Trends in tobacco consumption in India 1987–2016: impact of the World Health Organization Framework Convention on Tobacco Control

Which countries are ready for a tobacco endgame? A scoping review and cluster analysis

Various countries have set tobacco endgame targets to eliminate tobacco use by a certain year. Tobacco endgames are generally considered more feasible in countries with advanced tobacco control measures and a smoking prevalence of 15% or less. We conducted a scoping review of 563 articles sourced from news, academic literature, and grey literature to examine global tobacco endgame progress, and grouped 153 countries into clusters based on their tobacco policy implementation score and smoking prevalence to systematically identify countries that might be well positioned to succeed in a tobacco endgame. The EU, Pacific Islands, and 18 other individual countries have set tobacco endgame targets, with another seven countries described as well positioned for an endgame. These were mostly high-income countries with higher smoking prevalence. We identified 28 endgame-ready countries with advanced tobacco policies and a low smoking prevalence. Of these, only five were part of tobacco endgame movements; the remaining 23 were all low-income or middle-income countries in Africa, Latin America, or Asia. Therefore, the global tobacco endgame movement should focus more on low-income and middle-income countries with low smoking rates and advanced tobacco policies, particularly in Africa, Latin America, and Asia.

Shifting the gaze on implementation: examining the association between the implementation of tobacco control laws and prevalence of tobacco using data from a nationally representative survey

BACKGROUND

Tobacco use and the associated health burden is a cause of concern in India and globally. Despite several tobacco control policies in place, their sub-optimal and variable implementation across Indian states has remained a concern. Studies evaluating the real-world implementation of policies such as Cigarettes and Other Tobacco Products (COTPA) or National Tobacco Control Program (NTCP) in India and its association with reductions in tobacco use are limited. In this paper, we analyse data from a nationally representative survey to examine how policy implementation is associated with the tobacco use prevalence in India.

METHODS

We analysed data from the Global Adult Tobacco Survey (GATS 2016-17) India using multivariable logistic regression. The dependent variables were the use of smoked tobacco, smokeless tobacco, and tobacco in any form. The independent variables were proxies of implementation of the COTPA and the NTCP. We followed a step-wise backward elimination technique to reach the best fit models.

RESULTS

People exposed to no-smoking signages had lower odds of using tobacco (OR = 0.70, p < 0.001). People exposed to second-hand smoke (OR = 1.51, p < 0.001) and tobacco product advertisements (OR = 1.23, p < 0.001) had greater odds of using tobacco. Exposure to tobacco advertisements was associated with higher odds of using smokeless tobacco (OR = 1.23, p < 0.001), and smoked (OR = 1.33, p < 0.001) forms of tobacco.

CONCLUSION

We find significant association between the implementation of tobacco control laws/programs and tobacco use in India. Our findings highlight the potential that policy implementation holds in reducing population-level tobacco use thus drawing attention towards the implementation phase of policies. The findings have implications on prioritising enforcement of specific tobacco control measures such as smokefree laws, modifying COTPA signages to encompass all tobacco products including against smokeless tobacco use and strengthening indirect advertising restrictions. Future research could focus on developing and validating predictors specific to policy implementation to support policy evaluation efforts.

Tobacco usage in India: A meta-analysis of evidence drawn from regional studies between 2010 and 2022

OBJECTIVES

To generate a national and zonal pooled estimate of current tobacco usage (CTU) in any form, as well as stratified gender and tobacco type (smokeless and smoke) specific estimates among the Indian population, utilising evidence from 2010 to 2022.

METHOD

PubMed, Scopus, ScienceDirect, CINAHL and Google Scholar databases were searched for articles on tobacco use among Indian adults published between January 2010 and October 2022. The NIH Quality Assessment Tool was used to assess study quality, and a random-effects inverse-variance method was used to attain a pooled estimate of usage. Heterogeneity was estimated through I2 statistics and prediction intervals, and further subgroup analysis and meta-regression were conducted. A leave-one-out analysis was done to establish the sensitivity of the pooled estimate.

