Implementation of the cigarettes and other tobacco products act (COTPA) in India: City population size as a predictor of compliance

Background. India enacted the Cigarette and Other Tobacco Products Act (COTPA) in 2003, which prohibits smoking in public places and requires separate smoking and non-smoking areas in hotels and restaurants. This paper asks whether compliance rates differ by city population size. Methods. Cities in five states in India (Bihar, Karnataka, Kerala, Maharashtra, Rajasthan) were sampled according to population size (Tier 1: largest urban centers; Tier 2: cities with populations up to about 1 million; Tier 3: cities with populations less than 500,000; and Tier 4: two rural areas in close proximity to Tier 1 cities) (n=26 cities). Public venues (n=747) were randomly sampled from systematically identified locations within each city (n=26 cities). A composite score of overall compliance was computed by summing across venues for three outcomes: indoor smoking, “No Smoking” signage, and presence of facilitators of smoking. A hierarchical linear model was run using city size as the independent variable, adjusting for city- and state-level random intercepts. Results. Overall compliance rates ranged from 3 to 21. City size was associated with compliance, F(3, 22) = 5.29, p < .001. Compared to rural towns, compliance was significantly greater in Tier 1 (beta= 0.7, p<.05) and Tier 2 (beta = 0.82, p < .05) cities, with no difference in Tier 3 cities. Conclusions. Though overall compliance needs to be improved across the board, smaller cities appear to have a more difficult time with compliance. More aggressive efforts should be pursued to ensure compliance with COTPA in India.