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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 1  |  Page : 38-45

Compliance assessment with tobacco control regulations at wheelchair-based tobacco Point of sale in Delhi, India


1 Administrative Assistant, International Union Against Tuberculosis And Lung Disease (The Union) South-East Asia Office, New Delhi, India
2 Technical Advisor-Monitoring and Evaluation, Director, International Union Against Tuberculosis And Lung Disease (The Union) South-East Asia Office, New Delhi, India
3 Project Officer, Director, International Union Against Tuberculosis And Lung Disease (The Union) South-East Asia Office, New Delhi, India
4 Deputy Director, Tobacco Control Department, International Union Against Tuberculosis and Lung Disease (The Union), New York, United States
5 Deputy Regional Director, International Union Against Tuberculosis And Lung Disease (The Union) South-East Asia Office, New Delhi, India

Date of Submission18-Oct-2020
Date of Decision16-Mar-2021
Date of Acceptance17-Mar-2021
Date of Web Publication21-Apr-2021

Correspondence Address:
Dr. Shivam Kapoor
C6, Qutub Institutional Area, New Delhi - 110 016
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jncd.jncd_76_20

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  Abstract 


Background: In India, tobacco products are sold at the outlets/shops following the provisions regulating the point-of-sale (PoS) environment under the Cigarettes and Other Tobacco Products Act (COTPA, 2003).
Objectives: Given the lack of evidence regarding wheelchair-based tobacco PoSs (WC-PoSs), compliance assessment for Sections 5 and 6 of COTPA was conducted within Delhi.
Materials and Methods: Using multistage random sampling in the 11 districts of Delhi, 200 WC-PoSs were identified in May–June 2017. Areas 1 km around each selected landmark were mapped using a map tool, and WC-PoSs were screened using a self-designed study tool (background information and compliance checklist). Descriptive statistics were used to characterize the data using EpiData.
Results: Of the 11 districts, 4 were constituted majority of the WC-PoSs: South West (21.5%), West Delhi (20%), North West (17.5%), and North East (11%). The outlet characteristics were government sponsored (36.5%) and mobile outlets (95.5%). Majority of them (94.5%) showed noncompliance toward Section 5 of COTPA. While none of them complied with the display of Section 6(a) signage, only 6% of the outlets were found selling tobacco products within the 100 yards of educational institutes.
Conclusions: The sale of tobacco in Delhi at these unique PoSs continues with a lack of compliance with the rules of COTPA. The implications of this noncompliance in the national capital are of major significance for the rest of the country.

Keywords: Compliance, Cigarettes and Other Tobacco Products Act, India, point of sale, tobacco regulations


How to cite this article:
Kumar S, Kapoor S, Sharma R, Pandey AK, Singh RJ. Compliance assessment with tobacco control regulations at wheelchair-based tobacco Point of sale in Delhi, India. Int J Non-Commun Dis 2021;6:38-45

How to cite this URL:
Kumar S, Kapoor S, Sharma R, Pandey AK, Singh RJ. Compliance assessment with tobacco control regulations at wheelchair-based tobacco Point of sale in Delhi, India. Int J Non-Commun Dis [serial online] 2021 [cited 2021 May 11];6:38-45. Available from: https://www.ijncd.org/text.asp?2021/6/1/38/314213




  Introduction Top


India is the second most populous country in the world, with more than 1.2 billion inhabitants,[1] i.e., more than Europe and the United States of America combined. According to the Global Adult Tobacco Survey (GATS), 2016–2017,[2] there are 266.8 million adult tobacco users in India (28.6% of adult population), including 199.4 million smokeless tobacco users and 99.5 million smokers making tobacco usage a major public health challenge faced by the country.

India enacted the Cigarettes and Other Tobacco Products Act (COTPA) in 2003, much before ratification of the Framework Convention on Tobacco Control in 2004,[3] in order to discourage the use of tobacco, impose progressive restrictions, and take concerted action to prohibit tobacco use and ultimately to protect public health in the country. Section 5 of COTPA prohibits any kind of advertisement, brand promotion, and sponsorship of tobacco products. To protect the youth and adolescents, there is a provision under Section 6(a) under COTPA that prohibits the sale of tobacco by and to minor (a minor as per Indian legislation is anyone under the age of 18 years), and mandates the display of a prescribed warning signage at PoS. Section 6(b) also prohibits the sale of tobacco within 100 yards of educational institutes and its use within educational institutions. The National Tobacco Control Programme was launched in 2007 in view to enhance the implementation of COTPA.[4],[5],[6],[7]