RESULTS

CTU prevalence of any form among the adult Indian population was 35.2% [confidence interval (CI) 25.27-45.92, I2  = 99.7, p < 0.001] between 2010 and 2022 with a wide Prediction interval between 3.19 to 78.74. The regionally drawn estimate for the years 2016-2022 was 44.3% (CI 30.57-58.64, I2  = 99.8, p < 0.01). Highest prevalence was found in the East zone (55.4%) followed by the northeast with 51.8% tobacco consumption. Although residual heterogeneity persisted after subgroup analysis, the variability in estimates showed statistical significance when considering disaggregated estimates across administrative zones and gender-wise consumption. The estimated CTU among males was 54.1%, whereas in females it was 15%. Leave-one-out analysis indicated the findings are reliable and are not dependent on any one study.

CONCLUSION

This review highlights differences in tobacco usage estimates from national-level surveys and regional studies. More regionally representative surveys of tobacco usage to tailormade prevention efforts alongside increased regional efforts improved community-level advocacy and more coordinated and stringent tobacco prevention policy implementation at national and state levels are warranted.

The global impact of tobacco control policies on smokeless tobacco use: a systematic review

BACKGROUND

Smokeless tobacco, used by more than 300 million people globally, results in substantial morbidity and mortality. For smokeless tobacco control, many countries have adopted policies beyond the WHO Framework Convention on Tobacco Control, which has been instrumental in reducing smoking prevalence. The impact of these policies (within and outside the Framework Convention on Tobacco Control) on smokeless tobacco use remains unclear. We aimed to systematically review policies that are relevant to smokeless tobacco and its context and investigate their impact on smokeless tobacco use.

METHODS

In this systematic review, we searched 11 electronic databases and grey literature between Jan 1, 2005, and Sept 20, 2021, in English and key south Asian languages, to summarise smokeless tobacco policies and their impact. Inclusion criteria were all types of studies on smokeless tobacco users that mentioned any smokeless tobacco relevant policies since 2005, except systematic reviews. Policies issued by organisations or private institutions were excluded as well as studies on e-cigarettes and Electronic Nicotine Delivery System except where harm reduction or switching were evaluated as a tobacco cessation strategy. Two reviewers independently screened articles, and data were extracted after standardisation. Quality of studies was appraised using the Effective Public Health Practice Project's Quality Assessment Tool. Outcomes for impact assessment included smokeless tobacco prevalence, uptake, cessation, and health effects. Due to substantial heterogeneity in the descriptions of policies and outcomes, data were descriptively and narratively synthesised. This systematic review was registered in PROSPERO (CRD42020191946).

FINDINGS

14 317 records were identified, of which 252 eligible studies were included as describing smokeless tobacco policies. 57 countries had policies targeting smokeless tobacco, of which 17 had policies outside the Framework Convention on Tobacco Control for smokeless tobacco (eg, spitting bans). 18 studies evaluated the impact, which were of variable quality (six strong, seven moderate, and five weak) and reported mainly on prevalence of smokeless tobacco use. The body of work evaluating policy initiatives based on the Framework Convention on Tobacco Control found that these initiatives were associated with reductions in smokeless tobacco prevalence of between 4·4% and 30·3% for taxation and 22·2% and 70·9% for multifaceted policies. Two studies evaluating the non-Framework policy of sales bans reported significant reductions in smokeless tobacco sale (6·4%) and use (combined sex 17·6%); one study, however, reported an increased trend in smokeless tobacco use in the youth after a total sales ban, likely due to cross-border smuggling. The one study reporting on cessation found a 13·3% increase in quit attempts in individuals exposed (47·5%) to Framework Convention on Tobacco Control policy: education, communication, training, and public awareness, compared with non-exposed (34·2%).

INTERPRETATION

Many countries have implemented smokeless tobacco control policies, including those that extend beyond the Framework Convention on Tobacco Control. The available evidence suggests that taxation and multifaceted policy initiatives are associated with meaningful reductions in smokeless tobacco use.

FUNDING

UK National Institute for Health Research.

