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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 34  |  Issue : 3  |  Page : 213-216

Compliance to tobacco-free guidelines (Cigarettes and Other Tobacco Products Act) in medical institute of North India


1 Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
2 Department of Psychiatry, Government Medical College and Hospital; Mental Health Institute; Joint Director, GRIID; Chandigarh Mental Health Authority; State Resource Centre; State Nodal Agency Centre, Chandigarh, India

Date of Web Publication27-Sep-2018

Correspondence Address:
Dr. Nitasha Sharma
Department of Psychiatry, Government Medical College and Hospital Sector-32, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_87_17

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  Abstract 


Background: The study aimed to investigate the compliance to prohibition of smoking (under Section 4 of Cigarettes and Other Tobacco Products Act [COTPA]) and other provisions under COTPA in a medical college situated in Chandigarh, the first smoke-free city of the country. Methods: It was a cross-sectional survey conducted at 57 sites within the medical institute. The data were collected using the structured compliance monitoring tool based on the COTPA guidelines. Results: “No active smoking” was seen at 75% of sites and there was display of signage at 28% of sites. There was the absence of cigarette butts, used matchsticks, gutkha wrappers, etc., in corners which are the secondary indicators of smoking at 70% of all sites surveyed. Conclusion: The study highlights the various loop holes in successful enforcement of COTPA. The study highlights the need to sensitize the administration on COTPA implementation with the development of well-established coordinating systems, wide publicity, and empowering reporting officers to compound offence and impound fine.

Keywords: Cigarettes and Other Tobacco Products Act, compliance, tobacco


How to cite this article:
Sharma N, Chavan B S. Compliance to tobacco-free guidelines (Cigarettes and Other Tobacco Products Act) in medical institute of North India. Indian J Soc Psychiatry 2018;34:213-6

How to cite this URL:
Sharma N, Chavan B S. Compliance to tobacco-free guidelines (Cigarettes and Other Tobacco Products Act) in medical institute of North India. Indian J Soc Psychiatry [serial online] 2018 [cited 2021 Feb 27];34:213-6. Available from: https://www.indjsp.org/text.asp?2018/34/3/213/242357




  Introduction Top


Tobacco is considered as one of the leading causes of premature death. Worldwide, tobacco use causes nearly 6 million deaths per year, and current trends show that tobacco use will cause more than 8 million deaths annually by 2030.[1] According to the Global Adult Tobacco Survey (GATS-2) conducted by the Institute for Population Sciences, Mumbai, and Tata Institute of Social Sciences, Mumbai, on behalf of Ministry of Health and Family Welfare, 28.6% of adults use tobacco in any form. The figures show decline in tobacco users from 34.6% in GATS-1 to 28.6% in GATS-2, yet the figures are disturbing.[2],[3] There are estimates that nearly 23.7% of the deaths among men (527,500) and 5.7% of the deaths among women (83,000) aged 35–69 years are due to tobacco-attributable illnesses.[4] As per Jha et al., smoking is associated with a reduction in median survival of 8 years for women and 6 years for men. It is also projected that the absolute number of deaths in this age group will rise by about 3% per year.[5] The global fight against tobacco initiated long back in early 60's with Surgeon General's report on smoking and health,[6] while one of the landmark step in this direction was the World Health Organization Framework Convention on Tobacco Control (WHO FCTC).[7] The WHO FCTC was an evidence-based treaty with 168 countries as signatory including India that provided guidelines for the core demand reduction as well as core supply reduction provisions of tobacco. India has been one of the global leaders in tobacco control. India's first national level anti-tobacco legislation was passed in 1975, (Cigarettes Act of 1975). This was followed by incremental progresses in varied forms and measures with major landmark accent to The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COTPA).[8] The act covered most tobacco products such as cigarettes, cigars, bidis, cheroots, pipe tobacco, hookah tobacco, chewing tobacco, pan masala and gutkha, and banned smoking on major public places. Some of the salient features of COTPA include the following provisions:[8]

  • Prohibition of smoking in public places (Section 4)
  • Prohibition of advertisement, sponsorship, and promotion of tobacco products (Section 5)
  • Prohibition on sale of tobacco products to minors (Section 6a)
  • Prohibition on sale of tobacco products near educational institutions (Section 6b)
  • Display of pictorial health warning on tobacco products pack (Section 7).


