Institutional tensions, corporate social responsibility and district-level governance of tobacco industry interference:Analysing challenges in local implementation of Article 5.3 measures in Karnataka, India

INTRODUCTION: Accelerating progress on tobacco control will require Article 5.3 of the WHO Framework Convention on Tobacco Control to be systematically integrated into policies and practices of sectors beyond health at diverse government levels. However, no study has explored implementation challenges of Article 5.3 within multilevel systems such as India, where political decisions on tobacco control occur at diverse government levels, which may constrain action at local level. METHODS: Based on 33 semi-structured interviews with diverse government and civil society stakeholders across four districts in Karnataka, India (Mysore, Mangalore, Bengaluru (rural) and Udupi), this study examines challenges to implement Article 5.3 arising from competing agendas and policies of different actors at multiple levels. RESULTS: Our analysis reveals generally low levels of awareness of Article 5.3 and its guideline recommendations, even among those directly involved in tobacco control at district level. Efforts to implement Article 5.3 were also challenged by competing views on the appropriate terms of engagement with industry actors. Scope to reconcile tensions across competing health, agriculture and commercial agendas was further constrained by the policies and practices of the national Tobacco Board, thereby undermining local implementation of Article 5.3. The most challenging aspect of Article 5.3 implementation was the difficulties in restricting engagement by government officials and departments with tobacco industry corporate social responsibility initiatives given national requirements for such activities among major corporations. CONCLUSIONS: Promoting effective implementation of Article 5.3 in Karnataka will require policymakers to work across policy silos and reconcile tensions across India’s national health and economic priorities

Prevalence, regional patterns and socio-demographic factors associated with poly-tobacco use in India: A secondary data analysis

Background: Tobacco use is associated with early, intermediate and long-term complications throughout the life course. With an influx of newer products containing nicotine, poly-tobacco use is slowly emerging as a public health concern, that is defined as existing tobacco users currently using two or more tobacco or nicotine products. While many studies have investigated single use tobacco, there is a paucity of research on regional patterns and socio-demographic factors associated with poly-tobacco use in India. Objectives: To assess prevalence of poly-tobacco use and determine the socio-demographic factors associated with poly-tobacco use in India. Methods: Data from the Global Adult Tobacco Survey 2 (GATS, 2016–17) was analysed, which included information on tobacco use among people aged >15 years. The pattern of current tobacco status was described using descriptive statistics. Multiple logistic regression models were estimated to determine factors associated with poly-tobacco use. Results: The prevalence of poly-tobacco use in India was found to be 9.8%. Among the current tobacco users, the prevalence was 33%. Significant socio-demographic factors associated with poly-tobacco use included younger age, male gender, religion and backward caste. North-eastern region reported highest prevalence of poly-tobacco use in the country, followed by the central region. Conclusion: The number of poly-tobacco users in India is considerably high and a matter of concern, more so in north east and central regions of the country. There is a need to create awareness about dangerous effects of all types of tobacco products and strengthen implementation of tobacco control policies with special focus on regions with high burden

Programme and policy perspectives towards a tobacco-free generation in India: findings from a qualitative study

Objective This study explored multistakeholder perspectives on existing adolescent-specific tobacco control policies and programmes, to advance India’s transition towards a tobacco-free generation.Design Qualitative semi-structured interviews.Setting Interviews were conducted with officials involved in tobacco control at the national (India), state (Karnataka), district (Udupi) and village level. Interviews were audio recorded, transcribed verbatim and analysed thematically.Participants Thirty-eight individuals representing national (n=9), state (n=9), district (n=14) and village (n=6) levels, participated.Results The study findings highlighted the need to strengthen and amend the existing Tobacco Control Law (2003) provisions, particularly in the vicinity of schools (Sections 6a and 6b). Increasing the minimum legal age to buy tobacco from 18 to 21 years, developing an ‘application’ for ‘compliance and monitoring indicators’ in Tobacco-Free Educational Institution guidelines were proposed. Policies to address smokeless tobacco use, stricter enforcement including regular monitoring of existing programmes, and robust evaluation of policies was underscored. Engaging adolescents to co-create interventions was advocated, along with integrating national tobacco control programmes into existing school and adolescent health programmes, using both an intersectoral and whole-societal approach to prevent tobacco use, were recommended. Finally, stakeholders mentioned that when drafting and implementing a comprehensive national tobacco control policy, there is a need to adopt a vision striving toward a tobacco-free generation.Conclusion Strengthening and developing tobacco control programmes and policies are warranted which are monitored and evaluated rigorously, and where adolescents should be involved, accordingly

Exposure to tobacco imagery in popular films and the risk of ever smoking among children in southern India

