The Enforcement of Indias Tobacco Control ... - Wiley Online Library

World Medical & Health Policy, Vol. 6, No. 4, 2014

The Enforcement of India’s Tobacco Control Legislation in the State of Haryana: A Case Study Dipika Jain, Amit Jadav, Kimberly Rhoten, and Abhinav Bassi In 2003, the Parliament of India passed the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COTPA) to counter the growing societal and health burdens of tobacco in India. The major provisions (Sections 4–7) of COTPA mandate the display of pictorial health warnings on all tobacco product packets and strictly prohibit: smoking in public places, direct and indirect forms of tobacco advertisements, promotion and sponsorship of tobacco products, sale of tobacco products to a minor, and sale within 100 yards of any educational institution. However, India continues to have a high prevalence of tobacco consumption and the provisions of COTPA are routinely flouted. The purpose of the study is to analyze the trends in and the prevalence of COTPA violations in a sample test site (Haryana) to develop informed and practical tobacco control policy recommendations. Violations in five districts of the State of Haryana were observed and recorded. The data overwhelmingly show that the most fundamental provisions (Sections 4–7) of COTPA were frequently violated in each of the five districts. All districts had a high rate of noncompliance, with Sites having at least one violation of Sections 4–7 of COTPA, with rates fluctuating between nearly 70 and 90 percent. Such violations however, were unequally distributed between Sections 4–7 within the five districts with some districts having a higher frequency of Section 4 violations (Panipat and Jhajjar) and other districts with higher violation frequency of Section 5 (Mewat and Kurukshetra). However, all five districts had relatively low numbers of Section 7 violations (i.e., the required display of pictorial health warnings on all tobacco products). The study highlights the challenges of the tobacco control policy in India including: engagement of state and district level enforcement officials for effective enforcement of existing legislation, encouragement for civil society to partner and complement governmental efforts in monitoring progress and reporting violations of COTPA, and the need for supply-level controls on tobacco (e.g., pictorial health warnings and increased taxation) to reduce tobacco consumption. KEY WORDS: tobacco control, public policy, labeling and marketing

Introduction Tobacco Use in India Tobacco use is one of the leading causes of preventable death across the globe (World Health Organization, 2013). It is responsible for over six millions deaths

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each year and is estimated to increase to 8 million by 2030 (World Health Organization, 2011). More than one million people in India each year lose their lives to tobacco-related diseases (Lal, Wilson, & Gupta, 2012). India is the second largest consumer of tobacco in the world (Mishra, Pimple, & Shastri, 2012). Findings from the Global Adult Tobacco Survey (GATS) 2009–2010 estimate the number of tobacco users in India at 274.9 million and growing, especially amongst women (Government of India, 2010). Tobacco use has astronomical effects on India’s total health-care costs. The economic costs in India alone of diseases attributable to tobacco were USD $907 million in 2004 for smoked tobacco and USD $285 million for smokeless tobacco (John, Sung, & Max, 2009). Health-care spending on tobacco in India exceeds the revenue amassed from tobacco sales by 16 percent (Government of India, 2005). In addition to economic costs, there are human costs to tobacco use. A 30-year-old male smoker loses an average of 10 years off of his expected lifespan if he smokes for the duration of his life (Yadav, Arora, & Reddy, 2012). By 2020, it is expected that tobacco will account for 13 percent of all deaths within India (Panda et al., 2012). In response to the rising burden of tobacco, the Parliament in India passed the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act, 2003 (COTPA) that came into force on May 1, 2004. The major provisions of COTPA include the: prohibition on smoking in public places (Section 4), ban on direct and indirect forms of tobacco advertisements, promotion and sponsorship of tobacco products (Section 5), prohibition on sale of tobacco products to a minor and sale within 100 yards of any educational institution (Section 6), and required display of pictorial health warnings on all tobacco products packets (Section 7). Despite the Act’s aspirations to curb tobacco use, rampant violations of these laws continue to occur across India (Kumar et al., 2013). With an objective to understand the nationwide barriers to the implementation of COTPA, a test site (Haryana, India) was chosen as a case study. The study documented and analyzed COTPA violations in five districts of the state of Haryana: Sonipat, Panipat, Jhajjar, Kurukshetra, and Mewat. These districts were chosen by a needs assessment of the Government of Haryana. This study was conducted as a part of the project “Awareness to Action through Multi-Channel Advocacy for Effective Tobacco Control in India: Capacity Building in Five Indian States” organized by HRIDAY during December 2009–February 2012. The project intended to provide dedicated technical and legal support to governments at the national, state, and district levels to bolster effective implementation of the Indian tobacco control laws. Haryana was chosen as the test site for several reasons. Haryana has a high percentage of smokers per capita (Krishnan et al., 2008). In terms of implementation of the law Haryana saw nearly 700 individuals fined for violations of Section 4 of COTPA alone, in year 2009 (The Hindu, 2009). It is estimated that 47 and 6 percent of men and women in rural Haryana are tobacco users (Reddy & Gupta, 2004). The situation is only marginally better in urban areas of Haryana with 34 and 2 percent of males and females using tobacco (Reddy & Gupta, 2014).