However, despite having comprehensive legislation in place, the effective enforcement has been a big challenge in India. 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.[9] 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.[10] The Union Territory of Chandigarh was the first city in India to become smoke free in 2007.[11] Later, four other jurisdictions including Sikkim state, Vilupuram district and Coimbatore city in Tamil Nadu, and Shimla city in Himachal Pradesh were also declared smoke-free.[12] In such scenarios, sustaining smoke-free status over a period of time and more importantly regular monitoring of compliance are of paramount importance. Ten years after obtaining the smoke-free status, a compliance study in city Chandigarh reported poor compliance to Section 4 of COTPA with one-third public places (36.1%) complying with all Section 4 indicators.[13] To see the compliance of smoke-free status in a medical college, the present investigation was carried out. The main aim of the study was to assess compliance to prohibition of smoking (under section-4 of COTPA) and other provisions under COTPA within a medical college in the first smoke-free city of the country.


  Methods Top


It was a cross-sectional survey conducted in one of the top medical institutes of India. The institute offers various graduate and postgraduate courses in medical, paramedical, and nursing sciences. The hospital with a bed strength of more than 800 beds provide comprehensive health care encompassing preventive, promotive, curative, and rehabilitative health care to the residents of North India drawn from the urban/semi-urban and rural areas. With average monthly outpatient department registration of >10,000 and average monthly admission registration of >4000, the hospital caters to a large proportion of patients from aforementioned regions. The survey was conducted in May 2017, using a compliance monitoring tool based on the recommended guidelines under COTPA, 2003. The monitoring tool was developed by the researcher in English language based on the best practice guidelines on compliance monitoring given jointly by Johns Hopkins School of Public Health, Tobacco-Free Kids, and International Union against Tuberculosis and Lung Disease.[14] The tool was assessed for its face validity by experts in the concerned area. The tool was in the form of an observational checklist for each site observed. The items of the tool included five major domains, the observation for active smoking, presence of no smoking signage, secondary indicators of smoking, and selling of tobacco within 100 yards of institute. To ensure maximum/universal coverage within the hospital, all the target areas of hospital were line listed. The official map of the institute was referred to line list all target sites. Using the universal sampling technique, all the listed sites were included for the observation. There were total 57 sites for monitoring which included two categories – sites within hospital building and sites outside the hospital building which included sites around hospital entry gates, the parking spaces, and the residential and hostel sites. The data were collected by eight field investigators who were the postgraduate students (MD Psychiatry trainees) of the institute. All the field investigators were adequately trained on conducting the survey. All of them were first sensitized with the dimension of problems associated with tobacco followed by understanding of governing law and each one was directed to spend 20–30 min at each designated site of survey. The practical recommendations on timing of conducting survey such as evening hours for market places and residential areas, while morning hours for hospital buildings were also complied.[14] The collected data were analyzed using MS Excel. The results are presented in the form of table and expressed as percentages. The results present the compliance with respect to individual parameters.


  Results Top


[Table 1] depicts the findings of the compliance survey. As shown in [Table 1], there were total 57 sites that were observed, out of which 40 sites were within hospital buildings (registration halls, waiting areas, canteen, reception hall, sample collection rooms, corridors, stairs, etc.,), while 17 sites were outside building which included the entry gates, the parking spaces, and the residential sites (hostels and staff houses). A total of six parameters were assessed. The first parameter seen was “no active smoking” whose compliance was 97.5% within hospital buildings and 75% in all sites. Within the hospital, the display of signage board was found in 40% sites while overall compliance to this parameter was 28% only. Further, it was only three signages which met all the specifications given under the act except the display of the name of the reporting officer. Moreover, the institute does not have a designated reporting officer. The compliance with respect to the secondary indicators was 70%. Out of all sites visited, there was no selling of tobacco in 75% of the sites.
Table 1: Category-wise compliance to smoke-free law under the study parameters

