetics Act 1940
(Amendment), use of tobacco in all dental products was
banned.13 The Cable Television Networks (Amendment)
Act 2000 prohibited tobacco advertising in state
controlled electronic media and publications including
cable television.14 Under the Chairmanship of Shri Amal
Datta, the 22nd 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
221
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
2003.15 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 2nd October, 2008.16 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 31st 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
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Kaur J and Jain DC: Tobacco Control Policies in India
and regulating sale to and by minors.17 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 2007–2008.18 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:
National level
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.
State level
i. Tobacco control cells with dedicated manpower for
effective implementation and monitoring of anti
tobacco laws and initiatives.
District level
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.19-23
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%.24 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.
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Kaur J and Jain DC: Tobacco Control Policies in India
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
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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.22-23 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.25 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 31st
May. The tobacco control policies furthered by WHO are
highlighted on this day and are marked by celebrations
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Kaur J and Jain DC: Tobacco Control Policies in India
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.26-31 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.32
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.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.
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
247 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
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Figure 1: Mr. Ghulam Nabi Azad, the Union Minister of Health releasing India Global
Adult Tobacco Survey Report on 19th October, 2010 at New Delhi.
Figure 2: WNTD Celebrations led by the State Tobacco Control cell and TCC, at
Hyderabad, Andhra Pradesh
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.
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.34 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.
Role of civil society- civil society organizations have
played a vital role in implementation of tobacco control
policies and programme at various levels for a long time.
With support from the Bloomberg Global Initiative, many
of these organizations have been actively involved in
tobacco control advocacy and awareness generation at
the grass root level.
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.23 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
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.
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Kaur J and Jain DC: Tobacco Control Policies in India
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.
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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Control Programme. Compilation of Tobacco Control
Laws, rules and notifications. Available from: http://www.
whoindia.org/LinkFiles/Tobacco_ Free Initiative_ Compilation
of_Tobacco_Control_laws,_rules_and_notifications. pdf.
[Last accessed on 2011 Aug 09].
Government of India. Ministry of Health and Family Welfare.
Directorate General of Health Services. National Tobacco
Control Programme. Enforcement of Tobacco Control
Policies: Global Best Practices. Available from: [Last accessed
on 2011 Aug 09].
Government of India. Ministry of Health and Family Welfare.
Directorate General of Health Services. National Tobacco
Control Programme. Comparative analysis of FCTC and
Indian Laws relating Tobacco. Available from: http://www.
whoindia.org/EN/Section20/Section25_1686.html. [Last
accessed on 2011 Aug 09].
Government of India. Ministry of Health and Family Welfare.
Directorate General of Health Services. National Tobacco
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Control Programme. Tobacco Free Initiative Factsheet.
Available from: http://www.whoindia.org/LinkFiles/Tobacco_
Free_Initiative_FactSheet.pdf. [Last accessed on 2011 Aug
09].
Government of India. Ministry of Health and Family
Welfare. Directorate General of Health Services. National
Tobacco Control Programme. Tobacco Free Initiative
Handout. Available from: http://www.whoindia.org/LinkFiles/
Tobacco_Free_Initiative_Handout. pdf. [Last accessed on
2011 Aug 09].
Steering Committee on Section 5 of COTPA. Notification
GSR 489 (E) dated 9th June, 2010.
Gajalakshmi V, Peto R, Kanaka TS, Jha P. Smoking
and mortality from tuberculosis other diseases in India:
Retrospective study of 43000 adult male deaths and 35000
controls. Lancet 2003;362:507-15.
Gupta PC. Tobacco Control in India. Editorial. Indian J Med
Res 2006;123:579-82.
Cite this article as: Kaur J, Jain DC. Tobacco Control Policies in India:
Implementation and Challenges. Indian J Public Health 2011;55:220-7.
Source of Support: Nil. Conflict of Interest: None declared.
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Indian Journal of Public Health, Volume 55, Issue 3, July-September, 2011
Review Article
Tobacco Control Policies in India: Implementation and Challenges
*Jagdish Kaur1, D. C. Jain1
1
Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India
Summary
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 11th 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.
Key words: Anti tobacco law, Advocacy, Smoke-free, Tobacco control
Introduction
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.1
India is also the second largest consumer of tobacco
in the world, second only to China.2 The prevalence of
tobacco use among adults (15 years and above) is 35%.
The prevalence of overall tobacco use among males is
*Corresponding Author: Dr. Jagdish Kaur,
Chief Medical Officer, Directorate General of Health Services,
Ministry of Health & Family Welfare, Government of India, India.
E-mail: [email protected]
Access this article online
Website: www.ijph.in
DOI: 10.4103/0019-557X.89941
PMID: ***
Quick Response Code:
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.3
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.4
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.5 China
introduced a smoking ban in public buildings in Beijing
from May 2008 as a run-up to the Olympic Games6 and
a ban on smoking in public places came into effect from
1st May 2011. Singapore has had smoke-free legislation
since 1970, but has strengthened it recently.4 Hong Kong
enacted the smoking ban law in 1982 but could enforce
it only since 2007.7 Countries like Indonesia (2006),
Kazakhstan 2003), Malaysia (2004), Bangladesh (2006),
Pakistan (2003), Philippines (2002), Vietnam (2005),
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Kaur J and Jain DC: Tobacco Control Policies in India
Brunei Darussalam (1988) have banned smoking in
public places, but implementation is far from complete.7
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.8 The Government enacted the
Cigarettes Act (Regulation of Production, Supply and
Distribution) in 1975.9 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.10 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 1990.11 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.12
In 1992, under the Drugs and Cosmetics Act 1940
(Amendment), use of tobacco in all dental products was
banned.13 The Cable Television Networks (Amendment)
Act 2000 prohibited tobacco advertising in state
controlled electronic media and publications including
cable television.14 Under the Chairmanship of Shri Amal
Datta, the 22nd 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
221
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
2003.15 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 2nd October, 2008.16 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 31st 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
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222
Kaur J and Jain DC: Tobacco Control Policies in India
and regulating sale to and by minors.17 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 2007–2008.18 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:
National level
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.
State level
i. Tobacco control cells with dedicated manpower for
effective implementation and monitoring of anti
tobacco laws and initiatives.
District level
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.19-23
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%.24 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.
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Kaur J and Jain DC: Tobacco Control Policies in India
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
223
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.22-23 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.25 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 31st
May. The tobacco control policies furthered by WHO are
highlighted on this day and are marked by celebrations
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Kaur J and Jain DC: Tobacco Control Policies in India
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.26-31 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.32
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.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.
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
247 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
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Kaur J and Jain DC: Tobacco Control Policies in India
225
Figure 1: Mr. Ghulam Nabi Azad, the Union Minister of Health releasing India Global
Adult Tobacco Survey Report on 19th October, 2010 at New Delhi.
Figure 2: WNTD Celebrations led by the State Tobacco Control cell and TCC, at
Hyderabad, Andhra Pradesh
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.
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.34 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.
Role of civil society- civil society organizations have
played a vital role in implementation of tobacco control
policies and programme at various levels for a long time.
With support from the Bloomberg Global Initiative, many
of these organizations have been actively involved in
tobacco control advocacy and awareness generation at
the grass root level.
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.23 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
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.
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Kaur J and Jain DC: Tobacco Control Policies in India
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.
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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Cite this article as: Kaur J, Jain DC. Tobacco Control Policies in India:
Implementation and Challenges. Indian J Public Health 2011;55:220-7.
Source of Support: Nil. Conflict of Interest: None declared.
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Indian Journal of Public Health, Volume 55, Issue 3, July-September, 2011