Despite this, there have been gaps and challenges at policy level and their enforcement.[8] Section 5 under COTPA prohibits the direct and indirect advertisement of tobacco products[9] but somewhere it allows the display of tobacco product at point of sale (PoS) with certain specifications.[9],[10] The provision of point of tobacco sale in COTPA has been partisan and mainly used as a means of advertisement of tobacco products.[11],[12] There is an established relation between exposure to Tobacco Advertising, Promotion and Sponsorship (TAPS) and initiation of tobacco use among the Indian youth.[13],[14] A three jurisdictions review on tobacco vendors in India concluded that PoS advertising is an aggressive promotional strategy used by the tobacco industry and recommended an urgent need of comprehensive ban on TAPS at PoS.[15] Delhi is the national capital,[1] and adherence to COTPA provisions continues to be a big challenge in this city which must be addressed urgently.[16]

According to the Euromonitor report 2013,[17] 85% of all tobacco sales of all tobacco products take place through tobacco vends. The 15% are labeled as mixed sources for sale of tobacco products. There is a growing visibility of sale of tobacco products in the NCT of Delhi, India, at Point other than the conventional PoSs (vendors, kiosks, and general merchants) with sightings wherein tobacco products are being sold by the handicapped vendors on wheelchair. Most of them have their wheelchair registered under the government or civil society organizations. The physically handicapped persons have been provided wheelchairs by the Government of NCT of Delhi under mobile STD/PCO scheme.[18],[19] Furthermore, Delhi Transport Infrastructure Development Corporation (DTIDC) details a policy for allotment of license to shops/sites/vending machines/eatable shops/dhabas/PCO booths for physically handicapped persons in Delhi.[20] Many of these beneficiaries are found to be using these wheelchairs for the sale of tobacco products. Therefore, it has become another PoS which was never identified neither by enforcement agencies nor by any other monitoring agencies responsible for this cause. Given the evidentiary basis relating the tobacco retailers' density with tobacco usage,[21] finding ways to decrease the number of tobacco retailers is an important task, thereby reducing the tobacco availability in the market to the minimum. Hence, a study was done with the aim to assess the compliance status of Sections 5 and 6 of COTPA, 2003 at the WC-PoS within all the 11 districts of Delhi.


  Materials and Methods Top


A cross-sectional observational survey of the unexplored PoS, i.e., wheelchair-based tobacco PoSs (WC-PoSs), was conducted in the month of May–June 2017 in NCT of Delhi, India.[22] Delhi has 11 districts under the administrative control of a district collector. The districts are subdivided into 33 tehsils, and each tehsil consists of blocks.

Multistage random sampling was carried out during this survey. From each district, all the three tehsils were identified, and from each tehsil, seven areas were selected randomly further within each area; WC-PoSs were observed. Each of the busiest and most prominent areas from each tehsil was listed, and seven sampling units (public places, educational institutions, etc.) were subsequently identified by table of random numbers. A fixed central point in each sampling unit was identified as the busiest or most prominent point by a single investigator. A free map tool[23] was used to draw radius of 1 km around each point, and the landmarks were used in locating the entire vicinity [Figure 1]. The areas and lanes were also checked in Google Maps through GPS tracking through a handheld device (mobile phone). While using the free map tool during random selection of areas, it was made sure that there is no overlap of the areas. All the outlets which have scope for selling tobacco were screened. By following survey pathway, the investigator observed the compliance to Sections 5 and 6 of COTPA as and when WC-PoS was encountered. Observation was made for 10–15 min at each WC-PoS, relevant photographs were taken, and data were entered. This process was continued in a 1-km radius zone of the randomly selected areas of all 33 tehsils.
Figure 1: Study flowchart

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The study tool consisted of two parts: background information and compliance checklist. The background information assessed information on the district, address/fixed landmark, type of wheelchair (movable/fixed and sponsored/unsponsored), and business of vendor (exclusive tobacco outlet/mixed vend with tobacco as main business/mixed vend with tobacco not the main business). Since it was an observational design, sponsorship of the wheelchair was assessed by government/nongovernmental organization (NGO) logo on the chair, and no inquiry was carried out. A compliance checklist was formulated in English language with the existent compliance specifications[9],[10] following the compliance study guide.[24] A total of eight closed-ended questions were present with four items related to both Sections 5 and 6. The validity of the checklist was assessed by four public health researchers with prior experience in the field of tobacco control and research using Lawshe approach.[25] The experts rated the items as essential/not essential but important/neither essential nor important. The items considered essential were further rated on a scale of 1–10 and analyzed using Aiken's V-index (V >0.7 implied high degree of agreement) and therefore was considered for inclusion in the final checklist.[26] Section 6(b) of COTPA was assessed by drawing 100 yards radius[23] around the WC-PoS and then carrying out the compliance assessment. For this study, a training session about the study protocol and compliance assessment involving two field investigators was carried out by the study supervisor. A pilot testing was conducted in the south district to test the tool's feasibility in the 1st week of May 2017. The valid data obtained from the pilot testing were included in the final analysis. All the entered data forms were kept in a locked cabinet and later entered into a secure database EpiData (Classic) Analysis (version 2.2.3; The EpiData Association, Odense Denmark) by a data entry operator. A descriptive analysis was done for the district-wise distribution (%) of WC-PoS as well as for their compliance with the act.

The institutional review board waived review and informed consent because no individual participant information was collected.


  Results Top


Out of the 200 WC-PoSs found in the 11 districts of Delhi, majority were found to be in the four districts: South West (21.5%), West Delhi (20%), North West (17.5%), and North East (11%) [Table 1] with its epicenter in the South Delhi zone (31.5%) [Figure 2].
Table 1: Wheelchair-based tobacco point-of-sale characteristics

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Figure 2: Choropleth map showing distribution of wheelchair-based tobacco Point of sale in Delhi

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As found during the observation, more than one-third of these wheelchairs were government sponsored (36.5%) [Figure 3], with tobacco being their main form of business: exclusive or mixed (96.5%). In addition, majority (95.5%) of them were found to be mobile outlets [Table 1].
Figure 3: Wheelchair-based tobacco Point of sale: (a) Delhi government-sponsored point of sale in south district (picture taken on May 20, 2017), (b) Central government-sponsored point of sale in south-east district and west district (picture taken on May 20, 2017), (c) Sale by minor in north (picture taken on June 10, 2017), and (d) Sale by minor in north-east district (picture taken on June 14, 2017)

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[Table 2] summarizes the characteristics of WC-PoS with reference to COTPA compliance. Out of these, 189 PoSs (94.5%) were found to show noncompliance with the major compliance indicator (product advertisements display) of Section 5. The most common mode of advertisements was product display of tobacco products (93.5%), banners (93%), and dangles (92%), followed by promotional gifts (88%). In addition, 8 out of 11 districts had a noncompliance rate >90% while Central, East, and North East Delhi showed compliance of 40% (2 out of 5), 33.3% (1 out of 3 WC-PoSs), and 13.6% (3 out of 22 WC-PoSs), respectively. Of the 33 WC-PoSs with advertisement boards that displayed health warning, only one fulfilled the position specifications as per the existent laws. Not even a single district having WC-PoS was found to be displaying COTPA 6(a) signage while 6% of these wheel-chaired outlets were found selling tobacco products within the 100 yards of educational institutes.
Table 2: Tobacco vendor compliance with point-of-sale laws (n=200)

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While sale by minors [Figure 3] was restricted to 6 PoSs: North East (3 out of 22), North (2 out of 20), and West (1 out of 40), sale to minors was observed at 4 PoSs: North East (1 out of 22), North (1 out of 20), and West (2 out of 40).


  Discussion Top


Among the randomly sampled units, 200 WC-PoSs were found to be unequivocally distributed in all the Delhi districts, with a preponderance in the South zone. It was observed that Section 5 of COTPA (prohibition of TAPS) is being hugely violated on WC-PoS. We found varied advertisement modes that were used by these outlets, product display being the most common one. PoS tobacco advertising has been commonly reported as an industrial marketing ploy in India[11],[12],[16],[27] and its association with increasing tobacco usage among the Indian youth has been proven.[13],[14] GATS-2 reported that the percentage of adults who noticed any advertisement or promotion for smoking (42.8%) or smokeless products (33.8%) in Delhi was well above the national estimates (22.3% and 20.5%).[2] Even though some countries (for instance New Zealand) have complete restrictions on PoS tobacco promotion, India has an exemption for display of PoS board with specifications. On deeper analysis of the sublaws,[9],[10] the compliance results point to the need for immediate attention and enforcement of COTPA in the national capital.

With respect to Section 6 compliance, our results revealed that none of these PoSs were compliant with the significance of the signage. Strikingly, tobacco sales to and by the minors were encountered in the three districts while conducting the survey, wherein at 4 PoSs, the minors (customers) were found purchasing from the minor vendors. A two-wave observational study reported low compliance regarding youth access at PoSs in India.[28] In addition to controlling youth demand for tobacco through antitobacco campaigns and advertising/promotional restrictions, it is important to control the supply of tobacco to minors.[29],[30]

The surveyed WC-PoSs in this study were among the most prominent and busiest spots; customers from different age groups were likely to be exposed to them. Moreover, as majority of the tobacco products were glamorized so that they are visible to the minors (physical height level) and were the most common mode of advertisement-builds a serious ground for profound implications under the law. Surprisingly, none of the PoSs were found to display Section 6(a) signage, however, only 6% of them were found to be noncompliant with respect to Section 6(b). The exact comparison of our results with other studies could not be made as this was the first-ever attempt in compliance reporting for wheel-chaired tobacco selling outlets. In contrast, lack of compliance among school neighborhoods in the vicinity of Central Delhi was highlighted.[16] Results from a multinational study strongly correlated high compliance with comprehensive smoke-free laws and robust local enforcement activities.[31] Several compliance surveys have posited that the current enforcement of PoS policies in India appears to be inconsistent and lack coordination.[32],[33] Our findings highlight that law enforcement is as important and challenging as the law enactment itself.

