They were told that the researcher may follow some pre-determined interview stems while asking about tobacco use, but the participants are free to talk about anything they felt relevant to the topic of the research. The respondents were informed that for the purpose of the rigour of the research, their interviews would be audio-recorded but their responses would be kept confidential and none of the personal identifiers will be ever made public.
Having explained the process, if they were keen to participate, they were recruited after they provided written informed consent.
A similar brief was also given during the two focus group discussions and consenting was carried out. The researchers conducted in-depth interviews, focus group discussions and participant observations.
Basic socio-demographic data were collected in order to describe the sample recruited for the study. Interviews and focus groups were audio-recorded and later transcribed verbatim.
Trained young researchers conducted the in-depth interviews on the university campus; this ensured free and uninhibited communication between the respondents and interviewers. Participants were given the choice of a private office or a more informal setting such as the college grounds as deemed comfortable by the interviewee. As the research progressed, additional areas that came to light in previous interviews were explored further as advocated in qualitative research.
The open-ended interview allowed the young people to speak about topics that they considered important with respect to their tobacco habits. Researchers moderated the focused groups using structured guidelines. The focus group interviews explored with more open-ended questions. Two participant observations were conducted in the same university campus. All observations were kept anonymous and confidential. The participant observations were done in the food kiosks located right outside the main gate of the campus where students come for eating; these food kiosks also sell tobacco products to the students.
The policy analysis section is based on publicly available secondary data covering the time frame from to present. In-depth interviews and focus group discussions were transcribed verbatim. All data from interviews and focus groups were organised using NVivo version 9. Data collection and data analysis were conducted simultaneously. All interviews were coded by two independent researchers. Data analysis was conducted following principles of thematic analysis as suggested by Braun and Clark [ 29 ].
The inductive coding consisted of reading all transcripts and participant observation notes. Patterns from the data were generated and then organised as per similar attribute and used for creating themes.
Similar themes were then compared and contrasted to create global themes. Public policy analysis is defined as the study of how, why and to what effect governments pursue particular courses of action and inaction [ 30 ]. Health policy contexts are often highly political and debated. Health policy analysis is thus a social, as well as a political activity [ 31 ].
According to the trajectory of modern health policy analysis, policy reform is a political process, which needs to take into consideration the reasons why policy outcomes failed to emerge originally.
A policy triangle framework of analysis developed by Walt and Gilson [ 32 ] is followed in this paper. This was specifically developed for the health sector and found its use in a wide array of health issues in different countries, especially LMICs.
The current research juxtaposed and critically examined the qualitative findings of the tobacco use in young people alongside the findings of the policy analysis. A total of 30 participants took part in the in-depth interviewing and focus group discussions. The baseline demographic characteristics of the study respondents are presented in Table 1.
The youngest participant was 18 years old and the oldest was 22 years of age; one-third of the respondents were women. Thematic analysis of the qualitative data generated four global themes, namely, why people start smoking? Knowledge of ill effects of tobacco , perceptions about tobacco use and quitting and views on tobacco control measures of the country.
Smoking was largely considered a social behaviour by the young adults in this study and the factors that influenced smoking initiation were a Peer influence and social desirability b Curiosity about experimenting with smoking c Identifying smoking as a method of stress relief. These factors were reported as influencers by the youth who are smokers, as well as the ones who said that they do not smoke.
Many of the participants pointed out the role of peers in tobacco initiation in youth and encouraging young people to smoke their first cigarette.
Social desirability to feel more inclusive in a group and smoking to look smart enough to belong to that group was reported as a major factor in smoking initiation. We felt that if we had it cigarettes , we can be part of that group… male, 18, smokes occasionally.
To be honest, the first time I smoked, it was in front of a girl. She was a chain smoker and she was taunting me that I was a kid and not supposed to smoke and that I was coughing from the smoke.
So, I felt humiliated. Some of the students reported that they tried their first cigarette to understand why their father smokes regularly. Among the other reasons was common curiosity about tobacco, trying a cigarette as an experimental thing, which later formed a habit, trying the cigarette as it was fun to try something new. This might sound a little stupid, but I wanted to know why my father smoked. That has made me start it male, 19, smokes sometimes. Stress and subsequent relief from stress after smoking was identified as an influencer.
Stress was reported to be of facing examinations, family problems; in addition, associated symptoms of stress as headache, sleeplessness, feeling depressed, etc. Many of the young adults reported to be resorting to smoking as a relief from their stress, depression and tensions of personal lives.
