India continues to lead in reducing impact of onscreen tobacco use. On May 31, 2023, India’s government closed the loophole for streaming content, making India the first country in the world to issue regulations related to and designed to curb tobacco use in movies and other content that appears on streaming services.
The government, legislators, the World Health Organization and public health advocates have been working to address the problem of smoking and other tobacco use in motion pictures since at least 2003. (Onscreen smoking causes youth to smoke (WHO 2016, Surgeon General 2014, Surgeon General 2012, National Cancer Institute 2008].) In 2005, India’s Ministry of Health and Family Welfare issues rules designed to reduce the presence and impact of onscreen tobacco use in films in India. This action started a debate (more details) that led India to enact the world’s first rules designed to reduce the impact of smoking in films and in television programs:
- Display, before the film and at the intermission, a 20 second anti-tobacco declaimer and a 30 second each anti-tobacco advertisement produced by the MoHFW (examples below)
- Display anti-tobacco static health warning at the bottom of screen during any display of a tobacco product (example above)
- Provide a strong editorial justification for any tobacco use to the Central Board of Film Certification
Despite the fact that the CBFC had still not issued rules for implementing the requirement that any onscreen tobacco use have “strong editorial justification” and early concerns about compliance, the rules had a substantial impact on the presence of smoking in movies. Before implementation of the rules, the number of tobacco incidents per film was increasing by a factor of 1.1/year (95% CI 1.0 to 1.2, p=0.002). But, beginning in 2013, after the rules were in effect, the number of incidents per film started falling significantly by a factor of 0.7/year (95% CI 0.6 to 0.9; p=0.012) compared with the previous increasing trend. The percentage of youth-rated (U and UA) films with any tobacco incidents also declined from a peak of 76% in 2012 to 35% in 2017. This happened even though percentage of films complying with the rules (audio-visual disclaimers, health spots, static warnings) did not change significantly from 2012 to 2017. So, while there is still room for improvement in enforcing India’s 2012 rules, they were followed by a reduction in tobacco depictions in Bollywood films.
Because streaming did not exist when the rules were being debated and first implemented, streaming video was not included in rules. A study of ten online series on streaming platforms popular among youth and young adults (age 15-24 years) in New Delhi showed high levels of tobacco use and failure to voluntarily comply with the Indian Rules for theatrical films and television programs. The study included 10 series on Netflix and Amazon Prime Video; seven were rated age 16+, two were 18+ and one was 13+. The median number of tobacco incidents per episode in foreign productions was as follows: Amazon’s ‘The Marvellous Mrs Maisel’ (87.5, IQR 62.0-116.0) and Netflix’s ‘The Crown’ (29.0, 18.0-36.0) were higher than Indian productions: Netflix’s ‘Sacred Games’ (9.0, 0.5-14.5) and Amazon’s ‘Mirzapur’ (7.0, 4.0-11.0) (p=0.84). Tobacco incidents per hour ranged from 0 (Bodyguard, Riverdale, 13 Reasons Why) to 106.1 (The Marvellous Mrs Maisel).
Here is the exact language of the new rule:
11. Health spots, message and disclaimer in online curated contents of tobacco products by the publisher. (1) Every publisher of online curated contents [the streaming service] displaying tobacco products or their use shall.
a. display anti-tobacco health spots, of minimum thirty seconds duration each at the beginning and middle of the programme;
b. display anti-tobacco health warning as a prominent static message at the bottom of the screen during the period of display of the tobacco products or their use in the programme;
c. display an audio-visual disclaimer on the ill-effects of tobacco use, of minimum twenty seconds duration each, in the beginning and middle of the programme;
2. The health spots, message and disclaimer shall be made available to the publisher of the online curated content on the website “mohfw.gov.in” or “ntcp.mohfw.gov.in”
3. The anti-tobacco health warning message as specified in clause(b) of sub-rule (1) shall be legible and readable, with font in black colour on white background and with the warnings “Tobacco causes cancer” or “Tobacco kills”.