As per the mobile PCO scheme,[19] shifting of the booths within the local areas is permitted levying some minimal shifting charges. Majority (95.5%) of the WC-PoSs in this study were mobile, however, we could not assess their mobility range or business loci as the vendors were not interviewed. The challenges encountered in assessment of “mobile targets” might make these PoSs as an abandoned research focus area. A similar issue was raised for research among street food vendors.[34]

Another important thing to discuss is that the mobile PCO scheme operationalized in 2004–2005. It was implemented by the Delhi SC/ST/OBC/Minorities and Handicapped Finance and Development Corporation Limited, under which the Corporation distributed mobile wheelchairs to the physically challenged persons intending altruism and self employment, adding to public health.[18],[19] Due to an influx of mobile phones and technological boom, STD and PCO schemes could not survive as means of earning livelihoods. It was found that 36.5% of them were government sponsored and only one had NGO logo. Our study findings suggest tobacco selling as a prominent business among WC-PoS (n = 93.5%). Although we could not assess the total number of wheelchair-based outlets in these areas, these figures are alarming as it gives deeper insights to the attitudes of the handicapped persons who, in the process of overcoming employment challenges, are bound to make some questionable choices. The point that needs attention is that these choices might encourage the customer's behavior in terms of both empathy and sympathy.

A committee should be set up with District Tobacco Control Cell with members from local bodies, law enforcement agencies, education department, Minorities and Handicapped Finance and Development Corporation Limited, and DTIDC for combined action to reach out for stricter compliance and awareness among WC-PoS vendors. A provision of retail licensing by the government (specifying the retail business) during the distribution of wheelchairs should now be considered. Another measure could be government directions/guidelines, to be issued in the public interest specifying the permissible retail business. Research has found that unlisted retailers are more likely to violate regulations as these tobacco retailers do not list their business details with the government as required.[35] Tobacco retailer/vendor licensing is recommended as an efficient tool for ensuring responsible retailing and reducing tobacco usage, especially among the youth.[21],[36]

To the best of our knowledge, there is no previously available data portraying the picture of WC-PoSs in India. An exploratory approach with a multistaged random design in all the 11 districts of the national capital remains the highlight of this study. It contributes substantially to tobacco compliance research and opens vistas for operational research. However, there were study limitations that need mention. First, the cross-sectional observational design impedes inferring any associations or causality between the compliance and independent variables. Furthermore, due to its exploratory design describing the unique scenario of WC-PoS, hypothesis testing was unwarranted. Larger, more representative multicentric surveys at a national level can focus upon regional or state differences that may impact the strength of the results. Observational assessment of tobacco sale to and by minors is a strong finding in this study. However, observations carried for a brief amount of time might have led to underreporting of the results. Third, due to the design limitation, we were unable to inquire about the vendors' educational status, knowledge regarding the ill effects and potential harms related to tobacco use, and the existent tobacco laws in the country. These might be possible contributors in the high noncompliance rates at these vends. Improving vendor compliance through effective implementation of tobacco POS laws remains a crucial step for law enforcement. Finally, we did not assess any association between compliance and form of tobacco sold as both smoked and smokeless forms were found at all the observation units with varying brands and frequency. However, no special note was made for the brand names.


  Conclusions Top


Among the screened areas within all the 11 districts of Delhi 200 WC-PoSs centered mainly in South Delhi zone. Majority of them were mobile outlets and not complying with Section 5 with advertisements in the form of product display, banners, dangles, and promotional gifts. None of the WC-PoSs displayed Section 6(a) signage while only a few were located within 100 yards of educational institutions. Since this group constitutes “socially pertinent spot” it is of utmost public health concern and needs rigorous monitoring. Overall, these novel findings strengthen the case for stricter regulatory measures for these emerging PoSs in a sensitive manner, keeping in mind the employment requirements of the handicapped.

Ethical approval statement

Being an unobtrusive observational study, no individual participant information was collected, hence no prior informed consent from the vendors was taken for making observation.


  Acknowledgment Top


We thank the Bloomberg Initiative to Reduce Tobacco Use, supporting the Tobacco Control Unit at The Union South-East Asia Office (The Union), New Delhi.

Financial support and sponsorship

This study was supported under the Bloomberg Initiative to Reduce Tobacco Use program through a project awarded to The Union South-East Asia (The Union).

Conflicts of interest

There are no conflicts of interest.



 
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