Sale and promotion of tobacco products to youth around schools in a metropolitan city : A shoe leather survey

INTRODUCTION

Tobacco causes 6 million deaths globally and India accounts for one-sixth of the world’s tobacco- related deaths.^[1] The issue of tobacco control in India is complex, as its use is culturally rooted and easily available. Tobacco control law (Cigarette and Other Tobacco Products Act [COTPA]) in India was implemented in 2003;^[2] yet tobacco use has reached epidemic proportions. Tobacco industry largely target the youth as they are easily influenced by the urban culture and peer pressure; moreover are prone to be reckless and exhibit risk taking behaviors. The sale of tobacco products is banned about 100 yards from an educational institution, no sale to minors, yet, the number of youths taking up tobacco habit in India is increasing exponentially. Hence, the objective of this research was to document the density of tobacco retailers, point of sale (PoS) advertisements, attitude among retailers toward selling tobacco around educational institutions in Chennai metropolitan city.

MATERIALS AND METHODS

A total number of primary schools, higher secondary schools, and college institutions in Mogappair, Chennai city were obtained from the state school directory; all them were shoe leather surveyed to check for the display of warning sign around the premises; and every store within the radius of 100 yards from the institution was checked for tobacco sale and advertisement from June 18 to 30, 2019. The study was approved by the institutional ethical committee and consent was obtained from the shop keepers; no prior information was available regarding the sale of tobacco and advertisement before surveying. To assess the PoS advertisement, a checklist was designed specifically for this study. The checklist was developed in English and expected to be completed in not more than 5 min, it assessed the PoS advertisement (number and dimension of boards), display board stating prohibition of sale to minors, warning on boards as per regulation in each store, and no smoking sign. The checklist and the attitude questionnaire was pilot tested among ten stores and was found to be appropriate (attached as supplementary file). The face and content validity was assessed, and the reliability of the attitude questionnaire was found to be acceptable (0.72). Chi-square test was used to analyze nominal variables and to find association among the type of educational institution (primary school, secondary school, and colleges) and PoS and gender of salesmen, distance of PoS from educational institutions, and warning around institution premises.

RESULTS

A total of 57 retailers within the 100 yards of institution were surveyed and 94.7% of them sold tobacco, of which 31 were shops, 15 were cafes, and 8 were temporary settlements meant only for sale of tobacco. About 73% of PoS were located within 10 m from the institutions. Only one institution displayed tobacco ban and only one retailer had ban on tobacco sale to minor signage. About 46.4% felt it was wrong to sell tobacco as it causes cancer, 19.6% did not care (P < 0.05). About 47.3% did not want to stop tobacco sale as it was a means for their livelihood; 68.4% reported tobacco sale to be profitable; and 78.9% suggested that stopping tobacco production would reduce tobacco sales (P < 0.05) [Table 1].

DISCUSSION

Tobacco industry has been largely targeting the youth in developing countries, nearly 37% of children initiate tobacco use in India at the age of 10 years.^[3] Tobacco use among youth in India is a significant public health problem, which has derived very little attention presently. More than 50% of India’s population is below 25 years and the proportion of Indians taking up tobacco habit grows by 2–3% every year.^[4] The burden of tobacco epidemic is concentrated mainly over the developing countries in Asia, mainly because the two most populous countries being India next only to China, inadequate control measures, marketing gimmicks by tobacco companies, and poverty.^[5] The present trend of tobacco use is estimated to cause 10 million deaths by 2020–2025, of which 70% is expected in the developing world.^[6] India already contributes to one-sixth of global tobacco burden, if not controlled may be expected to increase by 2025.^[1]

Tobacco Control Law (COTPA) in India prohibits the sale of tobacco in and around educational institutions within a distance of 100 yards, but the results of our study showed the availability of tobacco at the doorstep of the institution even after 11 years of its implementation. Globally 1.1 billion people smoke of which 182 million are Indians.^[6] According to the global youth tobacco survey conducted in 2009, 14.6% of youth in India currently use any tobacco product, 4.4% currently smoke cigarettes, 12.5% currently use other tobacco products, and 15.5% of never smokers are likely to initiate smoking in the next year.^[7] A study conducted in Ahmedabad, Gujarat checked the compliance of COPTA among retailers around 30 randomly selected schools. They reported 87% of schools surveyed had tobacco sales within 100 yards similar to the results of our study.^[8]

To the best of our knowledge, this is the first study to look into the attitude of retailers toward tobacco sales in India. Tobacco Control Law (COTPA) in India has been implemented for more than a decade with limited success if at all. India bears the brunt of the global tobacco burden and tobacco use has reached epidemic levels. About 50% reported to quit tobacco sales if suitable alternative and compensation was provided, and more than half of them reported tobacco sales to be profitable. This provides a new insight as to the ineffectiveness in anti-tobacco legislation regulating tobacco sales. Money is lucrative factor which has to be considered and warrants new and innovative approach to improve compliance among retailers. More than majority felt that to improve compliance among retailers and to reduce tobacco sales was to stop the production of tobacco. Retailers are the terminal end to the tobacco distribution system, and a downstream approach without regulating the upstream flow is a serious flaw in the tobacco trade regulation.

Our study has its strength and is not without limitations; this is the first study to report a shoe leather survey of the tobacco PoS around educational institutions in a representative part of Chennai and Chennai being a metropolitan city provides an insight into the magnitude of access and availability of tobacco among the youth of the nation. Further, the attitude of retailers was self-reporting in nature and social desirability bias could have influenced their responses.

CONCLUSIONS

The unrestricted availability and enactment nonfeasance of tobacco control law in around educational institutions in Chennai shed light on the deterring hope in reversing the tobacco epidemic prevalent in India. As a signatory to the FCTC, its high time government takes appropriate action to effectuate anti-tobacco legislation to lower the tobacco burden in India and thereby reducing it globally.