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 Table of Contents  
PERSPECTIVE
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 10-14

Innovative approaches to implement MPOWER policies in low-resource settings: A significant reduction in tobacco use (21.2%–16.1%) since Global Adult Tobacco Survey-1 in Himachal Pradesh, India


1 Department of Health, National Health Mission, Shimla, Himachal Pradesh, India
2 Department of Community Medicine, School of Public Health, PGIMER, Chandigarh, India

Date of Web Publication18-Mar-2019

Correspondence Address:
Dr. Gopal Chauhan
National Health Mission, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jncd.jncd_31_18

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  Abstract 


MPOWER is the evidence-based toolkit for effective tobacco control under the WHO-framework convention on tobacco control (FCTC). Indian Tobacco Control Law (COTPA, 2003) and National Tobacco Control Program (NTCP, 2006) are not fully compliant to FCTC. Himachal Pradesh a northern hilly state in India with a population of about 7 million was not included under NTCP till 2014 whereas as per the Global Adult Tobacco Survey (GATS) 2009–2010 the prevalence of smoking among males (33.4%) was much higher than the national average (24.3%) with high exposure of passive smoking (82.5%) at homes. Implementing MPOWER without technical and financial support was a huge challenge. The multisectoral engagement especially the partnership between the local NGO (HPVHA) and the State Health Department under the guidance of the International Union against TB and Lung Diseases New Delhi helped in bridging the policy gaps through advocacy and capacity building. Building partnerships, sharing the responsibilities, and empowering the key stakeholders to utilize the funds collected as fine for tobacco control helped in policy implementation effectively. MPOWER implementation has achieved substantial progress in all six demand and supply reduction strategies of tobacco in the state of Himachal Pradesh. GATS, 2016–2017 shows a significant decline (21.2%–16.1%) in tobacco use and passive smoking at homes (82.5%–32.9%) in the state. Innovative approaches of implementing MPOWER policies are the way forward for effective tobacco control in low resource settings.

Keywords: Framework convention on tobacco control, MPOWER, tobacco control


How to cite this article:
Chauhan G, Thakur JS. Innovative approaches to implement MPOWER policies in low-resource settings: A significant reduction in tobacco use (21.2%–16.1%) since Global Adult Tobacco Survey-1 in Himachal Pradesh, India. Int J Non-Commun Dis 2019;4:10-4

How to cite this URL:
Chauhan G, Thakur JS. Innovative approaches to implement MPOWER policies in low-resource settings: A significant reduction in tobacco use (21.2%–16.1%) since Global Adult Tobacco Survey-1 in Himachal Pradesh, India. Int J Non-Commun Dis [serial online] 2019 [cited 2019 Aug 21];4:10-4. Available from: http://www.ijncd.org/text.asp?2019/4/1/10/254488




  Introduction Top


Tobacco is the leading cause of preventable deaths in the world killing more than 6 million people every year.[1] The WHO framework convention on tobacco control (WHO-FCTC) has mobilized efforts to combat tobacco epidemic through MPOWER policies implementation which focuses mainly on reducing the demand of tobacco products.[2],[3] In India, more than one million deaths occur every year due to tobacco use.[4] Tobacco Control Law (COTPA.2003) and the National Tobacco Control Program (NTCP 2007) are the key tobacco control measures in India, but they are not fully compliant to the WHO-FCTC and MPOWER.[5] Before notification of the Smoke-Free Rules in 2008, few jurisdictions such as Chandigarh City in north and Kottayam District in south India are the examples where NGO led advocacy has contributed for effective ban on smoking in public places.[6] Himachal Pradesh, a Northern hilly state with a population of about 7 million, is a famous tourist destination in India. More than 90% of people in the state are residing in villages. The extreme geographical and climatic conditions are the biggest barriers in providing basic health services to the people. The agriculture and farming is the main source of livelihood in the villages. Health is a state subject in India, and healthy financing for health remains a big issue due to other priorities. Himachal ranks one of the highest among the states and union territories of India in terms of per capita income, but more than 50% of this expenditure is incurred on transport and communication (https://en.wikipedia.org/wiki/Himachal_Pradesh#Economy). Due to the duals and high burden of diseases, the major health expenditure is on the communicable diseases and financing tobacco control remained a low priority in Himachal Pradesh. The state was not covered under the NTCP despite of the fact that as per the National Family Health Survey-3 (NFHS 2005–2006) the smoking prevalence in State (33.2%) was more than the country (32.7%). Global Adult Tobacco Survey (GATS)-1 also showed the prevalence of current male smokers (33.4%) more than the national average (24.3%) with high passive smoking exposure (82.5%) at homes. The strategic partnership between the local NGO (HPVHA) and State Health Department under the guidance of the international NGO-The International Union against TB and Lung diseases New Delhi developed the multisectoral action plan with innovative strategies for effective implementation of MPOWER package in the state. This paper describes the innovative ways of MPOWER implementation in the state of Himachal Pradesh from the year 2010 to 2015. The key interventions have been enlisted in a sequence. The data on the level of policy implementation and outcomes have been retrieved from the available websites, compliance studies, monthly and yearly reports (available in the State and HPVHA headquarters), and media reports. The progress of MPOWER implementation is related to the outcomes in GATS-2.

