The Meghalaya model of tobacco control

Meghalaya's success story of achieving a national first recognition in community-led tobacco control can be a template for people's movement against harmful effects of tobacco use across the northeast region. In a state where an estimated 8,000 people die every year due to tobacco use, the achievement is remarkable, but the real challenge is sustaining it. Intensifying the enforcement of the Cigarettes and Other Tobacco Products Act (COTPA), 2003, to regulate the trade and commerce, production, supply and distribution of tobacco products alongside the community-led intervention is crucial for sustaining the success story and for a ripple effect in other villages in the state. The achievement of the 264 Village Health Councils (VHC) in Meghalaya complying with the criteria of Tobacco-free Villages (TfV) in two pilot districts - East Khasi Hills and West Jaintia Hills - demonstrates the critical role of social institutions in rooting the global health framework in social practices and behaviour for reducing health risks. The provisions under COTPA, 2003, prohibit smoking in public places; ban the sale of tobacco products to and by minors and the sale of tobacco products within a radius of 100 yards of educational institutions; prohibitdirect and indirect advertising of tobacco products; and mandate the display of specified health warnings on all tobacco product packs. However, due to poor enforcement and a low level of awareness, smoking in public and violation of the Act are rampant across the region. This harsh reality explains why the incidence of cancer due to tobacco use is the highest in the region in India. In the backdrop of an alarming rise in tobacco use in the region, the "Meghalaya Model" is a glimmer of hope for a change through empowerment of the communities.Under the TfV programme, VHCs in Meghalaya have been empowered to make their villages tobacco-free by appointing the Community Gender Health Activist or a VHC member as the nodal person; holding meetings to discuss and raise awareness with villagers; signing of a joint declaration by the VHC Chairperson and school principals affirming no sale of tobacco near schools; issuing orders for no smoking in public places; installing signage in public places; and running awareness drives in the community. A village is declared tobacco-free after completing five of these prescribed activities with verified compliance. An official release issued by the Meghalaya Government quotes community members as saying that before TfV people smoked freely in homes and near their children, but now they don't smoke in homes anymore, and smoking in public places has drastically reduced. This reflects the effectiveness of the community-led intervention in bringing about the behavioural changes that are essential to make the villages tobacco-free. