Monitoring Field-Level Compliance and Temporal Trends of Statutory Pictorial Health Warnings on Tobacco Products in India, 2020–21: A 21-City Observational Study

Objective: To strengthen the WHO-Framework Convention on Tobacco Control (FCTC) MPOWER “warn” component, India implemented 85% pictorial health warnings (PHWs) on all tobacco packs in 2016, allowing a two-month grace period to clear old stock. We monitored compliance and the time taken to comply with the revised PHW rules effective December 1, 2020, during December 2020–May 2021. Methods: A cross-sectional survey assessed one prominent tobacco point-of-sale (PoS) in each of 21 cities across nine Indian states, with 24 follow-up visits. A “saturation approach” measured the weeks required for full adoption of new PHWs, with product and brand analyses conducted across all cities. Results: Tobacco companies took an average of 10 weeks to comply with PHW regulations for 399 products, exceeding the two-month legal limit. None of the surveyed cities attained both complete saturation and full regulatory compliance across all three tobacco product categories. Saturation in the first week of the observation was achieved by cigarette brands (“One and Only and Moments” ), smokeless tobacco brands (“ Eagle, and Gopal 100”) , and bidi brands (“ Desai bidi, Dinesh bidi, and Naresh bidi”) . Conclusions: Tobacco companies in India are non-compliant with the new PHW rules 2020, with diverse regional saturation trajectories. This clearly makes a case for the non-compliant industry behavior toward Indian regulations. There is a need to strengthen enforcement and reduce discrepancies across various city-states to ensure that the grace period is not violated by the tobacco companies.