Comparison of Secular Trends in Peptic Ulcer Diseases Mortality in China, Brazil and India during 1990-2019: An Age-Period-Cohort Analysis

BACKGROUND

Peptic ulcer disease (PUD) is a common disease worldwide, especially in developing countries. China, Brazil, and India are among the world's fastest-growing emerging economies. This study aimed to assess long-term trends in PUD mortality and explore the effects of age, period, and cohort in China, Brazil, and India.

METHODS

We collected data from the 2019 Global Burden of Disease Study and used an age-period-cohort (APC) model to estimate the effects of age, period, and cohort. We also obtained net drift, local drift, longitudinal age curve, and period/cohort rate ratios using the APC model.

RESULTS

Between 1990 and 2019, the age-standardized mortality rates (ASMRs) of PUD and PUD attributable to smoking showed a downward trend in all countries and both sexes. The local drift values for both sexes of all ages were below zero, and there were obvious sex differences in net drifts between China and India. India had a more pronounced upward trend in the age effects than other countries. The period and cohort effects had a similar declining trend in all countries and both sexes.

CONCLUSIONS

China, Brazil, and India had an inspiring decrease in the ASMRs of PUD and PUD attributable to smoking and to period and cohort effects during 1990-2019. The decreasing rates of Helicobacter pylori infection and the implementation of tobacco-restricting policies may have contributed to this decrease.

A Pandemic Treaty: Learning From the Framework Convention on Tobacco Control

The World Health Organization recently began developing a "pandemic treaty" in response to the perceived failures of the global COVID-19 response. The Framework Convention on Tobacco Control, which obligates members to certain global standards in tobacco control, is an example of a global public health agreement that may be used as a model for the pandemic treaty. Several challenges related to the convention, many from the tobacco industry itself, must be addressed if it is to be used as a prototype for a pandemic agreement. These include harm reduction policies, private-sector involvement, and its impact in low- and middle-income countries. A pandemic treaty may encounter similar challenges faced by the Framework Convention on Tobacco Control, particularly from industry groups with financial interests related to infectious disease control and prevention. Addressing challenges at the outset may facilitate the development and implementation of a more robust international instrument.

Variations in the patterns of tobacco usage among indian females - findings from the global adult tobacco survey India

Background

Males dominate in tobacco usage, as well as in tobacco research, knowing that women face more severe health consequences. There is a specific lack of information on epidemiological statistics, risks, and the level of knowledge among women regarding tobacco. This study examines the Global Adult Tobacco Survey (GATS)-India dataset to estimate female tobacco usage and assess socio-economic variations in tobacco consumption, awareness regarding the adverse effects of tobacco, noticing pack health warnings (PHW), and intention to quit tobacco use well as factors influencing these domains.

Methods

Using a geographically clustered multistage sampling method, the nationally representative GATS II (2016–17) interviewed 40,265 female respondents aged 15 years and above from all Indian states and union territories. Standard operational definitions were used to estimate the primary independent variables (community, individual, and household categories) and dependent variables like awareness regarding the adverse effects of tobacco, noticing pack health warning (PHW), and intention to quit tobacco. Sampling weights were adjusted while performing the analysis. Bivariate and multivariable analysis were used to generate the estimates.

Results

Of the total female respondents, 84.2% were never-users, 13.3% ever consumed Smokeless Tobacco (SLT) products, 1.8% ever smoked tobacco, and 0.8% were dual users once in their lives. Around 16% of the women had exposure to Second Hand Smoke (SHS) either at their homes, workplaces or in public places. Overall, maximum awareness was seen among non-smoker females (64.7%) and dual users (64.7%), followed by women exposed to SHS, SLT users, and smokers. PHW was noticed more by the bidi smokers, followed by SLT users and cigarette smokers. Factors that positively affected intention to quit smoking included younger age, secondary school education, self-employed status, the habit of buying packed cigarettes/bidi, believing that smoking causes serious illness, and attempted quitting in the last 12 months.

Conclusion

A high proportion of women consume tobacco which is significantly influenced by socio-demographic factors. Tobacco regulators should be especially concerned about women as the tobacco marketing experts target them. Mobilizing self-help groups and organizations working for women and children could assist broader campaigns to generate awareness and motivate quitting attempts.

