title: A Two-Wave Observational Study of Compliance With Youth Access and Tobacco Advertising Provisions of the Cigarettes and Other Tobacco Products Act in India.
abstract: BACKGROUND
  The Indian Cigarettes and Other Tobacco Products Act prohibits youths' access to tobacco products at points-of-sale and near educational institutions, requires signage stating these restrictions in these venues, and bans outdoor advertisements. This observational study examined compliance with these provisions, changes in compliance over 1 year, and factors associated with compliance.
  
  
  METHODS
  Data were collected in 2012 and 2013 from points-of-sale (n = 555 in 2012, n = 718 in 2013), educational institutions (n = 277 in 2012, n = 276 in 2013), and neighborhoods (n = 104 in 2012, n = 125 in 2013) in 25 urban and rural towns in five states. Compliance across years was compared using chi-square tests. Multilevel regression equations assessed factors associated with compliance at Wave 2 and change in compliance from Wave 1 to Wave 2.
  
  
  RESULTS
  Most points-of-sale had no/low compliance, with little change over time (58% to 63%, P = .108). The proportion of educational institutions observing just 1-2 provisions increased (39% to 52%, P = .002). Most neighborhoods complied with the advertisement ban at both waves (91% to 96%, P = .172). In the multilevel analysis, point-of-sale compliance increased in small cities; compliance decreased at points-of-sale and increased at institutions in mid-sized cities. Changes in point-of-sale compliance were due to compliance with access restrictions and signage requirements; changes in educational institution compliance were due to compliance with the sales ban.
  
  
  CONCLUSIONS
  Compliance with provisions regarding the sale and display of tobacco products is moderate, while compliance with the advertisement ban remains high in these five Indian states. Greater enforcement will further reduce youths' exposure to tobacco products.
  
  
  CONCLUSIONS
  The study adds to the literature on compliance and changes in compliance with policy to prohibit youth access to tobacco products in India, a country that has large geographic disparities in youth smoking prevalence. The findings highlight several important areas on which efforts can focus to improve compliance among points-of-sale, educations institutions, and neighborhoods to limit youths' exposure and access to tobacco products. Rural areas and large cities in particular need more concerted efforts.
authors.affiliation: Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; emead1@umd.edu.
authors.forename: Erin L
authors.initials: EL
authors.lastname: Mead
authors.affiliation: Department of Prevention and Community Health, George Washington University Milken Institute School of Public Health, Washington, DC;
authors.forename: Rajiv N
authors.initials: RN
authors.lastname: Rimal
authors.affiliation: Department of Health, Behavior and Society, Institute for Global Tobacco Control, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD;
authors.forename: Joanna E
authors.initials: JE
authors.lastname: Cohen
authors.affiliation: Department of Prevention and Community Health, George Washington University Milken Institute School of Public Health, Washington, DC;
authors.forename: Monique M
authors.initials: MM
authors.lastname: Turner
authors.affiliation: Department of Prevention and Community Health, George Washington University Milken Institute School of Public Health, Washington, DC;
authors.forename: Elena C
authors.initials: EC
authors.lastname: Lumby
authors.affiliation: International Research, Campaign for Tobacco-Free Kids, Washington, DC.
authors.forename: Ellen C
authors.initials: EC
authors.lastname: Feighery
authors.affiliation: International Research, Campaign for Tobacco-Free Kids, Washington, DC.
authors.forename: Vandana
authors.initials: V
authors.lastname: Shah
mesh_terms: D000293:Adolescent; D000329:Advertising / Q000331:legislation & jurisprudence*; D002947:Cities; D003132:Commerce / Q000331:legislation & jurisprudence*; D019983:Guideline Adherence; D006801:Humans; D007194:India; D055361:Multilevel Analysis; D012044:Regression Analysis; D012111:Residence Characteristics; D012574:Schools; D000074606:Smoking Prevention; D019460:Tobacco Industry / Q000331:legislation & jurisprudence*; D062789:Tobacco Products / Q000331:legislation & jurisprudence*; D014029:Tobacco Use Disorder