Innovations

The strategic partnership between the HPVHA and the state Health Department officials under the guidance of the International Union New Delhi held rounds of consultative meetings with the key officials in various departments mainly police, excise, and taxation, education, rural development, Panchayati Raj, health officials, media, and NGOs to develop the action plan for implementation of the tobacco control laws, programs and the MPOWER package in the state. Advocacy helped for the major breakthrough in Himachal, and the Tobacco Control workshop was organized on May 5, 2009, at the state capital and Secretariat at Shimla for sensitization of all the administrative and Technical heads of the Government Departments, Media, and NGOs about the need for tobacco control. The workshop was chaired by the Chief Secretary of the state, and all possible evidence were put forth by experts in the meeting, and so the tobacco epidemic was recognized as a big public health issue in the state. The valuable inputs from the stakeholder were taken, and the action plan was approved. The success of this meeting resulted in the issuing of various notifications and orders from the top administrative level for effective tobacco control. The State and District level Committees were constituted for monitoring tobacco and to enforce the tobacco control policies effectively. Subsequently, the Chief Minister chaired the State level function on World No Tobacco day 2009 and the statewide anti-tobacco campaign was launched and highlighted in media. Keeping in view the lack of resources the guidelines were issued to implement tobacco control policies as part of all existing health programs. In order to avoid the overlap and to strengthen the law enforcement the flying squads comprising officers from key departments such as health, police, excise, and taxation, food and drug administration were notified at State, District and Sub-District Level for imposing fine on violators, periodic search in different places and seizures of the tobacco products. To meet out the expenditure on IEC material, sensitization programs, capacity building, and transport of the flying squads the law enforcers were empowered to utilize the funds collected as fine for anti-tobacco activities. This strategy bridged the huge gap in financing tobacco control and resulted in strict implementation of the tobacco control strategies. A systematic approach was adopted to implement all the components of MPOWER in progressive and phased manner by opting for the simpler intervention first followed by the complex. Initially, Shimla, the capital city was selected for developing evidence-based Smoke-Free City model as a pilot in mid-2009. A baseline assessment was conducted by the independent agency about the compliance of smoke-free policies. Repeated awareness activities, sensitization and training workshops, and enforcement drives were conducted with huge media coverage to make Shimla a smoke-free city. No Smoking signages were displayed in all public places, and more than 5000 persons were fined for violating tobacco control laws in the city during the campaign. All the activities were highlighted in media for wide publicity. Based on the compliance study, Shimla, the capital city of the state was declared a “Smoke-Free City” on October 2, 2010, by the Chief Minister.[7] The smoke-free model was replicated in all 12 districts in the state and repeated compliance assessment studies were conducted [Table 1].[8],[9] The enforcement was further strengthened in all the districts and based on the compliance of the smoke-free rules the entire state was declared as smoke-free in 2013. Huge media coverage, awareness generation, and enforcement drives motivated the residents of Tashijong village with a population of about 1000 in Kangra District to make their village Tobacco Free in 2010. A robust mechanism was established to ensure complete ban on the use, production, carry, sale, and distribution of tobacco products at Tashijong. The villagers were awarded by the Chief Minister for this unique initiative. Awareness and enforcement were further strengthened up to village levels, and 3200 out of total 3400 Gram Panchayats (village councils) passed resolutions to support tobacco-free villages campaign in the state. The local bodies, village council meetings, media workshops, and parent-teachers associations were the main platforms for awareness generation at village and schools levels. The politicians and administrators were involved in highlighting the tobacco control achievements at different levels. The law enforcers and tobacco control advocates were rewarded to keep their moral high. The help of the legal system and courts was taken through public interest litigations and right to information act 2005 to strengthen the tobacco control drive. The academic institutes were involved in periodic compliance assessments, and a healthy competition was established for better compliance among different jurisdictions. The implementation of all the components of MPOWER package was strengthened in a phased manner.
Table 1: District and Year wise Compliance of Smoke free policies (%) under COTPA 2003 in Himachal Pradesh