4. The anti-tobacco health warning message, health spot and audio-visual disclaimer, shall be in the same language as used in the online curated content.
5. The display of tobacco products or their use in online curated content shall not extend to –
a. display of the brands of cigarettes or other tobacco products or any form of tobacco product placement;
b. display of tobacco products or their use in promotional materials.
Explanation. For the purposes of this rule “programme” means online curated audio-visual content.
(6) If the publisher of online curated content fails to comply with the provisions of sub-rules (1) to (5), an interministerial committee consisting of representatives from the Ministry of Health and Family Welfare, Ministry of Information and Broadcasting and Ministry of Electronics and Information Technology, shall take action suo motu or on a complaint, and after identifying the publisher of online curated content, issue notice giving reasonable opportunity to explain such failure and make appropriate modification in the content.
Explanation.- For the purpose of this rule,-
a. the expression “online curated content” means, any curated catalogue of audio-visual content, other than news and current affairs content, which is owned by, licensed to, or contracted to be transmitted by a publisher of online curated content, and made available on demand, including but not limited through subscription, over the internet or computer networks, and includes films, audio visual programmes, documentaries, television programmes, serials, series, podcasts and other such content;
b. the expression “publisher of online curated content” means, a publisher who, performing a significant role in determining the online curated content being made available, makes available to users a computer resource that enables such users to access online curated content over the internet or computer networks, and such other entity called by whatever name, which is functionally similar to publishers of online curated content but does not include any individual or user who is not transmitting online curated content in the course of systematic business, professional or commercial activity.
As noted above, the original rule, which applies to theatrical movies and television programs, that have depictions of tobacco use must display health warnings about the harms of tobacco at the start and middle of the movie or program, and throughout the scene depicting tobacco use. The current laws also ban any form of tobacco product placement in films and TV programs. The new rules extend these provisions to online streaming services, thus cutting off a key access point for Big Tobacco to young people. (The new rules do not include a provision requiring “strong editorial justification” for any tobacco use.)
India’s law sets a global precedent that has the potential to rein in smoking on content seen around the globe on the ever growing streaming services. Since much of the content on streaming services is not limited by traditional geographic boundaries, it is important that multiple countries, especially the US, where much of this content originates, get involved.
On June 2, Reuters reported that, “Streaming giants Netflix, Amazon and Disney on Friday privately discussed a possible legal challenge and other ways to stall India’s new tobacco warning rules, amid fears they will need to edit millions of hours of existing web content.” (Times of India reported the story based on Reuters.) As in the fight over the rules for theatrical films and television, they looked to the Ministry on Information and Broadcast for support inside the government. Given that MI&B had signed off on the theatrical rules, they hopefully will not support the US streaming companies. The Supreme Court supported the theatrical and television rules through an interim order in 2009, which it finalized in 2012.
The claim that the streaming companies will have to “edit millions of hours” of content likely overstates the problem, a common industry tactic. First, the rules require no change to any tobacco-free program, so those would be untouched. Second, anti-smoking spots and disclaimers occur outside the time of the program and the anti-smoking health warning is static superimposed on the existing images. There is no need to “edit” any content.
The streaming companies also ignore the fact that Hollywood often edits its own films when releasing them outside the US to profit from certain markets or to revise cultural references, so accommodating India’s new rules fits within existing media industry practices.
It is especially surprising that Disney is joining with this effort because Disney’s policy on smoking in their movies has dealt with these issues since 2007. Disney’s current policy (as of June 3, 2023) says:
The Walt Disney Company actively limits the depiction of smoking in movies marketed to youth.Our practices currently include the following:
- Disney has determined not to depict cigarette smoking in movies produced by it after 2015 (2007 in the case of Disney branded movies) and distributed under the Disney, Pixar, Marvel or Lucasfilm labels, that are rated G, PG or PG-13, except for scenes that: (1) depict a historical figure who may have smoked at the time of his or her life; or (2) portray cigarette smoking in an unfavorable light or emphasize the negative consequences of smoking. [These exceptions have been endorsed by the Smokefree Movies project since 2002 as well as the World Health Organization and the implementing guidelines for WHO Framework Convention on Tobacco Control Article 13.]
- Disney policy prohibits product placement or promotion deals with respect to tobacco products for any movie it produces and Disney includes a statement to this effect on any movie in which tobacco products are depicted for which Disney is the sole or lead producer.
- In an effort to increase consumer awareness, Disney will label physical packaging and digital offerings of youth-rated films that contain tobacco depictions.
- Disney will work with theater owners to encourage the exhibition of an anti-smoking public service announcement before the theatrical exhibition of any of its movies rated G, PG or PG-13 that depicts cigarette smoking.
So, what India is requiring is consistent with current Disney policy. What’s the problem?
India’s action raises questions for what will happen in the United States:
Will the streaming companies reduce tobacco use in versions distributed in India while maintaining high levels of smoking and other tobacco use in the US streaming shows popular with youth and young adults or will India’s actions benefit youth in the US (and elsewhere around the world) by stimulating the multinational streaming companies to stop promoting tobacco?
More important, how will health advocates in the United States press the streaming companies to comply with India’s rules and use that experience to protect American youth?
The new law takes effect in 90 days.
Additional resources: Our Research on Tobacco in Media in India
Arora M, Nazar GP, Chugh A, Rawal T, Shrivastava S, Sinha P, Munish VG, Tullu FT, Schotte K, Polansky JR, Glantz S. Tob Control. 2021 Jan;30(1):42-48. doi: 10.1136/tobaccocontrol-2019-055360. Epub 2020 Apr 9.
BACKGROUND: India implemented tobacco-free film and TV rules (Rules) to protect adolescents and young adults from tobacco exposure.
OBJECTIVE: To assess tobacco imagery in online series popular among adolescents and young adults.
METHODS: Ten popular online series on streaming platforms were identified after discussions with participants (aged 15-24 years) in New Delhi, and content-coded for tobacco imagery following the Breathe California protocol. Incidents of tobacco use and brand appearances in each series episode were counted, and compliance with Indian Rules was recorded.
RESULTS: 188 episodes across 10 series on Netflix and Amazon Prime Video were coded. Seven series were rated age 16+, two were 18+ and one was 13+. The median number of tobacco incidents per episode in foreign productions was as follows: Amazon’s ‘The Marvellous Mrs Maisel’ (87.5, IQR 62.0-116.0) and Netflix’s ‘The Crown’ (29.0, 18.0-36.0) were higher than Indian productions: Netflix’s ‘Sacred Games’ (9.0, 0.5-14.5) and Amazon’s ‘Mirzapur’ (7.0, 4.0-11.0) (p=0.84). Tobacco incidents per hour ranged from 0 (Bodyguard, Riverdale, 13 Reasons Why) to 106.1 (The Marvellous Mrs Maisel). Seven of 10 series had tobacco imagery and none were compliant with the Rules.
CONCLUSION: Contrary to Section 5 of India’s Cigarettes and Other Tobacco Products Act, its Rules are not being complied with by the streaming platforms. US-produced streaming media contains more tobacco incidents than Indian-produced media. There is an urgent need for better enforcement of existing Rules on streaming platforms in India, and modernisation of the WHO Framework Convention on Tobacco Control, Article 13 guidelines to account for new streaming platforms to protect youth from tobacco imagery globally.
Nazar GP, Arora M, Sharma N, Shrivastava S, Rawal T, Chugh A, Sinha P, Munish VG, Tullu FT, Schotte K, Polansky JR, Glantz S. Tob Control. 2023 Mar;32(2):218-224. doi: 10.1136/tobaccocontrol-2021-056629. Epub 2021 Jul 26.
BACKGROUND: India’s tobacco-free film and TV rules were implemented from 2012. To assess the effect of the rules, we studied tobacco depictions in top-grossing Bollywood films released between 2006 and 2017 and rule compliance after 2012.
METHODS: Tobacco incidents and brand appearances were coded in 240 top-grossing Bollywood films (2006-2017) using the Breathe California method. Trends in number of tobacco incidents per film per year were studied before and after implementation of the rules using Poisson regression analysis. Compliance with rules over the years was studied using Pearson product-moment correlations.
RESULTS: Forty-five films were U-rated (all ages), 162 were UA-rated (below age 12 years must be adult-accompanied), and 33 were A-rated (age 18+ years only). Before implementation of the rules, the number of tobacco incidents per film was increasing by a factor of 1.1/year (95% CI 1.0 to 1.2, p=0.002). However, beginning year 2013, the number of incidents per film started falling significantly by a factor of 0.7/year (95% CI 0.6 to 0.9; p=0.012) compared with the previous increasing trend. The percentage of youth-rated (U and UA) films with any tobacco incidents also declined from a peak of 76% in 2012 to 35% in 2017. The percentage of films complying with the rules (audio-visual disclaimers, health spots, static warnings) did not change significantly from 2012 to 2017.
CONCLUSION: India’s 2012 rules were followed by a reduction in tobacco depictions in Bollywood films. Enhanced monitoring of compliance is needed to ensure the continued effectiveness of the rules.
Yadav A, Glantz SA. BMJ Glob Health. 2021 Jan;6(1):e003639. doi: 10.1136/bmjgh-2020-003639.
INTRODUCTION: Tobacco imagery in films and television increased in India after it ended conventional tobacco advertising in 2004. The Ministry of Health and Family Welfare (MoHFW) introduced rules to eliminate this tobacco imagery in 2005 which took effect in amended form in 2012. This study presents the enablers and barriers in development and implementation of the regulations to curb tobacco imagery in films and television in India.
METHOD: We reviewed legislation, evolving regulations, parliamentary questions, judicial decisions, Bollywood trade publications and relevant news articles from 2003 to 2019 and interviewed key informants.
RESULTS: Based on the WHO reports and civil society demands, the MoHFW issued a complete ban on tobacco imagery in movies and television programmes in 2005. The Ministry of Information and Broadcasting (MoIB) joined the film industry in opposing the rules. A filmmaker challenged the rules in court, which ruled that they violated constitutional freedoms. On appeal by MoHFW, the Supreme Court allowed the rules to take effect. Continuing opposition by MoIB and the film industry weakened the rules and delayed implementation until 2012. As of 2020, rather than a ban, all films with tobacco imagery require strong editorial justification, 100 s of antitobacco messages produced by the MoHFW, and a static health warning at the bottom of screen during tobacco imagery display. In 2015, less than 48% of movies had tobacco imagery compared with 89% in 2005.
CONCLUSIONS: Although, not a ban, MoHFW, supported by local advocates and WHO, issued regulations that resulted in a substantial drop in on-screen tobacco imagery and increased exposure to antitobacco messages. India’s experience informs WHO Framework Convention on Tobacco Control parties as they develop and implement policies to curb tobacco imagery in entertainment media.
The Development and Implementation of Tobacco-Free Movie Rules In India. Yadav, A., & Glantz, S. A. (2020) UCSF: Center for Tobacco Control Research and Education. University of California eScholarship Collection: https://escholarship.org/uc/item/75j1b2cg.
Executive Summary
- The Indian film industry releases the largest number of movies in the world, 1500-2000 movies in Hindi and other regional languages, which are watched by more than 2 billion Indian moviegoers and millions more worldwide.
- The tobacco industry has been using movies to promote their products for over a century.
- In India, the Cinematograph Act, 1952 and Cable Television Networks Amendment Act, 1994 nominally provide for regulation tobacco in of film and TV, but the Ministry of Information and Broadcast (MoIB), the nodal ministry, has not considered tobacco use.
- The Cigarettes and Other Tobacco Products Act, 2003 (COPTA), enforced by the Ministry of Health and Family Welfare (MoHFW), prohibited direct and indirect advertisement of tobacco products.
- WHO supported reports in 2003 and 2005 reported that the fraction of movies with tobacco use (mostly smoking cigarettes) increased from 76% from 1991-2002 to 89% in 2004-2005, with the fraction of films with brand placement tripling from 16% to 46%.
- Over 90% of the brand appearances in 2004-2005 were Phillip Morris (which was launching its Marlboro in Indian market at that time) or ITC (Wills and Gold Flake).
- The WHO reports also opened a wider deliberation on tobacco imagery in films and television, including in Parliament.
- Members of Parliament raised formal questions on the issue submitted to the Government (314 questions during 2000-2019) with 47% against presentation of tobacco in movies and supporting effective regulation of film and TV content, 14% were negative, and the remaining 39% neutral.
- Many NGOs including Cancer Patients Aid Association (CPAA) , Burning Brain Society and HRIDAY advocated for tobacco free films and television during 2003-2005.
- In 2005, based on the evidence from two WHO reports and support from NGOs, Health Minister Anbumani Ramadoss introduced a complete ban in tobacco use in all movies and TV under COPTA to prevent indirect tobacco advertisement and minors’ exposure to tobacco presentation.
- Ramadoss issued the rules without consulting MoIB.
- The film industry called the regulations “dreadful” and “curtailing artistic freedom” and the Central Board of Film Certification (CBFC) , the statutory body under MoIB charged with reviewing, certifying for public exhibiting and rating films termed MoHFW rules “a decision taken in haste and very unaesthetic in taste.”
- Later in 2005, filmmaker Mahesh Bhatt filed litigation alleging that the rules violated fundamental freedoms to speech and expression, and trade.
- The MoIB sided with Bollywood against the MoHFW in the Delhi High Court.
- As the matter continued in the court, MoIB and CBFC supported and acted on behalf of film industry in negotiating with MoHFW on the different versions of the regulations.
- In 2006, the Prime Minister’s Office intervened and constituted a Committee of Secretaries that negotiated a compromise between MoHFW and MoIB that allowed tobacco imagery in new Indian films with “strong editorial justification,” with a disclaimer by the actor using tobacco before the film and adult certification (A rating).
- MoHFW issued the revised regulations based on these compromises in October 2006.
- In 2009, Delhi High Court ruled that the regulations violated constitutional freedoms of speech and trade.
- MoHFW appealed against this Delhi High Court decision before the Supreme Court which allowed the rules to go into effect.
- However, the rules could not be implemented due to resistance from MoIB and the film industry, which called the regulations requiring adult certification impractical.
- In 2011, MoHFW amended the rules to require U/A certification (parental guidance for children below the age of 12 years) and scrolling warnings displayed during on screen tobacco presentation.
- The film industry further demanded to drop any ratings and the scrolling health warnings.
- In 2012 MoHFW dropped ratings based on tobacco presentation and prescribed static on screen warnings during any tobacco presentation during the film.
- MoIB, CBFC, filmmakers, actors, and film industry professionals associations continued to challenge the regulations, some of them played for both sides.
- In 2012, 7 years after MoHFW issued the initial regulations and 9 years after COPTA passed, India implemented a comprehensive set of regulation to restrict tobacco imagery in films, requiring all films with tobacco imagery to:
- Provide a strong editorial justification to the CBFC
- Display, before the film and at the intermission, a 20 second anti-tobacco declaimer and a 30 second each anti-tobacco advertisement produced by the MoHFW
- Display anti-tobacco static health warning at the bottom of screen during any display of a tobacco product
- As of 2020, even after several compromises and modifications by MoHFW, CBFC still had not integrated “strong editorial justification” for tobacco use into its procedures for certifying films.
- No age-based rating for tobacco presentation meant that minors are able to watch such movies and TV programmes.
- WHO, NGOs, parliamentarians, filmmakers and some actors were key enablers in the MoHFW’s development and implementation of India’s tobacco-free movie and TV rules.
- NGOs including CPAA, HRIDAY, Voluntary Health Association, Salaam Bombay Foundation, Tamil Nadu People’s Forum for Tobacco Control, Kerala Voluntary Health Services championed the regulations and along with state health departments monitored compliance and reported violations by filmmakers.
- The regulations were followed by a 50% decline in the fraction of films presenting tobacco, from 89% in 2004-05 to 48% in 2015.
- Among the smoking films 27% fully complied with all three aspects of the rules while 99% complied with at least one.
- The cumulate exposure of the 100 seconds of anti-tobacco advertising in all films with tobacco yielded about 25 hours of anti-tobacco advertising per year in theaters in 2015.
- It is unlikely that these successes could have been achieved through voluntary action by the film industry, including production of “pleasant and aesthetic” anti-tobacco disclaimers or advertisements.
- Freedom of speech and expression, and trade remain the most common argument and self-regulation the most common solution offered by the industry.
- Although the tobacco industry is the primary beneficiary of depiction of tobacco use in movies, it did not play a direct or public role in opposing the MoHFW movie regulations.
- Adding age-based rating of films and TV is essential to prevent minors’ exposure to tobacco in these media.
- MoHFW should expand the pool of disclaimers, anti-tobacco advertisements and messages that are region specific in local language and rotated at regular intervals at least every six months.
- The CBFC still needs to implement transparent procedures for assessing the “editorial justification” for any tobacco use in films, and such films should be rated for adult audiences (A rating), as the film industry originally suggested.
- Tobacco presentation on internet based television and other streaming platforms remains out of the current regulations and presents a huge challenge of exposure to minors.
The Ministry of Health’s Effort to Regulate Tobacco Use in Movies in India, 2005-6. Polansky, J., & Glantz, S. A. (2006). UCSF: Center for Tobacco Control Research and Education. University of California eScholarship Repository: https://escholarship.org/uc/item/76v5f4b5
- Bans on traditional tobacco advertising highlight the strongly promotional role of tobacco imagery in films and video programs. On World No-Tobacco Day 2005, less than a year after India implemented its universal ban on tobacco advertising, its Minister of Health and Family Welfare announced a ban on tobacco imagery in the nation’s films and broadcast programs.
- Opposition, including from the Ministry of Information & Broadcasting, which quickly announced the proposed ban was unworkable and advocated entertainment industry self-regulation, succeeded in delaying limits for on-screen tobacco for more than a year despite NGO advocacy efforts.
- Elements of a policy compromise disclosed in June 2006 risk undermining the Ministry of Health’s intention: permanently to reduce adolescent exposure to tobacco imagery of major benefit the tobacco industry, particularly as Philip Morris International enters the Indian market to expand the market for premium cigarettes and battle for share British American Tobacco’s Indian affiliate, ITC.
- Recommendations for an effective policy in India’s constitutional and policy environment include:
- In place of the subjective terminology favored by the tobacco industry and its film industry proxies around the world, a categorical standard of zero tobacco imagery except for (a) portrayals of actual historical figures documented to have used tobacco and (b) the unambiguous depiction of the dire health consequences of tobacco use, with no brand display in any case;
- An independent review committee, with no conflicts of interest, mandated to safeguard the public health by transparently applying the policy standards to the relatively few media productions that propose to include tobacco imagery despite the new policy;
- Identical treatment for films imported from overseas and Indian films released before the policy, namely strong anti-tobacco spots vetted by experts in tobacco prevention showing before and after the film or program in any and all distribution channels;
- Public certification, under penalty of perjury, by credited producers of any Indian film or video program with tobacco imagery released after the policy and all imported films and video programs with tobacco imagery that no one associated with the production accepted any consideration to include tobacco.
Our Other Research about India
Yadav A, Glantz SA. Addict Behav. 2022 Jul;130:107306. doi: 10.1016/j.addbeh.2022.107306. Epub 2022 Mar 14.
Bans on tobacco advertising are important for reducing tobacco-caused disease. Previously secret internal tobacco industry documents and organizational and newspaper websites related to tobacco control efforts in India during 1990s were analyzed. The Ministry of Health and Family Welfare, World Health Organization, Indian Council of Medical Research, and civil society played important roles in pushing for tobacco control legislation beginning in the 1980s. Guided by transnational tobacco companies, especially British American Tobacco, Philip Morris International, and RJ Reynolds, Indian cigarette companies formed the Tobacco Institute of India (TII). Following the industry’s global strategy, TII proposed voluntary advertising codes, used diplomatic channels and high level political and judicial lobbying, and allied with other industry, sports and trade groups to delay legislation for ten years. TII argued for the social and economic importance of tobacco and that laws were unnecessary, unconstitutional, and would hurt the economy. These early global strategies were continuing in 2022 to delay and evade legislative efforts to ban tobacco advertising. Understanding these strategies can inform public health efforts to counter industry efforts to thwart the WHO Framework Convention on Tobacco Control in 2022 not only in India, where the Ministry of Health and Family Welfare has proposed strengthening India’s tobacco control law, but globally.
Sankaran S, Hiilamo H, Glantz SA. Tob Control. 2015 Nov;24(6):547-55. doi: 0.1136/tobaccocontrol-2013-051536. Epub 2014 Jun 20.
OBJECTIVES: To understand the competition between and among tobacco companies and health groups that led to graphical health warning labels (GHWL) on all tobacco products in India.
METHODS: Analysis of internal tobacco industry documents in the Legacy Tobacco Document Library, documents obtained through India’s Right to Information Act, and news reports.
RESULTS: Implementation of GHWLs in India reflects a complex interplay between the government and the cigarette and bidi industries, who have shared as well as conflicting interests. Joint lobbying by national-level tobacco companies (that are foreign subsidiaries of multinationals) and local producers of other forms of tobacco blocked GHWLs for decades and delayed the implementation of effective GHWLs after they were mandated in 2007. Tobacco control activists used public interest lawsuits and the Right to Information Act to win government implementation of GHWLs on cigarette, bidi and smokeless tobacco packs in May 2009 and rotating GHWLs in December 2011.
CONCLUSIONS: GHWLs in India illustrate how the presence of bidis and cigarettes in the same market creates a complex regulatory environment. The government imposing tobacco control on multinational cigarette companies led to the enforcement of regulation on local forms of tobacco. As other developing
countries with high rates of alternate forms of tobacco use establish and enforce GHWL laws, the tobacco control advocacy community can use pressure on the multinational cigarette industry as an indirect tool to force implementation of regulations on other forms of tobacco.
Basu S, Glantz S, Bitton A, Millett C. PLoS Med. 2013;10(7):e1001480. doi: 0.1371/journal.pmed.1001480. Epub 2013 Jul 9.
BACKGROUND: We simulated tobacco control and pharmacological strategies for preventing cardiovascular deaths in India, the country that is expected to experience more cardiovascular deaths than any other over the next decade.
METHODS AND FINDINGS: A microsimulation model was developed to quantify the differential effects of various tobacco control measures and pharmacological therapies on myocardial infarction and stroke deaths stratified by age, gender, and urban/rural status for 2013 to 2022. The model incorporated population-representative data from India on multiple risk factors that affect myocardial infarction and stroke mortality, including hypertension, hyperlipidemia, diabetes, coronary heart disease, and cerebrovascular disease. We also included data from India on cigarette smoking, bidi smoking, chewing
tobacco, and secondhand smoke. According to the model’s results, smoke-free legislation and tobacco taxation would likely be the most effective strategy among a menu of tobacco control strategies including, as well, brief cessation advice by health care providers, mass media campaigns, and an advertising ban) for reducing myocardial infarction and stroke deaths over the next decade, while cessation advice would be expected to be the least effective strategy at the population level. In combination, these tobacco control interventions could avert 25% of myocardial infarctions and strokes (95% CI: 17%-34%) if the effects of the interventions are additive. These effects are substantially larger than would be achieved through aspirin, antihypertensive, and statin therapy under most scenarios, because of limited treatment access and adherence; nevertheless, the impacts of tobacco control policies and pharmacological interventions appear to be markedly synergistic, averting up to one-third of deaths from myocardial infarction and stroke among 20- to 79-y-olds over the next 10 y. Pharmacological
therapies could also be considerably more potent with further health system improvements.