Jain et al.: The Enforcement of India’s Tobacco Control Legislation

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The objective of our violations reporting study was to collect, document, and analyze violations of COTPA in the five districts of Haryana. The study’s quantitative information on the implementation of COTPA can better inform our understanding of the points of failure for the current COTPA legislation and its implementation. The study’s data may be used to structure realistic reforms of the underenforced COTPA and to construct potential social interventions to curb tobacco use. In addition, valuable lessons may be drawn from data on the relative success of each of the various provisions of COTPA. There is a dearth of quantitative studies that have been undertaken to gauge the relative success of each section of COTPA (Panda et al., 2012). Therefore, this study envisions to bridge the gap in information and provide useful information for future tobacco reforms in India. Legal Background on Right to Tobacco Free Environment in India and Internationally In recent years, the Indian judiciary and legislature have confronted the tobacco epidemic with landmark court decisions and expansive legal reforms that recognize the existence of a right to health in India. The Indian Constitution formally recognizes the right to life as a fundamental right (India Constitution Article 21). Case law precedents have since interpreted this right broadly and expanded the right to also include a right to health (Consumer Education and Research Centre vs. Union of India 1955). From 1997 to 2001 (Kaur & Jain, 2011), the Indian judiciary took significant steps towards incorporating the right to a smoke-free environment within the Constitution’s right to health and as a fundamental human right. Drawing on the right to health paradigm set forth in Francis Coralie Mullin v Union Territory of Delhi (1981) and later explicitly enunciated by Consumer Education and Research Centre versus Union of India (1955), high courts in India held that exposure to tobacco smoke is a violation of the human right to life and health. In 2001, the Supreme Court of India held, in MurliDeora versus Union of India and Ors (2001), that smoking in public spaces violated the constitutionally mandated right to life. International conventions have recognized the right to a tobacco-free environment as a concern warranting a human rights paradigm (Dresler, Lando, Schneider, & Sehgal, 2012). The World Health Organization’s Framework Convention for Tobacco Control (F.C.T.C.) sets out international tobacco control measures (World Health Organization, 2003). It is predominantly based on and derived from international human rights conventions (World Health Organization, 2003). The assumption underlying the F.C.T.C. is that fundamental human rights allow global citizens to demand effective tobacco control measures to ensure their health and well-being (World Health Organization, 2003). This is nowhere more evident than in the foreword of the Convention wherein which it is stated that the F.C.T.C. is an “evidence-based treaty that reaffirms the right of all people to the highest standard of health” (World Health Organization, 2003). Thus, India is not alone in the global sphere for recognizing second-hand smoke exposure as a human rights issue.

