Compliance With Point-of-Sale Tobacco Control Policies in School-Adjacent Neighborhoods in Mumbai,India

Abstract

Purpose:

We assessed factors associated with tobacco vendor compliance with India’s Cigarettes and Other Tobacco Products Act (COTPA) provisions regulating tobacco sales and point-of-sale (POS) environments.

Design:

Study design was a cross-sectional random sample of tobacco vendors in Mumbai, India (2010).

Setting:

School-adjacent neighborhoods were the study setting.

Subjects:

Study subjects were tobacco vendors (n = 436).

Measures:

Face-to-face interviews, and audits of POS environments were used to assess compliance.

Analysis:

Factors associated with compliance were identified using logistic regression.

Results:

About 4% of vendors were fully compliant. Although 80% reported compliance with the ban on tobacco sales to minors, only 10% displayed signage about the ban. About 84% were compliant with the two–tobacco advertisement limit; of those displaying advertisements, 67% were compliant with size limits, 68% with content restrictions, and 8% with health warning requirements. Knowledge about fines for noncompliance was associated with compliance with the ban on sales to minors (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.26, 3.56) and signage requirement (OR, 4.42; 95% CI, 1.76, 11.13). Greater compliance with the two-advertisement limit was associated with higher store income from tobacco (OR, .26; 95% CI, .09, .73) and lower neighborhood socioeconomic status (p < .01); the latter was associated with advertisement size limits compliance (p < .05).

Conclusions:

Compliance with COTPA provisions was low. Interventions modifying vendor knowledge about provisions and fines may increase compliance, and they should target stores that are reliant on tobacco sales.

Keywords

tobacco control policy tobacco access policy compliance prevention research

Purpose

In the coming decades, the already devastating global burden of diseases from tobacco use is expected to rise in low- and middle-income countries.¹ India will experience a disproportionately higher share of this burden because it is the second largest consumer of tobacco in the world.² The prevalence of adult and youth tobacco use in India is high, with 48% of adult males, 20% of adult females, 19% of adolescent males, and 8% of adolescent females reporting current tobacco use.^2
–4 Because of the high prevalence of tobacco use, India experiences an estimated 1,000,000 deaths annually from tobacco-related diseases, making tobacco use a leading cause of premature mortality.⁵

With the Cigarettes and Other Tobacco Products Act (COTPA),⁶ India has made significant commitments to reducing the future burden from tobacco-related diseases. At the time of this study, COTPA banned the sale of tobacco within 100 yards of educational institutions and to persons younger than 18 years. At the point-of-sale (POS), COPTA required a sign indicating that it is illegal to sell tobacco to persons younger than 18 years, and regulated tobacco advertisements as follows: (1) limiting the quantity of tobacco advertisements at the POS to two; (2) specifying that the size of tobacco POS advertisement boards can be no more than 60 cm by 90 cm; (3) allowing only brand name and product image on tobacco advertisements; and (4) requiring that at least 25% of the surface area of tobacco advertisements include a health warning. Tobacco control experts agree that it is a research priority to study the impact of regulating tobacco sales and POS environments on reducing population-level tobacco use.^2,7 For example, a systematic review⁸ and a recent longitudinal study⁹ found that POS marketing increased susceptibility to tobacco use among youths, and stimulated impulse purchases.¹⁰

The existing body of research about tobacco POS policy compliance from a handful of countries,^{11

–18} including several studies in India,^19

–24 has generally used store audits including checklists, photographs, and other methods of documenting compliance at the POS environment. Several studies in India have used semistructured interviews with vendors^20,23,24 about store activities and vendor perceptions. The studies in India were primarily focused on provisions about POS advertising and pictorial warnings, whereas studies in other regions were concerned with tobacco product placement,¹² pricing, and the sale of single cigarettes.¹⁶

Reports on compliance with POS provisions are wide ranging, with studies from Europe,^11,12 North and Central America,^{16
–18,25