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  Level of MPOWER Implementation and the Key Achievements in the State Top


M-Monitor tobacco use and prevention policies

Apart from the monthly reporting mechanism, the compliance assessment studies have been conducted regularly through various agencies mainly by the academic institutes to assess the progress of policy implementation. [Table 1] shows the results of the periodic compliance assessment of the smoke-free policies in the state.[8],[9]

P-protect people from tobacco smoke

After achieving smoke-free city Shimla in 2010 Himachal became the first evidence-based smoke-Free state among large states in India in 2013. To protect people from tobacco 109181 violators has been panelized and UDS 197225 has been collected as fine for financing tobacco control since 2010 [Figure 1].
Figure 1: One year wise violations reported and fund collected for financing tobacco control in Himachal Pradesh

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O-offer help to quit tobacco use

The smoke-free policies implementation generated demand for tobacco cessation facilities in the state. There were two tobacco cessation facilities in 2010, and now, there are 14 such facilities in Government and 10 in NGO sector. A pool of more than 50 medical doctors, psychologist, and medical social workers trained from the National Institute of Mental Health and Neurosciences Bengaluru are providing tobacco cessation facilities in various health institutes in the state. About 500 persons are reporting in these centers for counseling and tobacco cessation services per month.

W-warn about the dangers of tobacco

To ensure the statuary and specified pack warnings on tobacco products the state developed the strategy to punish the violators through court cases and demonstrated convictions. The first cases were launched in the Shimla court in the year 2012 which resulted in convictions to the violators through court orders. The convictions are the first in India, and the procedure is now followed in the entire county. The convictions resulted in high compliance of pack warnings in the state.[10] The radio jingles, television spots, and print media are integral part of the warning campaign against tobacco.

E-enforce ban on tobacco advertising, promotion, and sponsorship

The state adopted the innovative strategy for removing the rampant outdoor advertisement of tobacco products in the form of big boards and hoardings on the point of sale and otherwise. The NGO-HPVHA was authorized to issue awareness and warning notices to the violators for removing the advertisements to avoid fine and imprisonment under the law. This strategy worked effectively, and about 99% boards were removed by the vendors by themselves. However, those who did not remove the advertisements their cases were launched in the courts which resulted in convictions in the form of fine and imprisonments. The dual approach reduced the direct and indirect advertisement of tobacco products significantly in the state.[10] Now there is hardly any visible direct or indirect outdoor advertisement of tobacco in the state.

R-raise the taxes

A committee of experts was constituted for advocacy for tax rise in collaboration with NGOs. Evidence were gathered about the effectiveness of tax rise for tobacco control and economic gains. These evidence were put forth to the finance department before every annual budget with a demand for adequate tax rise on tobacco products. As a result, there was a continued rise in tobacco taxes from 15 up to 40% since 2010–2015.

Himachal has shown a substantial progress in the implementation of all components of MPOWER. As a result, the state has achieved a significant reduction of 24.06% (21.2%–16.1%) in tobacco use since GATS-1. [Figure 2] highlights the key achievements in tobacco control in the state.
Figure 2: Key achievements in tobacco control in Himachal Pradesh from Global Adult Tobacco Survey-1–2

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  Conclusion and the Way Forward Top