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In light of these judicial efforts recognizing the harms of tobacco, COTPA was enacted in 2003 to curtail the use, sale, and advertisement of tobacco products. COTPA required amendments over the years to address the continuing violations and rampant tobacco use in India. In 2008, the Revised Smoke-Free Rules were passed and instituted fines for each type of COTPA violation. Despite case law recognizing the right to a smoke-free environment, discussed above, and extensive legislative reforms (including enactment of COTPA and various other reforms), India continues to be the second-largest consumer of tobacco products in the world (IBN Live, 2013). Policymakers continue to struggle in their efforts to craft an adequate solution to the tobacco epidemic in the country (Business Standard, 2013). Materials and Methods In collaboration with Health Related Information Dissemination Amongst Youth (HRIDAY), this empirical study was undertaken to evaluate the implementation of the Cigarettes and Other Tobacco Products Act 2003 (COTPA) in five districts of Haryana. A monitoring tool and protocol were developed to track the enforcement of the provisions of the Indian Tobacco Control Law at the district levels. Primarily, the protocol1 examined conduct violative of COTPA: smoking in public places, advertising of tobacco products, sale to and by minors, and the absence of pictorial health warnings on tobacco products. The options provided for each section of the monitoring tool included all possible violations of COTPA and were adapted from previously available monitoring tools. The tool and protocol were developed in English, translated into Hindi, and translated back English to avoid any information loss. Prior to administration in the field, both the tool and the protocol were pilot tested for content in Delhi as well as reviewed for expert opinions from five NGO directs, technical advisors, public health practitioners, and academics. The duration of the study was set for a 10-month period, in 2011–2012, during which the State Project Officer and the lead researchers and trained Research Assistants visited various public places, educational institutions, and point of sales within the districts to monitor the violations of Section 4, 5, 6, and 7 of COTPA. The initial phase of our project consisted of the in-field collection of COTPA violation data from five districts in the state of Haryana. The districts were chosen on the basis of a consultation with government officials of the State of Haryana. Government officials conducted a needs assessment of all districts in Haryana and concluded that these five districts had the highest burden of tobacco use. The groups conducted the violation reporting from various sites including shops, bus stands, hotels, mobile vendors, restaurants railway stations, district courts, and public areas near schools where tobacco sale is legally prohibited. Hotels were assessed on the basis of whether the hotel had smoking rooms in the hotel. This was determined by examining whether the hotel had the correct smoking and nonsmoking placards (required by COTPA) and whether the hotel mixed the smoking


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and non-smoking rooms on the same floor (prohibited by COTPA). Public areas near both private and public primary and secondary schools were observed. Given the numerous and clandestine nature of shops that sell tobacco within Haryana, it was not feasible to observe all potential sites (all shops, all public spaces near schools, all mobile vendors) within the state. Therefore, only a selection of sites was visited. A minimum of 200 sites were visited per district. In Panipat, 239 sites were visited. In Jhajjar, 219 sites were visited. In Mewhat, 205 sites were visited. In Kurukshetra, 205 sites were visited. Lastly, in Sonipat 205 sites were visited. These sites were chosen on the basis of several factors relating to convenience and ease of access including: (1) open to the public, (2) safety, (3) operating hours, and (4) distance from other chosen sites. The data were collected in the following manner. One trained data collector would visit the site and observe for 15–20 minutes. The trainer’s data were then reviewed and checked for error by an oversight expert. The time chosen for the site visitation depended on the site’s potential COTPA violations. For example, shops near schools would need to be observed when schools were open (e.g., not visited on Saturdays or Sundays). However, all sites were observed for all violations of Sections 4, 5, 6, and 7 of COTPA. Human subject review was not completed in this study as human subjects were not utilized; no persons were interviewed and no persons interacted with the observers in any manner during the course of the study. The violation data were analyzed according to percentages of sectional violations in each district and the results were reported to state and district level officials in Haryana. A joint HRIDAY-Jindal Global Law School letter was written to the Principal Secretary of Health & Family Welfare, Government of Haryana. The data were then analyzed utilizing probabilities calculation and the Chi-square null hypothesis test. This study has a number of limitations. First, the study is an observation only study and is not interview based. Thus, the study does not have the benefits achieved from qualitative interviews such as the opinions and thoughts of potential violators on COTPA and why they chose to violate it. Second, data collection happened over a succinct period of time. Multiple observations of a venue over a longer period of time may have provided more nuanced information. Third, the study has the potential, as all observation studies do, of suffering from subjective bias and error on the part of the observer. However, attempts to minimize this were made through the use of standardized protocols, data collection tools, and trainings for observers. Fourth, the observer themselves ran the risk of creating observer effects in which the presence of the observer in some way influences the behavior of those being observed. Despite these limitations, however, this study is reliable and provides new information on the implementation of COTPA Sections 4–7 in five districts of Haryana. Furthermore, and possibly most importantly, it sheds light on the potential of future success of observational compliance surveys in regards to antitobacco policy. This study involved a low-cost observational compliance survey that required only little initial training development. With additional studies utilizing observational compliance surveys, such as ours, more research and