–28} Australia,¹⁴ and New Zealand¹⁵ showing a high level of compliance, and studies from the Middle East¹³ and South Asia^19

–24 showing moderate to low compliance levels. Studies from countries other than India noted low compliance with restrictions about advertisement visibility beyond the POS (Lebanon)¹³; placement, including placement near products marketed to children (New Zealand)¹⁵; and signage stating no sale to minors (Norway and Australia)^12,14; and moderate to low compliance with bans on the sale and marketing of tobacco near schools (Mexico).¹⁶ Compliance levels in India were consistently lowest for restrictions on advertisement size,¹⁹ and there was moderate compliance with bans on the sale and marketing of tobacco near schools.^21,22

Researchers have examined community-level factors associated with compliance with tobacco POS policies, including the proportion of children in the local population, ethnic composition, and community socioeconomic status. A study in the United States²⁵ showed that vendors in low-income areas were less likely to be compliant, and a higher proportion of Hispanics within a community was a slightly positive indicator²⁵ for compliance. A study in New Zealand¹⁵ showed that in neighborhoods with a higher proportion of children the vendors were less likely to be compliant, whereas the proportion of ethnic minorities (Pacific Islander and Maori) was not associated with vendor compliance. Studies in India^20,21 showed that vendors in low-income areas were less likely to be compliant.

Studies from various regions (Ireland,¹¹ Lebanon,¹³ Australia,¹⁴ New Zealand,¹⁵ the United States^25,26,29) have examined vendor-level factors associated with POS policy compliance, primarily citing store type. These studies showed that larger stores, such as supermarkets and grocery stores or chains, were significantly more compliant than smaller stores, such as convenience stores and dairies.^11,15,25,29 Studies in the United States found that pharmacies and drug stores were 3.4 times more likely to be noncompliant than grocery stores,²⁵ and female vendors and younger vendors were less compliant with bans on sales to minors.²⁹ Studies from the United States²⁵ and Lebanon¹³ identified low levels of knowledge about POS policies and associated fines as contributing factors, but they drew the conclusion without data from vendor interviews.^13,25 A recent study conducted in Mumbai, India,²⁰ interviewed tobacco vendors and identified a lack of economic alternatives, tobacco manufacturer promotion activities, and community norms as reasons for limited compliance with the COTPA regulations.

In this study, we measured the level of compliance of tobacco vendors with COTPA policies in school-adjacent neighborhoods in Mumbai, India; vendor knowledge about COTPA POS policies; and vendor preference for and receptivity to intervention strategies to increase awareness and compliance with COTPA POS policies. We also identified vendor- and school-level factors associated with compliance and vendor-level factors associated with receptivity to interventions to increase compliance. We hypothesized that there would be low vendor awareness of COTPA POS policies and associated fines; that there would be low compliance with policies; and that higher knowledge of policies and fines for noncompliance would be associated with increased compliance. We also hypothesized that tobacco vendors who were less knowledgeable about and compliant with COTPA POS provisions and those that earned a higher proportion of their revenue from tobacco sales would be more receptive to interventions aimed at increasing awareness of and compliance with POS provisions.

Methods

Design

This study reports on cross-sectional data from a larger project that assessed whether tobacco vendor and advertisement density near high schools influenced student tobacco use.²¹

Sample

The sample included 26 high schools in Mumbai, India, which were randomly selected for a population-based student tobacco survey from April to August 2010. During the same time period, up to 20 tobacco vendors within a 500-meter radius of each school were randomly sampled for a face-to-face interview as well as direct observations of the POS environment (n = 436), which was defined as the areas where any goods for sale were displayed as well as the area where sales transactions were made. This study reports on the tobacco vendor survey data from the 26 school-adjacent neighborhoods. The vendor response rate was 99%. This study received Institutional Review Board approval (G8-09-007-01; project no. 768).