Tobacco control remains a low priority in developing countries due to dual and high burden of diseases. In order to reduce the rising burden of tobacco related diseases there is an urgent need to implement MPOWER policies for effectively at all levels.[11] Tobacco control is a complex issue and requires strong political and administrative will due to obvious tobacco industry interference.[12] Himachal is a classical example of innovations to implement all components of MPOWER policies effectively. The strategic partnership between the NGO and Government is the key to this success. Government agencies have strong administrative and implementing network but have certain limitations and they cannot stretch beyond the established protocols. On the other hand, NGOs have limitation in implementation of the strategies but do have wide scope of stretching beyond the existing protocols. The Government and NGO partnership in Himachal Pradesh and innovations for tobacco control has been validated by the WHO-SEARO awards in 2011 and 2012 also. The partnership has been successful to counter the tobacco industry interference through intensive advocacy at grassroots level and the Tobacco Industry was closed within 6 months of its inception in District Hamirpur of the state in 2011. The inclusion of academic institutes for compliance assessment helped in monitoring the progress in implementing the strategies regularly. Media and NGOs were instrumental in highlighting the achievements and to advocate for the need of effective tobacco control. The law enforcers are motivated and the Courts are well informed with supportive evidence. The successful partnership also helped the HPVHA to receive the Bloomberg grant for strengthening tobacco control in the state in 2011–2013. This study focuses on the level of MPOWER implementation in relation to decrease in tobacco use however the ultimate goal shall be the reduction in tobacco related diseases. A detailed study is required to see the proportional reduction in tobacco related diseases in the state and to see that what component of MPOWER is contributing the most for tobacco control in the state. Despite of the huge challenges in terms of resources and tobacco industry interference, Himachal Pradesh, has been able to implement MPOWER policies effectively and there is a significant reduction in tobacco use. Innovative approaches for implementing MPOWER policies is the way forward for effective tobacco control in resource constrain settings.

Acknowledgment

We would like to acknowledge the Department of Health, Himachal Pradesh, Himachal Pradesh Voluntary Health Association Phase-1 Sector-2, New Shimla, Himachal Pradesh, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. WHO Report on Global Tobacco Epidemic, 2013. Switzerland: World Health Organization; 2013. Available from: http://www.who.int/tobacco/global_report/2013. [Last accessed on 2018 Mar 08].  Back to cited text no. 1
    
2.
World Health Organization. WHO Report on Global Tobacco Epidemic, 2015. Luxembourg: World Health Organization; 2015. Available from: http://www.who.int/tobacco/global_report/2015. [Last accessed on 2018 Mar 08].  Back to cited text no. 2
    
3.
Roemer R, Taylor A, Lariviere J. Origins of the WHO framework convention on tobacco control. Am J Public Health 2005;95:936-8.  Back to cited text no. 3
    
4.
McKay AJ, Patel RK, Majeed A. Strategies for tobacco control in India: A systematic review. PLoS One 2015;10:e0122610.  Back to cited text no. 4
    
5.
Government of India, Ministry of Health and Family Welfare. The Cigarette and other Tobacco Product (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003. New Delhi: Ministry of Health and Family Welfare; 2010. Available from: http://www.mohfw.nic.in. [Last accessed on 2018 Jun 01].  Back to cited text no. 5
    
6.
Government of India, Ministry of Health and Family Welfare. Prohibition of Smoking in Public Places Rules, 2008. The Gazette of India. New Delhi: Ministry of Health and Family Welfare; 2008.  Back to cited text no. 6
    
7.
Government of Himachal Pradesh. Tobacco Free Initiatives in Himachal Pradesh: Smoke Free Shimla a Case Study: Department of Health and Family Welfare; 2010. Available from: http://www.hphealth.nic.in/pdf/2010. [Last accessed on 2018 May 30].  Back to cited text no. 7
    
8.
Lal PG, Wilson NC, Singh RJ. Compliance surveys: An effective tool to validate smoke-free public places in four jurisdictions in India. Int J Tuberc Lung Dis 2011;15:565-6.  Back to cited text no. 8
    
9.
Kumar R, Chauhan G, Satyanarayana S, Lal P, Singh RJ, Wilson NC, et al. Assessing compliance to smoke-free legislation: Results of a sub-national survey in Himachal Pradesh, India. WHO South East Asia J Public Health 2013;2:52-6.  Back to cited text no. 9
    
10.
Government of Himachal Pradesh, Department of Health Safety and Regulations. Consolidated Monthly Reports. Tobacco Control Program/COTPA 2003. DHSR Shimla; 2008-2015.  Back to cited text no. 10
    
11.
World Health Organization. WHO Report on the Global Tobacco Epidemic. The MPOWER Package; 2008.  Back to cited text no. 11
    
12.
World Health Organization. Building Blocks for Tobacco Control: A Hand Book. World Health Organization; 2004.  Back to cited text no. 12
    


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