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conclusions may be garnered by examining tobacco policy compliance in India and around the globe. See Table 1 for the data that were collected on the following indicators for various sections of COTPA. Results Table 2 depicts the total number of violations for each district and the distribution of violations over Sections 4–7. Table 3 depicts the percentage breakdown by section of the total number of violations for each district. Table 4 depicts the percentage of sites that were COTPA compliant for Sections 4–7 in each of the five districts. Percentage was determined by finding the percentage of sites that had no violations within the total number of sites studied. Table 5 depicts the results of the R C contingency test comparing the actual observed violation values to the expected violation values under a null hypothesis of random association. The R C contingency test examined the likelihood of whether such sectional violation data in each district could be attributed to random association by calculating the expected data and comparing it to the observed data. The districts fared differently, as to which Section of COTPA had the largest total number and percentage of violations in the district (Tables 2 and 3). Jhajjar and Panipat had the maximum number and percentage of total violations under Section 4 (165 and 120 violations, 50.61 and 42.55 percent) while Mewat and Kurukshetra had the maximum number and percentage of violations under Section 5 (145 and 94 violations, 46.18 and 33.57 percent). Sonipat had the maximum number of violations and highest percentage under Section 6 of the COTPA (166 violations and 58.25 percent).

Table 1. Indicators of Observation Section 4 People smoking in public areas Presence of objects such as ashtrays and matches, facilitating smoking in public places Presence/absence of “no-smoking” boards with complaint mechanism Presence of smoking areas/room in hotels and rooms with a capacity of 30 rooms/seats or more Section 5 of COTPA The advertising, promotion, and sponsorship of tobacco products across all mediums of communication and at point of sale Point of sale display boards at the shops adhered to the size (60 cm 45 cm), color, language, number and warning as prescribed by COTPA Tobacco products that contained advertisements on their packaging Advertisement or display of tobacco products at the entrance or inside warehouses or shops Section 6 of COTPA Sale and distribution of tobacco products to and by minors Sale of the products within 100 yards of an educational institution Warning boards prohibiting such tobacco access to minors Section 7 of COTPA Presence/absence of the pictorial warning on tobacco products Compliance of the warnings with specifications like form, size, and type as mentioned in COTPA Misleading terms and descriptors like light, mild, and low tar on the packaging of the tobacco products


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Table 2. Number and Type of Violations

Panipat Jhajjar Mewat Kurukshetra Sonipat

Total Pop.

No. of Locations

Total # of Violations

Section 4

Section 5

Section 6

Section 7

12,02,811 9,56,907 10,89,406 9,64,231 14,80,080

239 219 205 205 205

326 282 314 280 285

165 120 24 86 18

90 98 145 94 84

57 57 132 87 166

14 7 13 13 17

Data collected from five districts showing the total number of violations and the section with the highest number of violations per district. Data includes multiple violations within a single location.

Table 3. Percentage of Section Specific Violations Per District


Total # of Violations

% Section 4

% Section 5

% Section 6

% Section 7

326 282 314 280 285

50.61% 42.55% 7.64% 30.71% 6.32%

27.61% 34.75% 46.18% 33.57% 29.47%

17.48% 20.21% 42.04% 31.07% 58.25%

4.29% 2.48% 4.14% 4.64% 5.96%

Table 4. Compliance in all Five Districts


Total Locations

# Locations w/Violation(s)

# Locations w/o Violation(s)

% of Fully Compliant Locations

239 219 205 205 205

224 203 167 140 193

15 16 38 65 12

6.28% 7.31% 18.54% 31.71% 5.85%

Depiction of the total number of locations studied for each district and the number of locations that had violations or no violations of COTPA.

Table 5. R C Contingency Table Section 4 A: Observed contingency table Panipat 165.0 Jhajjar 120.0 Mewat 24.0 Kurukshetra 86.0 Sonipat 18.0 B: Expected contingency table Panipat 90.54337592 Jhajjar 78.32279758 Mewat 87.21049092 Kurukshetra 77.76731675 Sonipat 79.15601883

Section 5

Section 6

Section 7

90.0 98.0 145 94.0 84.0

57.0 57.0 132.0 87.0 166.0

14.0 7.0 13.0 13.0 17.0

112.028245 96.9078682 107.904506 96.2205783 97.938803

109.397445 94.6321453 105.370545 93.9609953 95.6388702

14.0309348 12.137189 13.5144586 12.0511096 12.266308

P-value of chi-squared test ¼ 5.5892E57; P value-cut off ¼ >0.05.