CONCLUSIONS: Smoke-free laws and substantially increased tobacco taxation appear to be markedly potent population measures to avert future cardiovascular deaths in India. Despite the rise in co-morbid cardiovascular disease risk factors like hyperlipidemia and hypertension in low- and middle-income countries, tobacco control is likely to remain a highly effective strategy to reduce cardiovascular deaths.
Association between smoke-free workplace and second-hand smoke exposure at home in India.
Lee JT, Agrawal S, Basu S, Glantz SA, Millett C. Tob Control. 2014 Jul;23(4):308-12. doi: 10.1136/tobaccocontrol-2012-050817. Epub 2013 Mar 23.
BACKGROUND: The implementation of comprehensive smoke-free laws has been associated with reductions in second-hand smoke exposure at home in several high income countries. There is little information on whether these benefits extend to low income and middle income countries with a growing tobacco-related disease burden such as India.
METHODS: State and individual-level analysis of cross-sectional data from the Global Adult Tobacco Survey India, 2009/2010. Associations between working in a smoke-free indoor environment and living in a smoke-free home were examined using correlation at the state level, and multivariate logistic regression at the individual level.
RESULTS: The percentage of respondents employed indoors (outside the home) working in smoke-free environments who lived in a smoke-free home was 64.0% compared with 41.7% of those who worked where smoking occurred. Indian states with higher proportions of smoke-free workplaces had higher proportions of smoke-free homes (rs=0.54, p<0.005). In the individual-level analysis, working in a smoke-free workplace was associated with a significantly higher likelihood of living in a smoke-free home (adjusted OR=2.07; 95% CI 1.64 to 2.52) after adjustment for potential confounders.
CONCLUSIONS: Implementation of smoke-free legislation in India was associated with a higher proportion of adults reporting a smoke-free home. These findings further strengthen the case for accelerated implementation of Article 8 of the Framework Convention on Tobacco Control (FCTC) in low and middle income countries.
Nazar GP, Lee JT, Glantz SA, Arora M, Pearce N, Millett C. Prev Med. 2014 Feb;59:47-53.
OBJECTIVE: To assess whether being employed in a smoke-free workplace is associated with living in a smoke-free home in 15 low and middle income countries (LMICs).
METHODS: Country-specific individual level analyses of cross-sectional Global Adult Tobacco Survey data (2008-2011) from 15 LMICs was conducted using multiple logistic regression. The dependent variable was living in a smoke-free home; the independent variable was being employed in a smoke-free workplace. Analyses were adjusted for age, gender, residence, region, education, occupation, current smoking, current smokeless tobacco use and number of household members. Individual country results were combined in a random effects meta-analysis.
RESULTS: In each country, the percentage of participants employed in a smoke-free workplace who reported living in a smoke-free home was higher than those employed in a workplace not smoke-free. The adjusted odds ratios (AORs) of living in a smoke-free home among participants employed in a smoke-free workplace (vs. those employed where smoking occurred) were statistically significant in 13 of the 15 countries, ranging from 1.12 [95% CI 0.79-1.58] in Uruguay to 2.29 [1.37-3.83] in China. The pooled AOR was 1.61 [1.46-1.79].
CONCLUSION: In LMICs, employment in a smoke-free workplace is associated with living in a smoke-free home. Accelerated implementation of comprehensive smoke-free policies is likely to result in substantial population health benefits in these settings.
It is time to make smokefree environments work in India.
John RM, Glantz SA. Indian J Med Res. 2007 May;125(5):599-603.
Smokeless tobacco industry’s brand stretching in India.
Yadav A, Ling P, Glantz S. Tob Control. 2020 Dec;29(e1):e147-e149. doi: 0.1136/tobaccocontrol-2019-055382. Epub 2020 Jan 9.
Stanton Glantz blog 