Scoping Review of Existing Evaluations of Smokeless Tobacco Control Policies: What Is Known About Countries Covered, Level of Jurisdictions, Target Groups Studied, and Instruments Evaluated?

OBJECTIVE

The implementation of smokeless tobacco control policies lags behind those for smoking. This scoping review summarizes the studies that evaluated public policies on smokeless tobacco regulation (SLT) and provides an overview of the jurisdictional level, target groups, and policy instruments.

METHODS

Seven databases were systematically searched for studies reporting on public policies regulating SLT. Two reviewers independently screened all studies. Data extraction was performed using a predefined extraction form. Extraction was replicated for 10% of the identified studies for quality assurance. A narrative synthesis of the included studies was used to analyze and interpret the data. The protocol was published beforehand with the Open Science Foundation (OSF).

RESULTS

Fourty articles comprising 41 studies were included. Most of the studies reported in the articles were conducted in the United States (n = 17) or India (n = 14). Most studies reported outcomes for students (n = 8), retailers/sellers (n = 8), and users/former users (n = 5). The impact of public policies on smokeless tobacco use, in general, was most frequently assessed (n = 9), followed by the impact of taxes (n = 7), product bans (n = 6), sales/advertising bans near educational institutions (n = 4), and health warnings (n = 3) on consumer behavior.

CONCLUSIONS

There are significant gaps in the evaluation of smokeless tobacco regulation studies that need to be filled by further research to understand the observed outcomes. WHO reporting on Framework Convention on Tobacco Control (FCTC) implementation should be linked to studies evaluating smokeless tobacco control measures at all levels of jurisdictions and in countries not members of the WHO FCTC or do not provide data.

IMPLICATION

Large gaps in the evaluation of SLT control policies exist. For some countries, WHO FCTC evaluations are available for different levels of jurisdictions. In countries with a strong federal structure, there is a lack of data beyond the national level to provide a more detailed look at compliance, indirect effects, or implementation gaps. More research is needed at all levels of jurisdictions, which add to the work of the WHO to understand what works for which target group, how the different levels of jurisdiction interact, how the real-world context can be incorporated, and what indirect effects may occur.

Socioeconomic inequalities in tobacco cessation among Indians above 15 years of age from 2009 to 2017: evidence from the Global Adult Tobacco Survey (GATS)

BACKGROUND

Tobacco is strongly associated with socioeconomic status (SES), however evidence on differences in tobacco cessation by socio-economic attributes remains fragmented, especially in developing countries. The present study aims to estimate socioeconomic inequalities in tobacco cessation among Indian men and women above 15 years of age.

METHODS

Two rounds of the Global Adult Tobacco Survey (2009-2010 and 2016-2017), India was used to estimate the association between socioeconomic indicators (wealth index and educational attainment) with tobacco cessation using a multinomial modeling approach.

RESULTS

After adjusting for SES and demographic variables, we found significantly lower odds in tobacco cessation rates among respondents of GATS-2 (2016-2017) compared to GATS-1 (2009-2010). Additionally, huge regional variations in smoking and smokeless tobacco cessation rates were observed. Population belonging to the low wealth-asset score had higher odds of cessation compared to the high asset index. While greater educational attainment was seen to have a positive effect on cessation, the results were insignificant. Individuals belonging to the northeastern geographic region were seen to have the lowest odds of cessation. Though awareness about the health hazards of tobacco increased, cessation declined for both men and women. Quitting smokeless tobacco among men and women was observed to be lower than smoking.

CONCLUSION

This study is the first to provide national-level evidence on the association between tobacco cessation and socioeconomic attributes among Indians above 15 years of age. Findings suggest the need to scale up tobacco cessation services separately for men and women, and also for smoking and smokeless tobacco forms.

The association between the retail price of manufactured cigarettes and bidis on current smoking status in India

INTRODUCTION

In India, the retail prices of bidis and cigarettes varied between the two Global Adult Tobacco Surveys (GATS) conducted in 2009-2010 and 2016-2017. The relationship between the retail price of smoked tobacco products and their use is unclear for India. Our study thus aimed to use available datasets to investigate the association between the retail price and current smoking status of bidis and cigarettes in India.