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In Jhajjar and Panipat, observational compliance researchers observed people smoking in public spaces prohibited by COTPA including hotels, restaurants, railway stations, and bus stops. According to Section 4, public place means “any place to which the public have access whether as of right or not and includes: hotels, restaurants, workplaces” (Section 4 COTPA, 2003). Cigarette stubs and matches were strewn outside and inside government offices, restaurants, railway stations, and bus-stands. The violations contact board required by Section 4 failed to have the required name and address of the person to be contacted, in case of violations observed. At the limited number of sites that actually had warning boards, the boards were damaged, obstructed, or tampered with. A public office in Bahadurgarh was the only exception where warning boards were displayed in accordance with the law. Patterns of smoking were also observed in several nonsmoking areas. In the districts of Mewat and Kurukshetra, which had the maximum number and highest percentage of Section 5 violations, the majority of warning boards at the point of sale failed to comply with the prescribed maximum size. The majority of sites had multiple “point of sale” display boards, which exceeded the size and mentioned the name of the tobacco company and brand (prohibited by the law). The health warnings on the display boards were disproportionately sized and were smaller than prescribed by the law. The majority of sites had easily accessible and visible tobacco products to minors. The tobacco products and cigarettes were displayed in the front counter along with the sweets and other eatables—within easy reach of minors. The District of Sonipat had the maximum number and percentage of violations under Section 6 of the COTPA. Observers noted that no shops had warning boards against the sale and distributions of tobacco products to and by minors. Observers documented violations in which sellers failed to demand proof of age even when the buyer’s age majority appeared by research observers questionable. Section 6 requires shop owners to require proof of age if there is any doubt of the buyer’s age; thus, the onus is on the shop owner. Adult shop owners often left unattended children to sell the products. All educational institutions had at least a couple of shops selling tobacco products within a hundred yards. The warning boards banning such sales were also missing in Sonipat. Several conclusions and observations can be drawn on the basis of the observed violation data. First, regardless of which Section had the maximum number of violations in the district, all districts had strikingly low raw numbers as well as percentages of Section 7 violations in comparison to the other Sections of COTPA (Tables 2 and 3); with Section 7 violations ranging from 2.48 to 5.96 percent of the total number of violations per district. Thus, the sites observed were largely compliant with Section 7. Of those sites that violated Section 7, beedi packets were predominantly the violative tobacco product. The packets that actually had health warnings in the prescribed colors and background, had indiscernible and blurry pictures; thereby, defeating the purpose of the warning. Second, the overwhelming majority of locations observed had violations and were COTPA noncompliant (Table 4). The percentage of compliance ranged from


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a meager 5.85 to 31.71 percent. In the districts of Panipat, Sonipat, and Jhaijar, over 90 percent of the locations had documented violations of COTPA (Table 4). The district with the fewest number of total violations was Kurukshetra (Table 4). Although most compliant out of the five districts, nearly 70 percent of sites observed in Kurukshetra contained violations (Table 3). Third, the observed violation data are statistically significant and cannot be explained by random association. In the R C contingency table (Table 5) the observed data and expected data are compared utilizing a chi-square equation. The R C contingency table for the data reveals a P value well below the P value (>0.05) cut-off for the continuance of the null hypothesis. Thus, the null hypothesis must be rejected, revealing that random association cannot explain the observational data. Thus, all such conclusions noting the relative percentages of section-specific violations are statistically significant. Therefore, the variability amongst districts and amongst section violations are not due to random factors and instead provide support for the conclusion that COTPA was violated in these districts of Haryana and such violations are not evenly distributed amongst sections or districts. Discussion The COTPA violations observed varied amongst the different districts (Table 2). However, all districts had documented violations and low percentages of compliance (5.85–31.71 percent). The purpose of this research study, however, is not merely to document the violations of COTPA. The goals of this study are twofold: one, to provide information on the nature of noncompliance of COTPA across India (varied and non-equally distributed across Sections of COTPA); second, to create and provide a re-creatable and exportable method that can be utilized domestically for COTPA violations as well as internationally for other national tobacco control policies. Our finding that COTPA is routinely violated with impunity has been noted within the literature (Panda et al., 2012). However, our study provides quantitative data of section-specific violations and thus, can be the starting point for showing a need for legislative or implementation reform for certain Sections of COTPA. The recording of violations is merely the first step of many towards designing realistic strategies to ensure compliance with tobacco control. Over the past several years, a handful of surveys and studies have been done on the compliance of COTPA within several states and districts of India (Aruna, Rajesh, & Mohanty, 2010; Kumar et al., 2014; Mead, 2013; Tripathy, Goel, & Patro, 2013). A compliance monitoring study of tertiary health-care institutions in Chandigarh found only a 23 percent overall compliance rate with Section 4 of COTPA (Tripathy et al., 2013). The compliance was assessed through an observational study of several factors including: evidence of smoking, display of signs, cigarette butts, bidi ends, and smoking aids (Tripathy et al., 2013). A recent study examining COTPA compliance in regards to youth tobacco access (e.g., tobacco sales must be at least 100 yards away), found a high percentage of noncompliance in five Indian states of Bihar, Karnataka, Kerala, Maharasthra, and