I smoke because I get relieved after sitting in class for so many hours and then after going for the coaching centre male, 18, smokes. Overall, most of the respondents had knowledge about cancer being caused from tobacco and smoking. Two distinct themes came out where one group strongly believed the ill effects to be true regardless of whether they smoked or not; the others were not sure of the ill effects.
This group of respondents could identify and believe cancer in most of the cases and lung diseases, asthma, other high-risk behaviour and addictions in a few of the cases as the ill effects of tobacco.
I know it causes cancer because I have read many times, and I have seen it in movies …. Male, 19, smokes. There were a large proportion of students who did not believe that tobacco causes cancer or other diseases. One student believed that healthy diet of having fruits could counter the negative effects of smoking.
The perception of the young adults on tobacco addiction and how they judged themselves in terms of being tobacco users revealed very diverse viewpoints. Table 2 captures the spectrum of responses that were given by various participants.
Most of the study participants believed that the current tobacco control measures such as package warning, movie warnings and pricing and taxes are not effective in stopping tobacco use.
With respect to these measures, four specific patterns emerged as discussed below. The students taking part in this study reported that they had never faced any issue with respect to accessing cigarettes. While most of them started smoking prior to the age of 18, they could easily access cigarettes from shops located around their schools and colleges or from their family members.
For the youth, it is very accessible, you find stalls around the university, it is their profit so they will sell it to you 20, male, non-smoker.
A majority of students in this study strongly felt that the pictorial warnings may be scary and disgusting to look at, but they have no effect whatsoever on the smokers. The role of increased taxation and pricing came up in the discussions as well. The students, who believed that the current measures work only to some extent, discussed many things about the possible tobacco control strategies.
A suggestion was to integrate tobacco education in schools. Here most of the students are addicted to smoking, so if you make a campaign in a school it may affect them more than an advertisement male, 18, smokes rarely. The group felt that in colleges, there should be personal contact between experts and the students to make the communication more persuasive. I feel if an experienced person went to the places where people smoke and interacted with them to help them understand that this is not making any changes in their life and that it is only affecting their health male, 18, smokes rarely.
Completely banning tobacco came out to be a strong suggestion from many but some of the students also pointed out that people might resort to other forms of addiction if the banning is not done properly with adequate cessation help. It complete ban would cause a lot of problem initially , but it could be beneficial for the country in the longer run and the new generation 20, male, smokes.
Globally, the widespread use of tobacco is one of the biggest public health challenges of this century. It has been recognised as a deterrent to the success of the United Nations Millennium Development Goals [ 34 ]. India is a signatory and a crucial stakeholder to the WHO FCTC, the biggest global initiative in the history of tobacco control [ 35 ]. India is home to approximately million tobacco users being the second largest consumer of tobacco in the world [ 36 ].
Key provisions of COTPA include ban of smoking in public places, prohibition on advertisement and promotion, sale to minors, health warning on packaging and testing of tar and nicotine content, etc. However, the National Tobacco Control Programme remains limited in terms of its coverage [ 37 ]. The Framework Convention Article 8 recommends providing protection against exposure to second-hand smoke in public places [ 35 ]. In India, smoking is completely banned in most public places, such as workplace, hospitals, educational institutions, trains, etc.
However, the law permits a smoking room in airports, hotels and restaurants housing more than 30 people. This amount is highly affordable and smoking in crowded public places, taxis and open spaces is common. Also, a significant gap remains, as a majority still gets to use a wide variety of chewable tobacco in public and spit on roads and indoors [ 41 ].
In the participant observation conducted in our study, students were found to be smoking right outside the college campus and all the food stalls located outside were found to be selling cigarettes and other tobacco products.
This verifies the finding that smoking in public places is not strictly banned and tobacco is freely being sold within the vicinity of educational institutions.
Due to its unique burden of smokeless tobacco, Indian law needs to target control of its use in public. Instead of declaring public places smoke free, the law needs to emphasise the achievement of tobacco-free public places. Enacting a complete ban on all forms of tobacco use in public places along with an adequate penalty needs to be imposed in order to protect exposure to passive smoking and reduction in overall use of tobacco in public places.
This amendment puts India among one of the global leaders in health warnings on tobacco [ 43 ]. But implementation remains weak due to certain gaps. Firstly, because of the availability of unpackaged cigarettes, a large proportion of users do not often come across these warnings.