METHODS

Current smoking status data for bidis and cigarettes were obtained from the two GATS rounds. The average state-level retail prices of bidis and cigarettes were obtained from India's Consumer Price Index- Industrial Workers database. Descriptive statistics were used to describe current smoking status patterns. Generalized Linear Mixed Models were used to investigate the association between the retail prices and current smoking status of bidis and cigarettes.

RESULTS

For cigarettes, an increase in the average retail price by one Indian Rupee was associated with a reduction in the odds of being a current smoker of 7% (OR=0.925; 95% CI: 0.918-0.932, p<0.001). For bidis, the association between the retail price and current smoking status was not statistically significant (OR=1.01; 95% CI: 1.00-1.02, p=0.082).

CONCLUSIONS

Current increases in the retail prices of tobacco products in India seem to have an impact on the use of cigarettes but not bidis. This highlights the need for tobacco product tax increases that result in sufficient retail prices increase to make all tobacco products less affordable and reduce their use.

Mixed Effect of Alcohol, Smoking, and Smokeless Tobacco Use on Hypertension among Adult Population in India: A Nationally Representative Cross-Sectional Study

Sporadic evidence is available on the association of consuming multiple substances with the risk of hypertension among adults in India where there is a substantial rise in cases. This study assesses the mutually exclusive and mixed consumption patterns of alcohol, tobacco smoking and smokeless tobacco use and their association with hypertension among the adult population in India. Nationally representative samples of men and women drawn from the National Family and Health Survey (2015-2016) were analyzed. A clinical blood pressure measurement above 140 mmHg (systolic blood pressure) and 90 mmHg (diastolic blood pressure) was considered in the study as hypertension. Association between mutually exclusive categories of alcohol, tobacco smoking and smokeless tobacco and hypertension were examined using multivariate binary logistic regression models. Daily consumption of alcohol among male smokeless tobacco users had the highest likelihood to be hypertensive (OR: 2.32, 95% CI: 1.99-2.71) compared to the no-substance-users. Women who smoked, and those who used any smokeless tobacco with a daily intake of alcohol had 71% (OR: 1.71, 95% CI: 1.14-2.56) and 51% (OR: 1.51, 95% CI: 1.25-1.82) higher probability of being hypertensive compared to the no-substance-users, respectively. In order to curb the burden of hypertension among the population, there is a need for an integrated and more focused intervention addressing the consumption behavior of alcohol and tobacco.

Vascular cognitive impairment in India: Challenges and opportunities for prevention and treatment

The burden of vascular contribution to cognitive impairment and dementia is substantially high in India. There are approximately 5.3 million dementia patients in India and nearly 40% are estimated to be due to vascular dementia. Several factors pose unique challenges to reducing the burden of vascular dementia and vascular cognitive impairment (VCI) in India. Wide heterogeneity in vascular risk factor profile, diversity in socioeconomic, ethnic and dietary factors, as well as regional and rural-urban differences impact uniform implementation of preventive and therapeutic strategies. There is limited evidence on the natural history of vascular disease from longitudinal cohorts in India. Additionally, the lack of advanced brain imaging and genetic information pose challenges to understanding pathophysiology and treatment response to VCI in India. Efforts are now being made to implement programmes to reduce cardiovascular risk and VCI at the population level. Cognitive and functional measures appropriate to the diverse linguistic and educational context have been developed to diagnose VCI across India. Multicentric clinical and research cohorts of stroke are also being established. Filling research gaps and developing intervention strategies for the Indian context are crucial to address the growing burden of VCI.

The effects of pharmacological interventions on smoking cessation in people with alcohol dependence: A systematic review and meta-analysis of nine randomized controlled trials

BACKGROUND

Pharmacotherapies are widely used for smoking cessation. However, their efficacy for people with alcohol dependence remains unclear.