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Rajasthan (Mead, 2013). According to the study’s findings, only 5 of the 505 vendors examined were fully compliant (Mead, 2013). In a 2010 observational compliance study of pictorial health warnings on tobacco products in Uttar Pradesh, researchers found that tobacco products marketed locally were overwhelmingly noncompliant with COTPA’s packaging and labeling requirements (Aruna et al., 2010). Many of the products observed lacked public health warnings as required by COTPA and contained misleading descriptors and promotional messages—clear violations of COTPA (Aruna et al., 2010). However, other districts have shown high compliance with COTPA. In 2010, four districts (Sikkim, Vilupuram, Shimla, and Coimbatore) demonstrated compliance with Section 4 of COTPA through an observational compliance survey (Lal, Wilson, & Singh, 2011). The survey examined adherence to specific requirements of Section 4 through site observations of the following factors: the noncompliant presence of smoking aids in public spaces, the size and presence of signage, and observations of smoking in public places or indicators of recent smoking in public places (Lal et al., 2011). The survey found nearly all four districts were over 90 percent compliant for all factors examined (Lal et al., 2011). According to a recent cross-sectional study (Goel, Ravindra, Singh, & Sharma, 2013) in the district of SAS Nagar Mohali, the district had a 92.3 percent compliance rate for Section 4 of COTPA. The study was conducted over November and December of 2011 and examined public space sites as defined by Section 4. Both studies concluded that observational compliance surveys are one of the most cost effective and easily administered research methods to determine the compliance of COTPA. A recent study in Himachal Pradesh similarly found high rates of compliance although noted that compliance varied greatly amongst COTPA sections and between districts (Kumar et al., 2013). Using a compliance observational survey, the study found overall that the districts examined had at least an 80 percent compliance for at least three of the five indicators examined (e.g. presence of cigarette butts and observed public smoking) (Kumar et al., 2013). Similar observational compliance studies of tobacco control policy have been done internationally. In a study of Massachusetts’ ban against selling tobacco to minors, researchers conducted an observational study examining the percentage of compliance and noncompliance with the ban across over 400 vendors (Rigotti et al., 1997). The study compared a control group of merchants with a group of merchants who lived in an intervention community (where researchers increased enforcement efforts) (Rigotti et al., 1997). A similar observational study in Boston was conducted to examine compliance with the city’s 100 percent smoke-free bar regulation. The study implemented an observational study of over 100 bars in Boston before and after the ban was enacted. Researchers administered an observational survey that included 40 variables and compared the differences between pre- and post-ban for statistically significant compliance (Skeer, Land, Cheng, & Siegel, 2004). Drawing from the international literature on observational compliance studies for tobacco control policy, our study adds the available knowledge for COTPA regulation in India as well as the effectiveness of similar such anti-tobacco measures.


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This study’s data indicate that Section 7 is less often violated (percentage wise across Sections as well as across districts) within Haryana than the other Sections of COTPA. The occurrence of Section 7 violations ranges from only 2.48 to 5.96 percent of the total number of violations observed in each district. A recent study of retail outlets in Delhi by the Voluntary Health Association of India (VHAI) similarly found that many of the tobacco companies studied were compliant with Section 7 and did indeed have health warnings on their tobacco products (The Hindu, 2013). Pictorial health warnings in India are regulated at the products level and therefore may offer an effective point of intervention with large potential downstream effects. In other words, the product itself is regulated prior to even entering the market. The remaining Sections of COTPA, however, involve regulation after the point of entry of the product into the market and may only be enforced effectively if enforcement officials are notified or they themselves observe noncomplying conduct. Although our research is inconclusive on the exact explanation for the low numbers and percentage of Section 7 violations in Haryana, it may point to the potential for pre-market interventions and the need for reform of the current post-market implementation measures. Of particular concern, in regards to this study’s data, is the flagrant violation of Section 6—allowing minors access to tobacco products. Minors’ access to tobacco is not only a violation of COTPA, but more seriously, it is a violation of the minor child’s rights under the Convention on the Rights of the Child (Convention on the Rights of the Child, 1989). The health of the child has been considered paramount in the Convention throughout (e.g., Articles 23, 24, and 39). Article 24 of the Convention prescribes that state parties recognize the child’s right to the “highest attainable standard of health” (Convention on the Rights of the Child, 1989), combat disease by providing health necessities (food and clean water), and diminish “the dangers and risks of environmental pollution” (Convention on the Rights of the Child, 1989). The exposure of tobacco to minors (i.e., smoking in public spaces) and the accessibility of tobacco for minors, in effect, violate their right to health under the Convention on The Rights of the Child (Cabrera & Gostin, 2011). Tobacco control is, thus, not only a child health concern but an international child rights issue as well (Cabrera & Gostin, 2011). This study has implications not only for India’s implementation of COTPA but also for tobacco control policies across the globe. Many of the sections of India’s COTPA are largely reflective of the tobacco control measures employed in the World Health Organization’s Framework Convention on Tobacco Control. For instance, Section 6 (prohibition on sale to minor) is similar to Article 16 of the Convention, “Sales to and By Minors” (Article 16 2003). Section 7’s mandatory warnings on tobacco products is similar to the Convention’s Article 11, “Packaging and Labeling of Tobacco Products” (Article 11 2003). Since 2004, countries across the globe have signed on as parties to the Convention and have since ratified the Convention’s articles into national law. For example, Argentina, Germany, Qatar, and Norway are all state parties to the Convention and have since ratified the Convention (World Health Organization, 2014). Our study provides an exportable