Background Exposure to smoking in films is a recognised cause of smoking uptake among children. In India, in an attempt to protect children, films containing smoking are required to include tobacco control messaging including audiovisual disclaimers, on-screen health warnings when tobacco imagery is displayed and antitobacco € health spots' before and during the film. We report a study of the association between ever smoking and exposure to tobacco imagery in locally popular films among children in Udupi district of Karnataka state in southern India. Methods A cross-sectional questionnaire survey of all students in grades 6-8 in schools in the Udupi district ascertained smoking status and potential confounders of smoking uptake, and whether children had seen any of 27 locally popular films we had coded and found to contain imagery of actual or implied tobacco use. Ever-smoking status was defined as any reported smoking of cigarettes, beedis or other tobacco products currently or at any time in the past. Independent effects on ever-smoking status were estimated using multiple logistic regression. Results Of 46 706 students enrolled in grades 6-8 in 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever smoking was reported by 914 (2.3%) participants and in a mutually adjusted model was significantly related to age, male sex, living in a home where smoking is allowed, having parents or siblings who smoke, low paternal education, low levels of family wealth, low self-esteem, rebelliousness and poor school performance. After allowing for these effects, the odds of ever smoking were not increased among students who had seen any of the listed films containing tobacco imagery when included in the analysis as a binary exposure (OR 0.9, 95% CI 0.4 to 2.0), and decreased in relation to level of exposure graded into tertiles of tobacco intervals seen. Conclusions In this cross-sectional study, children in southern India who had seen films containing tobacco imagery are no more likely to smoke than those who had not, indicating that the tobacco control messaging mandated by Indian law may be attenuating the effect of tobacco imagery in films on smoking uptake

Prospective cohort study of exposure to tobacco imagery in popular films and smoking uptake among children in southern India

Background Exposure to tobacco imagery in films causes young people to start smoking. Popular Indian films contain high levels of tobacco imagery, but those that do are required by law to display onscreen health warnings when smoking imagery occurs and to include other health promotion messaging before and during the film. We report a prospective cohort study of incident smoking in relation to exposure to film tobacco imagery and anti-tobacco messaging in a cohort of children in southern India. Methods We carried out a one-year longitudinal follow up questionnaire survey in 2018 of a cohort of 39,282 students in grades 6, 7 and 8 (aged between 10 and 15 years) in schools in the Udupi district of Karnataka State in India who participated in a 2017 cross-sectional study of exposure to smoking in films and ever smoking status. Results We obtained usable linked data in 2018 from 33,725 of the 39,282 (86%) participants with data from 2017. Incident smoking was reported by 382 (1.1%) participants. After adjusting for age, sex and common confounders significantly associated with incident smoking there was no significant independent effect of exposure to film smoking, either as a binary (Odds Ratio 1.6, 95% Confidence Interval (CI) 0.5 to 4.9) or as a graded variable, on smoking uptake. An exploratory analysis indicated that the presence of on-screen health warnings that complied fully with Indian law was associated with a significantly lower odds of smoking uptake (Odds Ratio 0.8 (0.6 to 1.0, p = 0.031) relative to the same exposure sustained in absence of compliant warnings. Conclusion Exposure to tobacco imagery in Indian films was not associated with a significantly increased risk of incident smoking in South Indian children. While it is possible that this finding is a false negative, it is also possible that the effect of film exposure has been attenuated by the presence of on-screen health warnings or other Indian tobacco-free film rules. Our findings therefore support the wider implementation of similar tobacco-free film measures in other countries

Potential risk factors of smokeless tobacco consumption among adolescents in South India

Introduction: Although most of the disease burden is due to tobacco smoking, smokeless tobacco (SLT) use contributed to an estimated 76,000 deaths in 2017. We have studied the potential risk factors for SLT use among adolescents in South India. Methods: A cross-sectional questionnaire survey of all students in grades 6 to 8 in schools in the Udupi district of Karnataka State ascertained SLT use status and potential determinants of SLT uptake. Ever SLT use was defined as any reported consumption of any SLT products, currently or at any time in the past. Independent effects on ever-SLT use status were estimated using multiple logistic regression. Results: Of 46,706 students from 914 participating schools, 39,282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever SLT use was reported by 775 (2.0%) participants and in a mutually adjusted model was significantly related to age, male sex, family use or friend’s use of SLT, low socio-economic status, high rebelliousness and low self-esteem. After controlling for these effects, the odds of ever-SLT use were significantly higher among students who had least awareness of the harmful effects of tobacco use [OR 3.7 95% CI (2.9,4.7)] and significantly lower among those not exposed to tobacco advertising [OR 0.7 95% CI (0.5,0.8). Conclusions: The prevalence of SLT use among children in Karnataka is relatively low as compared to other studies in India. The significant potential risk factors of SLT use include low awareness of the harmful effects of tobacco and tobacco control policies and exposure to tobacco advertising

Awareness and Association of Obesity-risk reduction factors among Junior high school students of south India

Background: Obesity epidemic has been on rise and this has been attributed to unhealthy practices including physical inactivity and unhealthy diet. Adolescence has been a critical period for development of obesity due to changes in body composition and behaviour. Objectives: To assess knowledge, attitude and practices (KAP) regarding obesity-risk reduction factors and its association with obesity-risk among Junior high school students. Methods: Study conducted among 397 Junior high school students from 12 randomly selected English medium schools from pool of eligible schools in Udupi District using pretested and validated questionnaire to assess their KAP regarding Physical activity and diet. Standardized equipments were used for measuring anthropometry and Total body fat (%). Data entered and analyzed on SPSS 15. Results: 51.4% of the participants were recruited from private funded schools and boys accounting 51.6%. Statistically significant difference in proportions was observed between boys and girls in Physical activity, dietary and overall KAP scores and Total body fat (%). Correlation between Total body fat (%) and overall KAP score showed decline in Total body fat (%) with increase in overall KAP score (r=-0.120; p=0.017). Conclusions: Male gender and public funded schools were protective against obesity-risk. Interventions are required to increase awareness regarding obesity-risk reduction factors among school children

Pre-Hypertension among Young Adults (20-30 Years) in Coastal Villages of Udupi District in Southern India: An Alarming Scenario.