OBJECTIVE

This study aimed to explore the effects of pharmacotherapies on smoking cessation for people with alcohol dependence.

METHODS

Five electronic databases were searched in January 2021 for randomized controlled trials (RCTs) reporting the use of pharmacotherapies to promote smoking cessation in people with alcohol dependence. The risk of bias was assessed using the Cochrane tool. RevMan version 5.3 was used to perform meta-analyses of the changes in smoking behaviour, and the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of the evidence.

RESULTS

The search identified nine RCTs involving 908 smokers with alcohol dependence; eight were published in the USA and one in Canada. The risk of bias was low in three studies and unclear in the remaining six. The meta-analysis results showed that, compared with the placebo group, Varenicline had a significant effect on short-term smoking cessation (three RCTs, odds ratio [OR] = 6.27, 95% confidence interval [CI]: [2.49, 15.78], P < .05, very low certainty). Naltrexone had no significant effect on smoking cessation in short-term or long-term observations (three RCTs, OR = 0.99, 95% CI: [0.54, 1.81], P = .97, moderate certainty), and Topiramate had no significant effects (two RCTs, OR = 1.56, 95% CI: [0.67, 3.46], P > .05, low certainty). Only one trial reported that Bupropion did not affect smoking cessation.

CONCLUSION

Varenicline may promote smoking cessation in people with alcohol dependence. However, Naltrexone, Topiramate and Bupropion have no clear effect on increasing smoking abstinence among drinkers. The small number of studies and the low certainty of evidence indicate that the results should be interpreted cautiously.

Effect of cigarette smoking on smoking biomarkers, blood pressure and blood lipid levels among Sri Lankan male smokers

Study purpose

The aim of this study was to determine the fractional exhaled nitric oxide (FeNO) levels, exhaled breath carbon monoxide (eCO) levels, blood pressure, blood lipid levels between smokers and non-smokers and to determine the association of smoking intensity with the above parameters.

Methods

This descriptive study was conducted in selected periurban areas of the Colombo District, Sri Lanka. Adult male current tobacco smokers (n=360), aged between 21 and 60 years were studied and compared with anthropometrically matched male non-smokers (n=180). Data were collected by interviewer-administered questionnaire, clinical assessment and measurement of FeNO by FENO monitor and eCO bySmokerlyser.

Results

Smokers had significantly lower mean FeNO levels and higher mean eCO values compared with non-smokers. Presentation of palpitations was higher among the smokers and a significantly positive correlation was identified between palpitations and eCO levels. There was a significantly positive correlation between the systolic blood pressure of smokers with the duration of smoking (DS), Brinkman Index (BI), Body Mass Index (BMI) and there was a significantly negative correlation with FeNO levels. The mean arterial pressure was positively correlated with the DS, BI and BMI. There was a significantly negative correlation between FeNO and the number of cigarettes smoked per day, DS and BI of smokers. Significantly higher total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), very LDL-C, TC: HDL ratio and low high density lipoprotein cholesterol (HDL-C) level was observed among smokers compared with the non-smokers.

Conclusions

Tobacco smoking was found to impact blood pressure and serum lipid levels thus enhancing the cardiovascular risk among smokers. The levels of eCO and FeNO are useful biomarkers for determining the intensity of smoking. The results indicate the necessity for urgent measures to stop cigarette smoking in Sri Lanka.

Tobacco use and nicotine dependence among patients with diabetes and hypertension in Ballabgarh, India