Measures

Two aspects of compliance with tobacco sales provisions were measured. First, each vendor was asked if they sold smoking and smokeless tobacco to persons younger than 18 years (minors) in the 30 days prior to the survey. Compliance was indicated by self-reports of not selling either smoking or smokeless forms of tobacco minors (Yes/No). Second, interviewers directly observed the POS environment and noted whether a sign was displayed indicating it is illegal to sell tobacco to minors (Yes/No).

Compliance with POS tobacco advertising provisions was measured through direct observation by interviewers, who noted the quantity, size, and content of advertisements. Vendors displaying two or fewer advertisements were categorized as compliant with the provision limiting the quantity of advertisements (Yes/No). For each tobacco advertisement, interviewers noted whether: (1) it was within the size limit; (2) 25% of the surface area displayed a health warning; and (3) it included only the brand name and/or product image. To be defined as compliant with a particular provision, all advertisements at the POS needed to meet the requirements of that provision; that is, all advertisements were less than 60 cm × 90 cm (Yes/No); all advertisement had 25% of their surface area displaying a health warning (Yes/No); and all advertisements contained only brand name and/or product image (Yes/No).

Finally, being fully compliant was defined as compliance with all of the following: ban on tobacco sales to minors; requirement of a sign indicating it is illegal to sell tobacco to minors; quantity of tobacco advertisements displayed; size of advertisements; presence of health warnings on advertisements; and content of advertisements.

Vendors were asked if they were aware of the: (1) ban on tobacco sales to minors; (2) fines associated with the sale of tobacco to minors; (3) requirement of a sign indicating it is illegal to sell tobacco to minors; (4) fines associated with not displaying the sign; and (5) ban on the sale of tobacco within 100 yards of educational institutions. A “1” was recorded if the vendor had knowledge of the provision and a “0” was recorded if the vendor did not. A summary score was created for knowledge about POS provisions by summing responses across the five items (Cronbach α = .60). We did not ask vendors about knowledge of COTPA advertising provisions because of our resource constraints and in order to reduce responder burden.

Vendors were asked: “what resources would you use to learn about the tobacco laws and sale procedures?” Responses included: handouts; one-on-one education; in-person class; audiocassette or disc; videocassette; VCD or DVD; print media, such as newspapers; radio or TV promotions; or not sure. Handouts, audiocassette or disc, videocassette, and VCD or DVD were categorized as small print or audiovisual media; one-on-one and in-person classes were categorized as in-person education; newspapers and posters, and radio and television promotion were categorized as mass media. Receptivity to free training to increase compliance was measured by asking vendors: “how likely would you be to come to a free training on the tobacco laws and sale procedures?” Responses included “very likely,” “somewhat likely,” “not likely,” or “not sure.”

The following covariates were included: age in years, gender (male or female), religion (Hindu, Muslim, or other), education (less high school education vs. high school education or higher), median split for monthly family income, knowledge that tobacco use is harmful (Yes/No), past 30-day tobacco use (Yes/No), percent monthly share of retail income from tobacco sales, store type (general stores, which are about the size of corner shops and sell a variety of goods; pan walla, which are usually small stands and specialize in selling betel leaf and tobacco quid; tobacco stores specializing in selling mostly loose tobacco; and other stores), and tertile of each school’s fee structure as a proxy for school-adjacent neighborhood socioeconomic status (SES).

Analysis

First, descriptive statistics were calculated for vendor demographics, other covariates, measures of compliance, knowledge about provisions, and vendor preference for and receptivity to interventions to increase compliance. Second, to assess factors associated with tobacco vendor compliance with sale and advertising provisions, a series of logistic regression models were tested that included each measure of compliance as outcomes. The study covariates described above and measures of knowledge about sales provisions were included as predictors. Finally, logistic regression was used to assess factors associated with the likelihood of coming to free training designed to increase awareness of and tobacco vendor compliance with the provisions. Responses for receptivity of training were coded as 1, “very likely” or “somewhat likely”; and 0, “not likely” or “not sure.” The sample of vendors was clustered at the school-adjacent neighborhood level. The standard errors for the regression analysis were therefore adjusted for this clustering by using the cluster option in Stata 12.0.