INTRODUCTION:According to Joint National Committee-7 (JNC-7) guidelines, a systolic blood pressure (SBP) of 120 to 139 mm Hg and/or diastolic blood pressure (DBP) of 80 to 89 mm Hg is considered as pre-hypertension. Existing evidence suggest that the cardiovascular morbidities are increasing among pre-hypertensive individuals compared to normal. OBJECTIVE:To assess the magnitude and factors associated with pre-hypertension among young adults (20-30 years) in coastal villages of Udupi Taluk (an area of land with a city or town that serves as its administrative centre and usually a number of villages), Udupi District, Karnataka state, India. DESIGN:Community based cross sectional study. SETTING:6 (out of total 14) coastal villages of Udupi Taluk, Karnataka state, India. SAMPLE:1,152 young adults (age group: 20-30 years) selected by stratified random sampling in 6 coastal villages of Udupi Taluk, Karnataka state, India. METHOD:A semi structured pre-tested questionnaire was used to elicit the details on socio-demographic variables, dietary habits, tobacco use, alcohol consumption, physical activity, family history of hypertension and stress levels. Anthropometric measurements and blood pressure were recorded according to standard protocols. Serum cholesterol was measured in a sub sample of the study population. Multivariate logistic regression was applied to identify the independent correlates of pre-hypertension among young adults (20-30 years). MAIN OUTCOME MEASURES:Prevalence, Odds ratio (OR) and adjusted (adj) OR for pre-hypertension among young adults (20-30 years). RESULTS:The prevalence of pre-hypertension in the study population was 45.2% (95%CI: 42.4-48). Multivariate logistic regression analysis revealed that age group of 25-30 years (adj OR: 4.25, 95% CI: 2.99-6.05), white collared (adj OR: 2.29, 95% CI: 1.08-4.85) and skilled occupation (adj OR: 3.24, 95% CI: 1.64-6.42), students (adj OR: 2.46, 95% CI: 1.22-4.95), using refined cooking oil (adj OR: 0.53, 95% CI: 0.29-0.95), extra salt in meals (adj OR: 2.46, 95% CI: 1.52-3.99), salty food items (adj OR: 6.99, 95% CI: 3.63-13.48), pre-obese (adj OR: 1.66, 95% CI: 1.03-2.67) and obese (adj OR: 9.16, 95% CI: 2.54, 36.4) were the significant correlates of pre-hypertension. CONCLUSION:In the study population, prevalence of pre-hypertension among young adults (20-30 years) was high (45.2%). Biological (age 25-30 years, pre-obesity and obesity) and behavioral (sedentary occupation, intake of extra salt in meals/salty food and not using refined cooking oil) factors were associated with pre-hypertension. Study emphasizes the need of community based screening of pre-hypertension under National Rural Health Mission. It also provides apt information for the evidence based designing of interventions for lifestyle modifications among high risk young adults in the study area

Quantifying audio visual alcohol imagery in popular Indian films: a content analysis

Objectives Though exposure to alcohol imagery in films is a significant determinant of uptake and severity of alcohol consumption among young people, there is poor evidence regarding the content of alcohol imagery in films in low-income and middle-income countries. We have measured alcohol imagery content and branding in popular Indian films, in total and in relation to language and age rating.Design In this observational study we measured alcohol imagery semiquantitatively using 5-minute interval coding. We coded each interval according to whether it contained alcohol imagery or brand appearances.Setting India.Participants None. Content analysis of a total of 30 national box office hit films over a period of 3 years from 2015 to 2017.Primary and secondary outcome measures To assess alcohol imagery in Indian films and its distribution in relation to age and language rating has been determined.Results The 30 films included 22 (73%) Hindi films and 8 (27%) in regional languages. Seven (23%) were rated suitable for viewing by all ages (U), and 23 (77%) rated as suitable for viewing by children subject to parental guidance for those aged under 12 (UA). Any alcohol imagery was seen in 97% of the films, with 195 of a total of 923 5-minute intervals, and actual alcohol use in 25 (83%) films, in 90 (10%) intervals. The occurrence of these and other categories of alcohol imagery was similar in U-rated and UA-rated films, and in Hindi and local language films. Episodes of alcohol branding occurred in 10 intervals in five films.Conclusion Almost all films popular in India contain alcohol imagery, irrespective of age rating and language. Measures need to be undertaken to limit alcohol imagery in Indian films to protect the health of young people, and to monitor alcohol imagery in other social media platforms in future