 Tobacco use is one of the most important modifiable risk factors for cardiovascular mortality and has a synergistic effect with diabetes and hypertension. This study was conducted to estimate the prevalence of tobacco use and nicotine dependence among adult diabetic and/or hypertensive patients. We conducted a cross-sectional study among 419 consecutively enrolled patients from the non-communicable diseases (NCDs) outpatient clinic of a secondary level hospital in Ballabgarh, India between July 2018 and January 2019. We administered a pre-tested questionnaire to assess tobacco use and Fagerstrom Test for Nicotine Dependence (FTND) to assess nicotine dependence. Current tobacco users were defined as those who smoked in the past seven days. Nicotine dependence was classified as low, moderate or high for the FTND score of 0 -3, 4-6, and 7-10, respectively. Seventy-nine patients had diabetes, 226 had hypertension, and 114 had both. The prevalence of tobacco use was 20.8% (95% CI : 17.1 - 24.9); prevalence of smoking was 15% (95% CI: 11.9 â€" 18.8) and smokeless tobacco use was 7.2% (95% CI: 5 - 10.1). Moderate to high nicotine dependence was found among 59.7% of tobacco users; 75.9% tobacco users attempted to quit tobacco in the past one month. One-fifth of attendees of a NCD clinic in a secondary level hospital used tobacco, most of whom had moderate-to-high nicotine dependence.  High level of nicotine dependence and inability to quit despite making an attempt for it necessitates the inclusion of tobacco cessation services in the management of patients with non-communicable diseases.

Declining trend of smoking and smokeless tobacco in India: A decomposition analysis

There has been a relative reduction of tobacco consumption between Global Adult Tobacco Survey-India (GATS-India) 2009–10 and GATS-India 2016–17. However, in terms of absolute numbers, India still has the highest number of tobacco consumers. Therefore, this paper aims to examine the socioeconomic correlates and delineate the factors contributing to a change in smoking and smokeless tobacco use from GATS (2009–10) to GATS (2016–17) in India. We used multivariable binary logistic regressions to examine the demographic and socioeconomic correlates of smoking and smokeless tobacco use for both the rounds of the survey. Further decomposition analysis has been applied to examine the specific contribution of factors in the decline of tobacco consumption over a period from 2009 to 2016. Results indicated that the propensity component was primarily responsible for major tobacco consumption decline (smoking- 41%, smokeless tobacco use- 81%). Most of the decrease in propensity to smoke has been explained by residential type and occupation of the respondent. Age of the respondent contribute significantly in reducing the prevalence of smokeless tobacco consumption during the seven-year period, regardless of change in the composition of population. To achieve the National Health Policy, 2017 aim of reducing tobacco use up to 15% by 2020 and up to 30% by 2025, targeted policies and interventions addressing the inequalities identified in this study, must be developed and implemented.

Utilisation, Availability and Price Changes of Medicines and Protection Equipment for COVID-19 Among Selected Regions in India: Findings and Implications

Background: COVID-19 has already claimed a considerable number of lives worldwide. However, there are concerns with treatment recommendations given the extent of conflicting results with suggested treatments and misinformation, some of which has resulted in increased prices and shortages alongside increasing use and prices of personal protective equipment (PPE). This is a concern in countries such as India where there have been high patient co-payments and an appreciable number of families going into poverty when members become ill. However, balanced against pricing controls. Community pharmacists play a significant role in disease management in India, and this will remain. Consequently, there is a need to review prices and availability of pertinent medicines during the early stages of the COVID-19 pandemic in India to provide future direction. Objective: Assess current utilisation and price changes as well as shortages of pertinent medicines and equipment during the early stages of the pandemic. Our Approach: Multiple approach involving a review of treatments and ongoing activities across India to reduce the spread of the virus alongside questioning pharmacies in selected cities from early March to end May 2020. Our Activities: 111 pharmacies took part, giving a response rate of 80%. Encouragingly, no change in utilisation of antimalarial medicines in 45% of pharmacies despite endorsements and for antibiotics in 57.7% of pharmacies, helped by increasing need for a prescription for dispensing. In addition, increased purchasing of PPE (over 98%). No price increases were seen for antimalarials and antibiotics in 83.8 and 91.9% of pharmacies respectively although shortages were seen for antimalarials in 70.3% of pharmacies, lower for antibiotics (9.9% of pharmacies). However, price increases were typically seen for PPE (over 90% of stores) as well as for analgesics (over 50% of pharmacies). Shortages were also seen for PPE (88.3%). Conclusion: The pandemic has impacted on utilisation and prices of pertinent medicines and PPE in India but moderated by increased scrutiny. Key stakeholder groups can play a role with enhancing evidenced-based approaches and reducing inappropriate purchasing in the future.