Secondly, the packaging of smokeless tobacco commonly used in rural India does not always bear pictorial warnings. The majority of students in our study felt that the package labelling and movie warnings are not being effective in controlling the use of tobacco products in addicts. A few of the respondents also pointed out that they prefer to buy loose cigarettes so that they can avoid the pictures on the packets.
Article 13 of the FCTC requires implementation of a comprehensive ban on tobacco advertising, promotion and sponsorships [ 35 ]. The Indian law enforces a ban on direct advertising through most forms of mass media [ 40 ]. But it does not comply with the treaty entirely as it allows point of sale advertisement in shops and does not completely ban sponsorships by tobacco companies.
The amended Indian rules regulate depiction of tobacco use in the media in collaboration with the Central Board of Film Certification [ 38 , 39 ]. However, tobacco companies continue to use legal loopholes in the form of surrogate advertisement and brand diversification. Tobacco companies continue to sponsor cultural events, newspapers and magazines, popular shows and hold a prominent place in the Indian advertising world [ 45 ].
Most of the respondents in our study reported that they ignore on-screen warnings about the ill effects of tobacco during the portrayal of smoking at the cinema. India experienced a rise in showing on-screen smoking when measures were implemented to control other advertising mediums for tobacco companies [ 6 ]; a WHO bulletin on this issue emphasises the need to control the portrayal of such smoking on screen in movies and other programmes.
There is evidence from the developed world that a significant percentage of youth take up smoking due to their exposure to on-screen portrayal of tobacco use [ 6 , 8 , 16 ]. Article 16 of the Framework Convention treaty prohibits the sale of tobacco products to and by minors [ 35 ]. India faces a huge conflict in complying with this treaty requirement. Currently, the tobacco law prohibits sales to individuals under the age of It also bans sale within yards of educational institutions and sale through any vending machines [ 40 ].
It also prohibits the display of tobacco products at points of sale to restrict easy access to minors and bans minors from handling or selling tobacco products. However, compliance remains a major challenge due to the huge amount of child labour being engaged in tobacco manufacturing, widespread sale of loose cigarettes and bidis attracting young users and displayed kiosks of tobacco inside shopping malls, supermarkets and restaurants. In other studies done by the WHO, it has been reported that laws restricting access to tobacco products have been failing as young people are reported to have easy access to tobacco [ 22 ].
The participant observation has clearly revealed that access to cigarettes is not controlled in colleges and age is not verified before selling tobacco products to students.
The respondents who reported that they have very easy access to tobacco and cigarettes regardless of their age also reaffirm the same finding. There are other gaps in the law that make India noncompliant with the Framework Convention treaty. There is no direct provision in the law to promote public awareness on tobacco [ 35 ].
But the coverage and effectiveness of such campaigns in rural India is not known. The Global Youth Tobacco Survey suggests that counselling children and adolescents on the effects of tobacco and smoking and emphasising tobacco education as part of the college curriculum are impactful steps that need to be taken on a global scale [ 47 ]. Peer influence came out as a major factor for the youth to start smoking.
If this impact can be reversed into peers who would act as anti-tobacco champions in schools, the same peer pressure can probably be used as a protective factor. Tobacco education needs to be integrated from school levels, which are the foundation years for forming negative or positive opinions.
We have juxtaposed the qualitative findings with the relevant portions of the findings form our policy analysis Table 3 so that it gives the reader a quick glance at the strengths and gaps of the policy implementation. Furthermore, the country currently lacks capacity to provide tobacco cessation services. There are only a few cessation centres providing limited coverage and suffering from high loss of follow-ups [ 37 ].
Nicotine replacement items and cessation drugs are available but they are not covered under the national health insurance [ 38 , 39 ]. Progress on this keeps declining and only 9. The overall knowledge about tobacco and its ill effects in healthcare students and health professionals have also been found to be low [ 48 ].
This translates to the lack of counselling and cessation support being offered to young people in the country. In our study, none except one respondent knew about tobacco cessation clinics. In addition, none of the students reported that they had received any counselling or support to quit smoking. This verifies the complete lack of cessation support in communities. For an effective and sustainable intervention, tobacco control needs to be integrated in all health and development agendas of the government.