Results

About 83% of respondents were storeowners. The mean age was 39 years, and 48% had an education level of high school or higher. The sample was mostly male (88%), and mostly Hindu (77%) or Muslim (18%). Median monthly household income was 6000 INR (or $95 U.S.), and the average percentage of store income from tobacco sales was 56%. Past 30-day tobacco use was 44%, and 94% of vendors understood that tobacco use was harmful.

Table 1 shows that most vendors knew about the ban on tobacco sales to minors (89%) and the provision requiring signage about the ban (85%), but far fewer vendors knew about the ban on tobacco sales within 100 yards of educational institutions (35%). Most vendors were aware of the fine for selling tobacco to minors (72%), but only a few (22%) knew about the fine for not displaying signage about the ban.

Table 1.

Tobacco Vendor Knowledge and Attitudes About Tobacco Point-Of-Sale (POS) Provisions, Compliance With Provisions, and Preference of and Receptivity to Interventions to Increase Compliance (n = 436).

	Frequency (%)
Knowledge about tobacco POS provisions
Knowledge of ban on tobacco sale to minors	388 (89.0)
Knowledge of law about signage of ban on tobacco sale to minors	371 (85.1)
Knowledge of fine associated with selling tobacco to minors	314 (72.0)
Knowledge of ban on tobacco sale near educational institutions	154 (35.3)
Knowledge of fine for not displaying signage	97 (22.3)
Compliance with specific tobacco POS provisions
Fewer than three tobacco advertisements	366 (83.9)
Ban on tobacco sale to minors	351 (80.5)
Signage of ban on tobacco sale to minors	45 (10.3)
Tobacco advertisements display only brand image	121 (68.4)*
Tobacco advertisements meet size limits	120 (67.8)*
Tobacco advertisements have health warning	14 (7.8)*
Compliant with all above provisions	16 (3.7)
Preference for and receptivity to interventions to increase compliance with tobacco POS provisions
Preference for resources to learn about tobacco POS laws
Small print or audiovisual media (handouts, CDs, DVDs, cassettes)	42 (9.6)
In-person education	41 (9.4)
Mass media (newspapers, posters, billboards, radio, television)	339 (75.7)
Not sure	14 (3.2)
Likelihood of coming to free training about tobacco POS laws
Very likely	90 (20.6)
Somewhat likely	200 (45.9)
Not likely	137 (31.4)
Not sure	9 (2.1)

*Percentages based on the denominator of tobacco vendors that displayed at least one tobacco advertisement at the POS (n = 177).

Less than 4% of vendors were fully compliant with tobacco POS policies. Although about 80% reported that they were compliant with the ban on the sale of tobacco to minors, only 10% displayed signage about the ban. An important caveat is that the compliance measure about the ban on tobacco sales to minors was based on self-reports. About 84% of vendors displayed fewer than three tobacco advertisements, but of those that displayed advertisements, 68% were compliant with the requirement that only brand name and product image be shown, 67% were compliant with the size limit, and only 8% were compliant with the requirement of a health warning.

When asked about which intervention strategies they would prefer to learn about tobacco POS laws, most vendors reported mass media strategies (76%), and about 19% reported small print media, audiovisual media, or inperson education. About 67% said they would be likely to attend a free training that raised awareness of tobacco POS laws.

Table 2 shows that the most important factor associated with self-reported tobacco vendor compliance with the ban on tobacco sales to minors was having knowledge about the fines for being noncompliant (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.26, 3.56). Vendors that were more likely to display a sign about the ban on tobacco sales to minors had an education level of high school or higher (OR, 2.06; 95% CI, 1.02, 4.17), knowledge of the provision (OR, 6.82; 95% CI, 1.39, 33.51), and knowledge of the associated fines (OR, 4.42; 95% CI, 1.76, 11.13). Store type and school-adjacent neighborhood SES were not associated with tobacco vendor compliance with the ban on sales to minors or the presence of the required signage.

