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Introduction We studied adolescent and adult perceptions of the effects of larger size, 85% versus 40%, Graphic Health Warnings (GHWs) on conventional and plain tobacco packs, in India. Methods A cross-sectional survey was conducted with 2121 participants (aged ≥13 years), during the period 2015–16, in Delhi and Telangana, India. Four categories of GHWs on tobacco packs were shown: A – 40% existing (April 2013–April 2016), B – 40% new (April 2016–present), C – 85% new, and D – plain packs (85% new). Regression models tested percentage differences in choice of categories for eight outcomes, adjusted for gender, area of residence, socioeconomic status, age, and tobacco use. Results Of the total 2121 participants, 1120 were from Delhi, 1001 from Telangana, 50% were males, 62% were urban residents, 12% were adolescents, and 72% had never used tobacco. Among packs shown, the majority of participants perceived the 85% size GHWs more effective than the 40% size GHWs across all outcomes. The perceived increase in noticeability of GHWs was 45% for category C (p

Background Globally women face the problem of tobacco both as user and non-user. She face the greatest indirect burden including the health, economic and social cost of tobacco use by a family member while the tobacco industry continue to target women globally to increase their profits by recruiting more female tobacco users. This is increasingly complex with multiple products and multiple factors at play. Though in the developed countries tobacco use among females is declining, it is still very high and in places increasing among the low SES. In LMICS the gender gap is further narrowed while in some cases girls being ahead of boys. Methods The paper undertakes extensive review of available literature on girls and women with respect to tobacco. The information is reviewed for a gender analysis on prevalence, pattern and tobacco industry tactics for promoting tobacco use. Results Women are exposed to tobacco smoke at home. They suffer greater impact when pregnant. In case of tobacco use by family women are the ones who bear the indirect cost of such tobacco use by family. On the other hand they are targeted by tobacco industry and lured to using tobacco at an early age. In societies where smoking by women has been considered a taboo for long, the number of girls and women smokers is increasing. They are also using all kinds of smokeless tobacco products easily available in such societies, especially in South East Asia. Conclusions Tobacco control efforts globally should become gender responsive. Policy makers should recognise the importance of taking into consideration the gender aspects of tobacco use. It is important to understand the social and health issues challenging girl´s and women´s both due to their own tobacco use and tobacco use by a family member. We need more female leaders in the fight against tobacco control globally.

Background Until 1990, spitting was an offence in United Kingdom carrying a £5 fine. Spitting was also banned in other developed countries especially in Europe early in the 20 th Century as a preventive measure against tuberculosis and later to maintain cleanliness. Several health experts consider spitting a public health concern and smokeless tobacco in all its forms induces spitting, thereby causing risk for communicable diseases like tuberculosis. Methods A comprehensive review of existing literature on prohibition of spitting in public places was undertaken. Legislative and policy publications were reviewed for the reasons of such prohibition and punishments thereon. Results Spitting has been considered a public inconvenience and a nuisance. Spitting of chewing and other smokeless tobacco stains and defaces public vehicles, buildings and other public property and is a public nuisance. In a scientific study done in India the most frequent cited reason for quitting tobacco use was spitting and ash dropping which was embarrassing in-front of others. Several states in India have banned spitting by law. Nepal has banned use of any kind of tobacco products in public places. Bhutan prohibits smearing lime and spitting doma in public area. Hangzhou- a province in China has banned spitting in public places. Countries like Singapore, Myanmar and Australia also have imposed ban on spiting in public and impose hefty fine for violation of the provisions. Conclusions Several countries and cities have promulgated norms against spitting in public places, including spitting after SLT use. There is a need to undertake further research to study impact of spitting ban on SLT use.

