Accessibility of tobacco by youth in India: An observational study of compliance with the cigarettes and other tobacco products act (COTPA)

Background: COTPA prohibits the sale of tobacco products by youth (<18) and within 100 yards of schools, requires specific signage stating these restrictions at vendors and schools, and requires vendors not to display tobacco products within easy access to youth. We examined the extent of compliance with these provisions and factors associated with compliance. Methods: In 26 urban and rural towns in five Indian states (Bihar, Karnataka, Kerala, Maharashtra, Rajasthan), we assessed compliance among 505 vendors and 298 schools. Multilevel logistic regression models were used to identify factors associated with compliance, adjusting for a city-level random intercept and state-level robust variance estimate. Results: Only five (1%) of the vendors were fully compliant with the provisions banning sales by youth, restricting the accessibility of tobacco products by youth, and requiring the correct signage. Forty percent were moderately or highly compliant (with ≥2 provisions). The odds of vendor compliance did not change as a function of town size (P=0.85) or vendor type (P=0.31). Vendors sold tobacco within 100 yards of 67% of the schools. Only 6% of schools displayed required signage, none of which were in rural towns. The odds of compliance with the ban on sales near schools was 96% lower in moderately sized cities than rural towns (P<0.001) and 92% higher in secondary than primary schools. Conclusion: Compliance with COTPA provisions regarding the sale and display of tobacco products is low in these five states in India. Greater enforcement is needed to reduce the accessibility of tobacco products by youth.