Table 2.

Adjusted Logistic Regression of Tobacco Vendor Compliance With (1) the Ban on Tobacco Sales to Minors and (2) the Presence of Signage on Ban on Tobacco Sales to Minors (n = 436).

	Odds Ratio (95% Confidence Interval)
	Compliant With Ban on Tobacco Sale to Minors	Displayed Sign About Ban on Tobacco Sale to Minors
Age	1.01 (0.98, 1.03)	1.03 (0.99, 1.07)
Male	1.01 (0.43, 2.40)	2.73 (0.46, 16.28)
High school education or more	1.41 (0.80, 2.51)	2.06 (1.02, 4.17)*
Median or higher monthly household income	0.87 (0.51, 1.48)	1.17 (0.67, 2.05)
Muslim religion	0.64 (0.34, 1.19)	0.39 (0.11, 1.37)
Past 30-day tobacco use (yes)	0.98 (0.52, 1.84)	0.92 (0.34, 2.45)
Knowledge that tobacco is harmful (yes)	0.95 (0.25, 3.63)	0.34 (0.11, 1.03)**
Knowledge of ban on sale to minors	1.05 (0.45, 2.46)	—
Knowledge of fine for noncompliance with ban on sale to minors	2.12 (1.26, 3.56)***	—
Knowledge of signage requirement	—	6.82 (1.39, 33.51)***
Knowledge of fines for not displaying signage	—	4.42 (1.76, 11.13)***
Percent store income from tobacco sales	1.76 (0.69, 4.50)	2.60 (0.75, 9.06)
Store type
General store	Reference	Reference
Pan walla (street tobacco vendor)	0.50 (0.18, 1.39)	1.08 (0.28, 4.17)
Tobacco store	1.22 (0.25, 6.00)	0.41 (0.02, 6.95)
Other	0.87 (0.41, 1.86)	0.34 (0.10, 1.18)
Neighborhood socioeconomic status
Low	1.31 (0.64, 2.68)	1.90 (0.92, 3.94)
Medium	1.21 (0.58, 2.53)	1.46 (0.55, 3.89)
High	Reference	Reference

*p < 0.05.

**p = 0.056.

***p < 0.01.

Table 3 shows that the percentage of store income from the sale of tobacco products (OR, .26; 95% CI, .09, .73) and neighborhood SES were the only factors associated with tobacco vendor compliance with the provision limiting the quantity of tobacco advertisements. Vendors in the low-SES (OR, 4.44; 95% CI, 2.83, 6.99) and medium-SES (OR, 5.49; 95% CI, 2.20, 13.72) neighborhood groups were at higher odds of being compliant with this provision than vendors in high SES neighborhoods. Male vendors had lower odds of compliance with the tobacco advertisement size limit (OR, .24; 95% CI, .07, .75). Pan wallas compared with general stores (OR, 3.80; 95% CI, 1.06, 13.71), and vendors in low-SES compared with high-SES neighborhoods (OR, 3.65; 95% CI, 1.06, 12.51) were at higher odds of being compliant with the tobacco advertisement size limit. Muslim religion was the only factor associated with tobacco vendor compliance with health warning requirements on tobacco advertisements (OR, 2.15; 95% CI, 1.11, 4.18). Median or higher household income (OR, 3.43; 95% CI, 1.67, 7.01) was the only factor associated with tobacco vendor compliance with the requirement that all tobacco advertisements only include the brand name and/or product image.

Table 3.