Background Article 16 of WHO FCTC focuses upon limiting the supply and exposure of tobacco products to Minors. Implementation of Article 16 has been researched by few local and regional studies, primarily focusing on Cigarettes. This paper evaluates global progress in the area of access of SLT products to minors and compares with cigarettes. Methods A cross-sectional database of notified policies in FCTC ratified countries (n = 179) was prepared for SLT and CIG. Indicators studied were: Ban on Sale to minors; Treaty requirements (under the Ban on Sale to Minor); ban on sale by minor, prohibition on distribution of free tobacco products and prohibition on sale of loose/individual tobacco products. Countries were categorized according to World Bank Income groups and WHO regions. Data was analyzed using SPSSv17.0. Results Unequal implementation of provisions under Article 16 has been implemented for CIG and SLT products (nearly 79% Parties for CIG and 67% for SLT). Most countries have a partial (or none) policy in place (only 12% Parties have notified all provisions under Article 16(1) for CIG, and 10% for SLT). Implementation has been evaluated for CIG through indicators in GYTS, but not for SLT. Conclusions A comprehensive policy formulation on banning sale of tobacco to minors and its proper enforcement is required to prevent access and availability of tobacco including SLT to minors.

Background The FCTC country reports indicate that 70% of the reporting parties have implemented Article 12 in their jurisdictions. The MPOWER Report 2015 also indicates that nearly 40% of the Parties conducted at least one anti-tobacco national mass-media campaign. However, both reports do not provide any specific information on implementation of Article 12 with respect to SLT products. There are 23 Parties with more than 1 million SLT users. Methods This paper presents an analysis of the FCTC country reports, MPOWER report, besides the relevant indicators under GYTS, GSPS, GHPS and GATS with respect to mass-media, education and training efforts undertaken and reported by the Parties with high SLT burden. The health warning regulations of these parties has been reviewed. The paper also looks at other sources of mass-media information on hazards of SLT use like YouTube. Results The analysis reveals that: Only a limited number of Parties have implemented national and sub-national mass-media campaign on SLT. India is the only country with dedicated national mass-media on anti-SLT awareness, besides tobacco free schools, communities and villages. Only nine Parties from high burden countries have implemented health warnings on SLT. Some countries have also used mass-media including YouTube for raising anti-SLT awareness besides earned media. School education have limited information on hazards of SLT use. Limited Parties have included prevention of tobacco use in school curriculum. Teachers are not trained nor do they have access to teaching materials for youth tobacco prevention. Conclusions Parties with high SLT burden should use the Global Tobacco Surveillance System to collect data on various aspects of Article 12 on SLT use. This will help in developing and implementing focused and comprehensive national media education and communication initiatives to prevent SLT use, especially among vulnerable population group. Social media campaigns can also be used as effective interventions for SLT control.

Background There are approximately 346 million adult smokeless tobacco (SLT) users in the world dominated by the South-East Asian region accounting for nearly 86%. India alone accounts for 67% of the SLT users in the world. While the literature on price and tax measures for smoked tobacco products like cigarettes are more systematic and widely available this is not the case with SLT products. This paper presents the global status of price and tax measures implemented on SLT products by the Parties to FCTC. Methods An analysis of the country reports from the FCTC reporting instrument and the MPOWER Report 2015 is presented including a comparative analysis of cigarettes and SLT products. A review of the existing literature on the price and tax measures along with gaps and recommendations is also presented. Results Taxes on SLTs vary considerably across countries, from no tax on SLTs in five countries to 80.63% in Madagascar. Similarly, there is larger variation in prices of SLT products across countries and within country, across products. Available estimates show that the price elasticity for various SLTs are largely less than one, and hence, responds to price increases. Estimates on affordability of SLTs indicate that these products have become more affordable over the years. The recent changes in SLT taxation under the GST reform in India have reduced the tax burden further on these products. Conclusions Parties should equally implement price and tax measures on SLT. Taxation on SLT should be such that it keeps up with inflation, at the same time, ensuring that their prices sufficiently go up, making SLTs less and less affordable. The tax rates should be standardised across the SLT products to prevent substitution with other tobacco products. Efforts should be made to establish a standardized unit for the purposes of pricing or taxing SLTs.