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  Discussion Top


The present study was undertaken to study the compliance to Section 4 and Section 6b of COTPA in a large hospital located in first smoke-free city of nation. In the present study, out of 57 sites surveyed, no active smoking was seen in 75% of the sites. These results were in contrast to the results of compliance in similar settings in same city where authors reported no active smoking in 47.5% sites.[15] The other researchers have reported “no active smoking” compliance rates to be as high as 94% in one of the districts in Rajasthan,[16] 83% in 12 districts of Himachal Pradesh,[17] and 80% in Chandigarh.[13] The wide variations in compliance can be attributed to various cultural and social factors but more so can be the result of strong administrative will in strict enforcement of law. As one of the highest compliance rates to COTPA were seen in Rajasthan, which can be the result of strong enforcement policies. In fact, Rajasthan tops the list of states in the country which has fined 14,864 violators COTPA in 8 months of 2016.[18] Furthermore, a state-level committee in Rajasthan for tobacco control, October 2012 recommended that no person should be offered a government job if he or she smokes or chews tobacco.[19]

Another important parameter studied in the present survey was the “display of signage board.” In the present study, out of 57 sites studied, there was display board only at 16 sites (28%) and only 5% of the total displays matched recommended specifications. Further, none of the display board had notification and display of reporting officer. These findings are consistent to reports by Tripathy et al. in another health-care institution with display of signage compliance to be 28%.[15] The compliance to display of “No Smoking” signages ranged from 15.0% at health institutions to 66.6% at transit sites and educational institutions as reported by Goel et al.[13] The low compliance to display of signage at various settings can be the result of poor monitoring at the administrative level. The implementation of COTPA is a state subject and there is laxity in enforcement.[17]

One of the parameters with lowest levels of compliance was the display of reporting officer on the signage board. In the present study, none of the site displayed the name and contact number of reporting officer. Tripathy et al. also reported such compliance to display of reporting officer to be low at 5%.[15] However, the compliance to display of reporting officer was found quite high in a survey at Rajasthan, in which name and phone number of reporting officer was mentioned in 75% signages.[16] The poor compliance to this parameter can be due to the absence of coordinated reporting and monitoring mechanism that leaves the notified officers (if any) unaccountable for, on the issue of noncompliance.

Johns Hopkins Bloomberg School of Public Health and the International Union against Tuberculosis and Lung Disease (The Union) has given the guidelines to conduct compliance studies which talks about valid indicators of compliance.[14] While the primary indicator for noncompliance is observation of smoking in no smoking zone, however, they have talked about secondary indicators as well, include the presence of ashtrays, cigarette butts, and used matchsticks. These secondary indicators of compliance were also observed in the current survey which revealed the absence of cigarette butts, used matchsticks, gutka wrappers, etc., lying in corners at 70% sites. The researchers found 100% noncompliance to these secondary indicators near all the entry gates as well as at all residential sites. Although using these parameters to define noncompliance is arguable as these cigarette buffs could possibly also indicate the previous smoking activity. Yet, in the current study, there was still some consistency in compliance rates with respect to primary and secondary indicators of compliance with compliance rates of 75% and 70%, respectively Whereas, a similar survey found that the compliance to primary indicator, namely, “No active smoking” was 47% compared to compliance to secondary indicators to be low at 7.5%.[13]


  Conclusion and Recommendations Top


India faces burden of tobacco with 28.6% of all adults either smoke tobacco or use smokeless tobacco.[2] The major steps taken by the Government of India to curb this menace includes the enactment of COTPA in 2003, Government of India's ratification to WHO's FCTC in 2004 and a launch of NTCP by MOH and FW in 2007–2008. Despite various achievements, the complete enforcement and compliance is still a challenge. Well-designed compliance studies serve as basic tool that can help to assess the effectiveness of comprehensive laws and highlight the potential need for improved implementation and enforcement of the law. The present compliance survey in a medical institution has some rewarding yet other disturbing results. There was no active smoking in sites within the hospital with high compliance of 97%. However, the administration fails to meet the basic guidelines of signage of “No Smoking” to be displayed at various sites. Surprisingly, none of the sites had any mention of the reporting officer. Thus, the study highlights the various loop holes in successful enforcement. The study highlights the need to sensitize the administration on this with the development of well-established coordinating systems, wide publicity, and empowering reporting officers to compound offence and impound fine. For successful implementation, an administrative will coupled with respect to the law of land by masses and political will are required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Health Effects of Cigarette Smoking. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; 15 May, 2015. Available from: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm. [Last accessed on 2016 Jun 07].  Back to cited text no. 1
    
2.
Government of India, Ministry of Health and Family Welfare. Global Adult Tobacco Survey(GATS2) factsheet. Government of India, Ministry of Health and Family Welfare; 2016-17. Available from: https://www.mohfw.gov.in/sites/default/files/GATS-2%20FactSheet.pdf. [Last accessed on 2018 Jan 01].  Back to cited text no. 2
    