Adjusted Logistic Regression of Tobacco Vendor Compliance With Point-Of-Sale Advertising Provisions (n = 436).^†

	Odds Ratio (95% Confidence Interval)
	Fewer than Three Advertisements	Advertisements Meet Size Limits^‡	Advertisements Have Health Warning^‡	Advertisements Display Only Brand or Product Image^‡
Age	1.01 (0.99, 1.04)	0.99 (0.96, 1.02)	1.02 (0.99, 1.05)	1.01 (0.98, 1.04)
Male	0.47 (0.16, 1.36)	0.24 (0.07, 0.75)*	0.44 (0.12, 1.69)	0.64 (0.24, 1.76)
High school education or more	1.15 (0.59, 2.24)	0.51 (0.24, 1.08)**	1.05 (0.55, 2.00)	1.21 (0.67, 2.20)
Median or higher monthly household income	1.03 (0.51, 2.07)	1.01 (0.45, 2.24)	1.46 (0.75, 2.85)	3.18 (1.56, 6.48)***
Muslim religion	1.73 (0.76, 3.96)	0.64 (0.18, 2.24)	1.95 (1.05, 3.60)*	0.82 (0.31, 2.14)
Past 30-day tobacco use (yes)	1.30 (0.65, 2.59)	1.19 (0.63, 2.25)	0.50 (0.20, 1.27)	0.97 (0.36, 2.65)
Knowledge that tobacco is harmful (yes)	0.55 (0.12, 2.50)	0.54 (0.02, 12.29)	4.40 (0.52, 37.27)	4.25 (0.70, 25.73)
Percent store income from tobacco sales	0.26 (0.09, 0.73)***	0.39 (0.12, 1.29)	1.58 (0.37, 6.68)	3.11 (0.54, 17.90)
Store type
General store	Reference	Reference	Reference	Reference
Pan walla (street tobacco vendor)	0.51 (0.14, 1.83)	3.80 (1.06, 13.71)*	1.09 (0.25, 4.75)	1.48 (0.43, 5.18)
Tobacco store	0.63 (0.10, 3.95)	Omitted^§	0.44 (0.05, 4.17)	0.28 (0.05, 1.67)
Other	0.49 (0.15, 1.57)	2.65 (0.75, 9.38)	2.51 (0.67, 9.47)	0.71 (0.23, 2.23)
Neighborhood socioeconomic status
Low	4.44 (2.83, 6.99)***	3.65 (1.06, 12.51)*	0.48 (0.18, 1.30)	0.64 (0.27, 1.49)
Medium	5.49 (2.20, 13.72)***	5.00 (0.91, 27.51)****	1.57 (0.50, 4.89)	0.81 (0.34, 1.92)
High	Reference	Reference	Reference	Reference

^†Note: adjusted for store type, which was nonsignificant.

^‡Odds ratios are based on the subset of tobacco vendors that displayed at least one tobacco advertisement at the point-of-sale (n = 177).

^§Tobacco stores were removed from the sample for this analysis because 100% of them were compliant with the advertisement size limit.

*p < 0.05.

**p = 0.078.

***p < 0.01.

****p = 0.064.

Table 4 shows that older vendors (OR, .98; 95% CI, .96, 1.00) were at lower odds of reporting that they would come to free training. Past 30-day tobacco use (OR, 1.59; 95% CI, 1.01, 2.51), knowledge of tobacco POS provisions (OR, 1.42; 95% CI, 1.12, 1.80), and compliance with the ban on tobacco sales to minors (OR, 2.53; 95% CI, 1.55, 4.11) were associated with coming to an in-person training.

Table 4.

Adjusted Logistic Regression of Tobacco Vendor Receptivity to Free Training to Increase Awareness of and Compliance With Point-of-Sale (POS) Provisions (n = 436).