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method, observational compliance surveys, with low costs that can allow examination of noncompliance of other national tobacco control policies. The predominant cost of our observational compliance study was merely the time to train researchers and provide them with hard copies of the observational study survey. This method is easily exportable, particularly to countries that have incorporated similar provisions as to those found India’s COTPA and in the World Health Organization’s Framework Convention on Tobacco Control. Second, the patterns that emerged from our study (unevenly distributed violations across Sections and locations) may offer clues to developing successful tobacco control strategies both within India and abroad. For example, if other studies across India or the globe confirm the repeated noncompliance with a particular method of tobacco control (e.g., pictorial warnings), this may guide tobacco policy reforms. As similar tobacco control techniques as Sections 4–7 of COTPA exist crossnationally, information on compliance and noncompliance may offer key insights to the global fight against tobacco-related negative health outcomes through tobacco policy reforms. Conclusion and Policy Implications The present study’s data reveal the under-enforcement and ineffectiveness of COTPA within the five districts in of the State of Haryana. Further research (particularly in the areas of health economics and public health) must be done to determine what factors (e.g., presence of police, income, urbanization, etc.) lead to variable violations of COTPA across districts of India. Based on the observations, it is suggested that policymakers and implementers have a long way to go to ensure compliance with COTPA. There are several insights to be gained from the data on COTPA violations gathered in this study. In the test case of Haryana, law enforcement officers were not engaged in enforcing COTPA (even, at times, violating it themselves). Provided, as the study suggests, that local level enforcement of COTPA is marginal (at best) a national monitoring mechanism should be compulsory for all states along with regular reporting to ensure full compliance with COTPA. This nation-wide enforcement and reporting body would incentivize states to promote compliance at the local levels. States found flouting COTPA through the indifference of law officers and other such stakeholders, would be fined. Second, the study suggests that the only COTPA control (Section 7) at the supply level has a higher relative percentage compliance than Sections 4–6 of COTPA—which are regulated at the demand level. Market reforms come in one or two forms: control demand or control supply. The first option, to control demand, manifests itself as any effort that the government makes to control the sellers or users of tobacco products. COTPA largely reflects this first option in its efforts to influence users with: smoke-free public spaces, warning billboards, limited advertising, and age requirements. As evident by our findings from five districts within Haryana, demand-focused controls have largely been shown be ineffective in India’s efforts to control tobacco. The second option, supply-side