3.
Government of India, Ministry of Health and Family Welfare. Global Adult Tobacco Survey (GATS) India Report. New Delhi: Ministry of Health and Family Welfare; 2009-2010. Available from: http://www.who.int/tobacco/surveillance/en_tfi_india_gats_fact_sheet.pdf. [Last accessed on 2016 Jun 07].  Back to cited text no. 3
    
4.
Mishra GA, Pimple SA, Shastri SS. An overview of the tobacco problem in India. Indian J Med Paediatr Oncol 2012;33:139-45.  Back to cited text no. 4
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5.
Jha P, Jacob B, Gajalakshmi V, Gupta PC, Dhingra N, Kumar R, et al. A nationally representative case-control study of smoking and death in India. N Engl J Med 2008;358:1137-47.  Back to cited text no. 5
    
6.
History of the Surgeon General's Reports on Smoking and Health. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; 15 May, 2017. Available from: https://www.cdc.gov/tobacco/data_statistics/sgr/history/index.htm. [Last accessed on 2018 Jan 08].  Back to cited text no. 6
    
7.
The WHO Framework Convention on Tobacco Control. World Health Organization. Available from: http://www.whoindia.org/en/Section20/Section25_927.htm. [Last accessed on 2017 May 16].  Back to cited text no. 7
    
8.
Cigarette and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act-2003. New Delhi: Ministry of Health and Family Welfare, Government of India; 2003.  Back to cited text no. 8
    
9.
National Tobacco Control Programme. Ministry of health and Family Welfare, Government of India. Available from: https://www.nhp.gov.in/National-Tobacco-Control-Programme1_pg. [Last accessed on 2017 May 20].  Back to cited text no. 9
    
10.
Kaur J, Jain DC. Tobacco control policies in India: Implementation and challenges. Indian J Public Health 2011;55:220-7.  Back to cited text no. 10
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11.
Dawson J, Singh RJ. Tobacco Control Case Study-Smoke Free City: Chandigarh. International Union against Tuberculosis and Lung Disease; 2009. Available from: http://www.tobaccofreeunion.org/assets/Technical%20Resources/Case%20Studies/Chandigarh_Case_StudySummary_web-ready_EN.pdf. [Last accessed on 2017 Jun 07].  Back to cited text no. 11
    
12.
Lal PG, Wilson NC, Singh RJ. Compliance surveys: An effective tool to validate smoke-free public places in four jurisdictions in India. Int J Tuberc Lung Dis 2011;15:565-6.  Back to cited text no. 12
    
13.
Goel S, Sardana M, Jain N, Bakshi D. Descriptive evaluation of cigarettes and other tobacco products act in a North Indian city. Indian J Public Health 2016;60:273-9.  Back to cited text no. 13
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14.
Assessing Compliance with Smoke-Free Laws. “How-to” Guide for Conducting Compliance Studies. Johns Hopkins Bloomberg School of Public Health. Available from: http://www.tobaccofreecenter.org/files/pdfs/en/smoke_free_compliance_guide.pdf. [Last accessed on 2017 May 18].  Back to cited text no. 14
    
15.
Tripathy JP, Goel S, Patro BK. Compliance monitoring of prohibition of smoking (under section-4 of COTPA) at a tertiary health-care institution in a smoke-free city of India. Lung India 2013;30:312-5.  Back to cited text no. 15
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Jain ML, Chauhan M, Singh R. Compliance assessment of cigarette and other tobacco products act in public places of Alwar district of Rajasthan. Indian J Public Health 2016;60:107-11.  Back to cited text no. 16
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Kumar R, Chauhan G, Satyanarayana S, Lal P, Singh RJ, Wilson NC, et al. Assessing compliance to smoke-free legislation: Results of a sub-national survey in himachal Pradesh, India. WHO South East Asia J Public Health 2013;2:52-6.  Back to cited text no. 17
    
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19.
No Jobs for Smokers in Rajasthan Power Companies; 2014. Available from: http://www.timesofindia.indiatimes.com/india/No-jobs-for-smokers-in-Rajasthan-power-companies/articleshow/35477219.cms. [Last accessed on 2017 Jun 07].  Back to cited text no. 19
    



 
 
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