	Likely to Come to Free Training, Odds Ratio (95% Confidence Interval)
Age	0.98 (0.96, 1.00)*
Male	1.20 (0.56, 2.57)
High school education or more	0.71 (0.50, 1.03)**
Median or higher monthly household income	1.40 (0.96, 2.03)***
Muslim religion	1.14 (0.66, 1.96)
Past 30-day tobacco use (yes)	1.59 (1.01, 2.51)*
Knowledge that tobacco use is harmful (yes)	2.38 (0.82, 6.90)
Summary score of knowledge about tobacco POS provisions	1.42 (1.12, 1.80)****
Percent store income from tobacco sales	0.45 (0.17, 1.17)
Store type
General store	Reference
Pan walla (street tobacco vendor)	1.08 (0.48, 2.43)
Tobacco store	1.11 (0.27, 4.45)
Other	1.45 (0.66, 3.18)
Neighborhood socioeconomic status
Low	1.38 (0.86, 2.20)
Medium	0.98 (0.56, 1.71)
High	Reference
Compliant with ban on tobacco sale to minors	2.53 (1.55, 4.11)****
Has signage of ban on tobacco sale to minors	0.95 (0.44, 2.06)
Fewer than three tobacco advertisements	1.22 (0.50, 3.00)
Tobacco advertisements meet size	0.83 (0.35, 1.96)
Tobacco advertisements have health warning	1.50 (0.72, 3.14)
Tobacco advertisements display only brand or product image	0.63 (0.33, 1.20)

*p < 0.05.

**p = 0.070.

***p = 0.080.

****p < 0.01.

Discussion

Full compliance with COTPA POS provisions was low (3.7%), suggesting that much work is needed to achieve widespread compliance. The overall low compliance levels are consistent with findings from other low and middle income settings.^{13,15
–17,20,22,25,30,31} There was a high level of awareness of POS provisions regarding the ban on tobacco sales to minors and associated fines. There was also a high level of awareness of the provision requiring signage about the ban on tobacco sales to minors; however, there was generally low awareness about the fines associated with tobacco vendor noncompliance with this provision. Increasing knowledge about the provisions and the consequences of noncompliance will be important for increasing tobacco vendor compliance with these tobacco POS provisions. The multivariate results from our study and from others^26,32 suggest that these knowledge factors were associated with compliance. This is particularly true for the COTPA provision requiring a sign about the ban on tobacco sales to minors. Displaying a sign indicating no tobacco sales to minors could serve as an important deterrent to tobacco vendors and would-be minor customers attempting to purchase tobacco, and increase awareness of the ban in the community at large.

Vendors who reported a greater percentage of the store’s income from tobacco sales were less likely to be compliant with the provision limiting the quantity of tobacco advertisements. For stores more reliant on income from tobacco sales, the potential revenue gained from marketing tobacco products may offset the comparatively nominal legal consequences of noncompliance. Although about 84% of vendors were compliant with the limit on the quantity of tobacco advertisements, there was moderate noncompliance with size limits and widespread noncompliance with the presence of necessary health warnings. Marketing of tobacco through posters and storefront marquees near educational institutions appears to be an important risk factor for youth tobacco use.²¹

A very common practice, which was also described by other researchers,^19,24 was to use a large marquee above a store entrance that displayed one to two tobacco advertisements. Although the main content of the advertisement met COTPA size specifications, the brand colors and imagery stretched well beyond the size limits and could be seen by the general public from at least as far as 50 meters away. This practice and overall noncompliance with advertisement size limits were more common for general stores than for pan wallas. General stores are the most common type of convenience shop selling packaged foods, beverage, candy, and tobacco products in urban India, and pan wallas are one of the most common retailers of tobacco. These vendor types represent important tobacco access points with which young people as well as the general public regularly interact.

Studies are inconsistent with respect to vendor compliance with tobacco POS provisions and neighborhood SES.^15,17,33 In this study, vendors in lower SES neighborhoods were at higher odds of being compliant with provisions about the quantity and size of advertisements. There may be more rigorous enforcement in lower SES neighborhoods, and/or tobacco vendors in these neighborhoods may be more fearful of attention from enforcement agencies and/or the consequences of being caught. Our prior research did find that low-income school-adjacent neighborhoods in Mumbai had a greater density of tobacco vendors.²¹ Enforcement activities may be more common in high–tobacco vendor density areas.