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tobacco control efforts, have seen promising results from countries around the globe (Chaloupka, Straif, & Leon, 2011). These efforts include such policies as: reducing tobacco growing by addressing the sustainability of tobacco farmers’ livelihoods (Li, Wang, Xia, Tang, & Wang, 2012) and curbs on illicit trade in tobacco products (Joossens & Raw, 2012). For example, recent research on tobacco tax policies from Denmark, Finland, and numerous other countries have shown that policies decreasing the affordability of tobacco by tax hikes have significant effects on the rates of tobacco use (Joossens & Raw, 2012). Increasing tobacco taxes has been shown to be the single most effective manner to reduce tobacco use (Mugyenyi & Ntie, 2013). This trend continues regardless of whether the country increasing tobacco taxes is a low-income, middle-income, or high-income country (Chaloupka, Yurekli, & Fong, 2012). In fact, studies have shown that even in low-income countries price increases from tobacco taxation affect all levels of tobacco consumption (e.g., cessation of current users, reduced levels of tobacco consumed, lower rates of initiation of smokers) (Chaloupka et al., 2012). The Republic of Korea’s tobacco policies in the 1990s are a prime example of the tobacco taxation’s high degree of effectiveness (Levy et al., 2010). A recent study on Korea’s tobacco success found that higher tobacco taxes were instrumental to the country’s effective tobacco control measures (Levy et al., 2010). In particular, tobacco tax increases reduce the numbers of youth (Joseph & Chaloupka, 2014) using tobacco and prevent sporadically smoking individuals from transitioning to habitual smokers (Joseph & Chaloupka, 2014). It is recommended by the World Health Organizations that countries raise tobacco taxes to at least 70 percent of the retail price (World Health Organization, 2011). Currently, however, India’s tax rates for tobacco products are far below the guidelines set by the World Health Organization. For example, as of 2010, bidis packs cost on average only 4 Rs.—only 9 percent of the retail price and India’s cigarette tax amounted to only 38 percent of its retail price (John et al., 2010). However, the Indian Government will likely face strong opposition if it elects to increase taxes on tobacco products. A recent study of the transnational tobacco industry’s practices in low- and middle-income countries reveals that the tobacco industry attempts to control the access and affordability of tobacco through four primary forms of conduct: economic activity, marketing/promotion, political activity, and manipulative activity (Lee, Ling, & Glantz, 2012). What is particularly noteworthy, for the purposes of our taxation recommendation, is the study’s finding that the tobacco industry is heavily involved in lobbying, offering voluntary self-regulatory codes, and mounting corporate social responsibility campaigns (Lee et al., 2012). Policymakers wishing to institute policies affecting the profit maximization of the tobacco industry (e.g., taxes, restricting imports, etc.) must understand the potential of these political activities in the understood in the Indian political context. Although the political tactics employed by transnational tobacco companies in low- and middle-income countries are similar to those of high-income countries, these lower-income countries, whose political systems and economic institutions are less stable and controlled by corruption, are more prone to political manipulation by the tobacco industry (Lee et al.,

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2012). According to a case study on such effects within Malawi, researchers found that developing countries were particularly in danger of the political sway of the profitable tobacco industry (Otanez, Mamudu, & Glantz, 2009). The study dramatically exposes the potential for political lobbying held by the tobacco industry through its control over jobs and foreign capital (Otanez et al., 2009). To confront such influence in countries across the globe, Lee’s study recommends four main modes of conduct for low- and middle-income countries to confront the tobacco industry. Unsurprisingly, each of these recommendations is included within COTPA with the glaring exception of increasing tobacco taxes. Dipika Jain is associate professor and executive director of the Centre for Health Law, Ethics and Technology, Jindal Global Law School, O.P. Jindal Global University. Amit Jadav is legal consultant in the Public Health Foundation of India and manager legal HRIDAY (Health Related Information Dissemination Amongst Youth). Kimberly Rhoten is a research fellow in the Centre for Health Law, Ethics and Technology, Jindal Global Law School, O.P. Jindal Global University. Abhinav Bassi is research officer, HRIDAY.

Notes Conflicts of interest: None declared. Corresponding author: [email protected] The authors would like to thank the World Lung Foundation who included this project in the Bloomberg Initiatives to Reduce Tobacco Use (BI) and provided the grant funding for this study. The contents of this paper are the sole responsibility of the authors and can under no circumstances be regarded as reflecting the positions of the International Union against Tuberculosis and Lung Disease (The Union) or the donors. Furthermore, the authors would like to acknowledge the research assistance of many research students including: Radhika Bhuyan, Gautam Sundaresh, Swarnim Swasti, Harshit Malik, Samhith Malladi, Dhanush Kumar, Asees Kaur, Shyamsundar Chandrashekar, Anagha Nandakumaran, Arjunpal Walia, Ankit Grewal, Gauriza Nagalia, Samridhi Vasudeva, and Suraj Chaudary. We would also like to acknowledge the invaluable support provided by O.P. Jindal Global University. In particular, we would like to acknowledge the Jindal Global University staff for their assistance as well as the meaningful support of Vice Chancellor, Professor Raj C. Kumar. Without their support, our research would not have been possible.

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