Integration of tobacco control strategies, especially awareness and cessation support with primary and secondary level healthcare delivery is critical to the success of COTPA and the National Tobacco Control Programme [ 49 ]. Integration of tobacco control with primary healthcare will not only ensure increased coverage of the rural, uneducated and low socio-economic classes but also better utilise available resources. It is estimated that approximately 55, children and adolescents start their use of tobacco every day in India [ 8 , 16 ].
This early debut as experimentation with tobacco and cigarettes often leads to nicotine dependence, adverse health consequences and a large majority of tobacco use continues well into adulthood [ 21 ]. Compared to the trends of the s, there is a notable increase in the age-specific prevalence of smoking in men aged 15—29 years in [ 49 ].
The results of the qualitative analysis reveals few critical factors in understanding the culture of tobacco use in youth: influencers for tobacco debut, the reasons for continuing to smoke, the inability of the youth to quit smoking even when the wish exists, the knowledge and beliefs systems around the ill effects of tobacco, and the attitude and reaction towards the tobacco control measures that are employed in the country today. The awareness of young people on the harmful effects of tobacco such as cancer was reported in similar studies conducted in developing countries such as Canada [ 50 ], and also the factors that influenced the youth regarding tobacco-related behaviour were comparable to a great extent to our findings from India.
The youth in Canada reported that they were influenced by peer dynamics and social factors [ 50 ] as in our study.
When compared to other developing countries, the deterrents of tobacco use and thoughts of quitting, such as worry about family and the perceived health hazards of tobacco use were also reported by studies conducted in Africa [ 51 ]. In India, a quantitative exploration revealed social factors, peer influence, social desirability to influence tobacco habits and knowledge of harmful effects to be significantly poor [ 7 ].
In our study, certain behavioural aspects of tobacco use in young people have been clearly portrayed in terms of the effects of peer pressure, social desirability, social contrast about smoking being a depiction of freedom and negative family experience about smoking acting as a protective factor against it.
A critical theme that emerged in our study was the pattern of continued tobacco use and the inability to quit stemming from a lack of knowledge on how to quit, the constant peer pressure and use of tobacco by peers acting as a deterrent to quitting and the unavailability of an evidence-based support system to assist quitting. The study also pointed out how the anti-tobacco messages play in the mind of young people. When compared with the subgroup of youth who had a personal experience of a family member facing harmful effects of tobacco with those without, the beliefs, awareness and sensitivity towards the ill effects of tobacco use was higher for the affected group.
We found some of the young people were also not very convinced regarding the harmful effects of tobacco. The qualitative findings of our study triangulate very well with the findings from the policy analysis. We hope a couple of important factors will potentially influence the tobacco control efforts. The second Global Adult Tobacco Survey results highlight an overall increase in cigarette consumption and very low rates of smoking cessation in India [ 49 ].
The global health community and the Indian government will likely feel it compelling to make policy revisions to strengthen tobacco control efforts in the country.
To this effect, an amendment to the main tobacco control law seems highly feasible. Secondly, with the new Sustainable Development Goals targeting compliance to the FCTC treaty as a priority [ 52 ], tobacco laws will play a crucial role in the success of all nations. However, historically such strict enactments of laws have faced resistance from the tobacco industry and the pro-tobacco lobby.
The government needs to demonstrate very strong political will to be able to enact these modifications and make tobacco control more efficient in the country. Leaving out tobacco control from the Millennium Development Goals gave the tobacco industry a significant advantage over the last decade. The current paper analyses the tobacco picture from all aspects, behavioural, social, political and legislative and provides a thorough understanding of the uniqueness of tobacco in India.
The paper also provides solutions that are fit for addressing the unique barriers faced in this country. This paper has a few important limitations. The evidence from published reports may differ from the actual on-ground compliance scenario in different states in India, as the policy arm of this study did not involve any primary collection of data; hence, all the arguments could not be confirmed with key respondents or officials working in the government on tobacco control.
In addition, the qualitative arm of the study was conducted in a university situated in a metropolitan city in India; hence, most of the students interviewed are predominantly from urban communities; hence, the perception of tobacco use in rural youth is not adequately addressed by this study. Lastly, there are other widespread environmental and economic concerns due to tobacco farming and manufacturing, which have not been discussed in this paper due to its limited scope.
The tobacco epidemic continues to rise in the developing world along with the burden from tobacco-associated cancers. By , India is estimated to have the highest rise in tobacco consumption compared to all other countries and deaths from tobacco are estimated to exceed 1. It is not feasible to reverse the effects of the tobacco epidemic without bringing tobacco to the top of the public health agenda of the country and without a focus on the prevention of tobacco debut.
