Editorial

In Indian early one in two men and one in five women use tobacco causing eight to nine lakh adult deaths a year [1,2]. Government of India enacted the ‘Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, in 2003 (hereafter referred to as COTPA). The major provisions of COTPA include;

1. Prohibition of smoking in public places;
2. Prohibition of direct and indirect advertisement of tobacco products;
3. Prohibition on sale of tobacco products to and by minors, and within 100 yards of educational institutions; and
4. Display of pictorial health warnings on tobacco products [3].

However, after a decade of enactment the compliance remains sub-optimal [4]. There is dearth of literature on how COTPA is being implemented and how it could be improved [5]. This paper analyzes COTPA implementation in Karnataka, India and hypothesizes it's effectiveness as a Nicotine displacement therapy an effective alternative or supplement to nicotine replacement therapy (NRT).

We developed a case study of COTPA implementation in Karnataka to understand the role of various government agencies by using following data ranging from January 2011 to June 2014: Government orders and circulars for COTPA issued by state departments, monthly crime review reports for COTPA by police, monthly education reports by education department, data on COTPA enforcement by district anti-tobacco cells and media reports related to tobacco in Karnataka.

Under the chairmanship of District collector departments involved in implementing COTPA were advised to increase awareness of the law through multi stakeholder meetings at districts and police department spearheaded by the Superintendent of police took a lead in implementation and co-ordination with other departments. COTPA authorizes 21 government agencies however, in Karnataka, five government agencies - health, police, education, transport and urban development played role in implementation. Using sale of tobacco products to vendors as a surrogate to analyze the effectiveness of implementation revealed sale of tobacco worth Rs. 1,57,263 INR in September 2014 plummeted to Rs. 55,775 INR to the same shopkeeper in early October 2014. This corresponded with the period of intensive awareness and enforcement drives in the district.

For implementation of law to be successful, two aspects need to be addressed; Awareness and Enforcement. Often society awakens to a new law only owing to enforcement; although not desirable, this is inevitable owing to poor mechanisms to create awareness of the law. In our views effective COTPA implementation will result in reduction of tobacco consumption due to:

1. Nicotine displacement therapy by COTPA enforcement - We believe NRT serves as a nicotine continuation therapy since it does not replace the addictive substance as suggested by the term. Especially in low and middle income countries where access to NRT is limited we need to consider alternatives. Nicotine usage releases adrenal hormones which creates renewed energy, confidence and a sense of instant short term wellbeing in smokers. The authors observe that COTPA implementation creates a similar scenario, owing to fear of enforcement. The same has been confirmed by violators in public places to enforcing authorities leading to reduced consumption among these violators.
2. Increased awareness of the law improves compliance and aids in quitting - the authors observe that proper mechanisms to create awareness of the law coupled with effective enforcement helps in improved compliance to the law. A Smoke free public place incentivizes quitting among smokers and helps reduce nicotine dependence.
3. De-normalization of smoking in public places - Effective implementation through enforcement mechanisms were critical in de-normalizing smoking in public evident with behavior trends observed among youngsters dissociating coolness quotient associated with smoking. This was a result of COTPA violations being seen as a petty crime.
4. Effective warnings and lack of advertisement for products - Prohibition of advertisement is a strong deterrent to indict new consumers especially youth. Effective implementation of sections of COTPA through has impacted in reduced sales of tobacco products in vicinity of schools, thus discouraging youth further. Violation of pictorial warnings was found to be especially pronounced in beedi sector which when tackled by effective implementation lead to increased awareness among users and compliance among manufacturers.
5. Earned media as a conduit for awareness of law - Media campaigns planned by government and earned media have played an important role to improve compliance among consumers, manufacturers and vendors and knowledge about rights of citizens who are potential passive smokers.

Learning from Karnataka

1. Policy making process should consider issues of role clarity for enforcement and implementation upfront in order to avoid gap between policy on paper and its implementation in practice.
2. The departments implemented COTPA when they effectively institutionalized it within their own departmental structure and functions. There was a direct correlation between the extent of institutionalisation and implementation.
3. Ensuring a reviewable reporting system was pivotal in driving COTPA implementation thereby increasing accountability and sustainability [4].
4. Mere knowledge of regulations might not translate into implementation at local level and often requires tremendous effort and motivation from government and non government partners [6].