To date, we have not found any tobacco vendor–level interventions in India designed to increase compliance with COTPA POS provisions. Intervention research from other countries can serve as a starting point for identifying evidence-based and promising strategies. For example, studies indicate that a combination of vendor education and enforcement efforts improves compliance, particularly enforcement that is frequent and uniform across communities.^26,34,35 A graduated system of fines was found to be effective in avoiding backlash to enforcement.²⁶ Some interventions have indicated that community organizing, and targeting local policy and norm change can also help to improve vendor compliance.^32,36 This approach is also supported by tobacco vendors in Mumbai slums, who cited community and cultural norms as prominent factors in noncompliance.²⁰

Our findings suggest that a variety of strategies could be tested to increase compliance with POS laws. First, educating vendors about the harms of tobacco use and delivering cessation services to vendors who use tobacco may be helpful as there was a high proportion (44%) who reported current tobacco use. Tobacco using vendors were more likely to report that they would attend in-person trainings about COTPA provisions. Interventions could also include mass media strategies, which were most commonly endorsed by vendors and could have the broadest reach. Inperson education and small media strategies were also commonly endorsed, indicating promising participation rates.

Adequate enforcement of COTPA provisions seems necessary, but current enforcement activities appear to be inconsistent.³⁷ The Union Ministry of Health is the central enforcer; however, reports suggest that communication and coordination between the federal ministry and state and district agencies require increased attention and resources than currently allocated.³⁷ Some challenges include identification of appropriate enforcement agencies, including the local health ministries, police departments, and schools. In addition, there is a need to firmly establish appropriate roles, responsibilities, and accountability processes for the enforcement of COTPA policies by these agencies. A combination of strategies is needed to create a culture of compliance that makes adherence to and enforcement of tobacco control laws normative. These strategies could include activities to increase vendor knowledge about the laws, clearly delineate enforcement responsibilities and expectations, and increase community awareness and support for laws.

There are a few notable strengths and limitations to this study. First, a critical limitation to the study included using a self-reported measure for compliance with the ban on tobacco sales to minors. Because of resource limitations we could not make direct objective measurements of vendor compliance with the provision banning tobacco sales to minors. We anticipate the compliance rate reported here is biased upwards. Despite this limitation, the other measures of vendor compliance in this study were assessed objectively through direct observation. Second, this study was based on a relatively small random cross-sectional sample of vendors in school-adjacent neighborhoods in Mumbai, therefore limiting the generalizability of the findings to other types of neighborhoods and other parts of the country, and precluding causal inferences. However, a wealth of information was gained about tobacco vendors in school-adjacent neighborhoods frequented by youth, vendor awareness and compliance with impotant COTPA provisions, and factors associated with compliance.

This study suggests that full compliance with POS tobacco sale and advertisement policies was low in school-adjacent neighborhoods in Mumbai, India, and that vendor-level factors, such as knowledge of policies and associated fines, as well as neigborhood SES, were important contributing factors. Vendors seemed generally receptive to participating in interventions to improve tobacco vendor compliance with POS laws.

SO WHAT? Implications for Health Promotion Practitioners and Researchers

What is already known on this topic?

The levels and determinants for tobacco point-of-sale (POS) policy compliance are unknown in India, a country that experiences a high burden of disease and mortality from tobacco use.

What does this article add?

This study shows that overall compliance was low, with only 4% of tobacco vendors being completely compliant with all tobacco POS policies. Knowledge about tobacco POS policies and associated fines, and neighborhood socioeconomic status were associated with compliance.

What are the implications for health promotion practice or research?

More needs to be done to increase compliance, particularly for stores that are highly reliant on tobacco sales. Increasing vendor knowledge about provisions and associated fines, and improving enforcement may increase compliance.

Footnotes

Acknowledgments

This work was supported by the Fulbright-Nehru Scholar Program and the Jonsson Cancer Center Foundation.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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