India has been at the forefront of tobacco control efforts for many decades. When compared to a global standard, the Indian law reveals significant opportunities for improvement and policy reform. This analysis highlights the need for revisiting the tobacco control laws in India, addressing the existing barriers to have significant impacts on the tobacco picture of this country. The results from this study will inform policy from many aspects—the public health experts working on behavioural aspects of tobacco use and effects on tobacco awareness in young people, the government and private sector policymakers on the existing gaps in cessation support and the government responsible for implementation of the tobacco control laws of the land.
Long-term engagement with a broad range of stakeholders would be required for tackling the tobacco crisis. Overall, tobacco control needs to be seen not only as a public health issue but also as a fundamental human right.
The authors do not have any conflicts of interest to declare and the study adhered to national ethical guidelines for clinical research. National Center for Biotechnology Information , U. Journal List Ecancermedicalscience v. Published online Mar Author information Article notes Copyright and License information Disclaimer. Correspondence to: Soumita Ghose ac. Received Jul This article has been cited by other articles in PMC. Abstract Tobacco is one of the biggest global health concerns of this century with a significant contribution to the increasing burden of cancers, chronic diseases and associated mortality.
Keywords: cancer, tobacco, youth, tobacco policy, tobacco law, India, smoking, adolescent. Background Tobacco is the single most important preventable cause of death globally [ 1 ].
Methodology Study design The study used a qualitative design to explore the perception of tobacco use in youth, in particular, the enablers of tobacco debut and subsequent use and the barriers to successful implementation of tobacco control measures, all of this examined in light of the policy framework analysis of tobacco control related legislations.
Setting The qualitative study was conducted in students enrolled in a university located in the metropolitan city of Kolkata that admits students from different states of India, such as West Bengal, Jharkhand, Bihar, Uttar Pradesh and others. Eligibility criteria for the study The eligibility criteria to participate in the study were fairly broad as described below: Inclusion criteria: Young adults more than 18 years of age, studying in the university were eligible to participate in the study.
Research team The research team consisted of a public health researcher with expertise in qualitative methods, a psychiatrist practicing and researching full-time in the field of psycho-oncology, a faculty of health management and two visiting interns with a background in health economics and business, respectively, who were also students themselves during the time of the study. Recruitment of participants The study was conducted inside the campus of the university after obtaining the necessary approvals.
Sampling method A purposeful sampling was employed by the researchers as advocated by Collins [ 26 ] and included a diverse range of students. Explaining the study and obtaining informed consent All students who approached the researchers were briefly informed about the study. Data collection methods for the qualitative study The researchers conducted in-depth interviews, focus group discussions and participant observations.
In-depth interviews Trained young researchers conducted the in-depth interviews on the university campus; this ensured free and uninhibited communication between the respondents and interviewers. Interview Stems used in the study:. Focus group interviews Researchers moderated the focused groups using structured guidelines. Participant observation Two participant observations were conducted in the same university campus.
Data collection for policy analysis The policy analysis section is based on publicly available secondary data covering the time frame from to present. Data analysis Qualitative data analysis In-depth interviews and focus group discussions were transcribed verbatim.
Policy analysis Public policy analysis is defined as the study of how, why and to what effect governments pursue particular courses of action and inaction [ 30 ]. Results Participant characteristics A total of 30 participants took part in the in-depth interviewing and focus group discussions. Table 1. Demographic characteristics of study population.
Open in a separate window. Results of the qualitative analysis Thematic analysis of the qualitative data generated four global themes, namely, why people start smoking? Why do people start smoking? Peer influence and social desirability Many of the participants pointed out the role of peers in tobacco initiation in youth and encouraging young people to smoke their first cigarette. Curiosity about experimenting with tobacco Some of the students reported that they tried their first cigarette to understand why their father smokes regularly.
That has made me start it male, 19, smokes sometimes I want to experience that thing for experimenting female, 18, smokes often Stress and pressure relief Stress and subsequent relief from stress after smoking was identified as an influencer.
Knowledge of ill effects of tobacco Overall, most of the respondents had knowledge about cancer being caused from tobacco and smoking. Thank you for subscribing to our Daily News Capsule newsletter. Whatsapp Twitter Facebook Linkedin. Sign Up. Edit Profile.
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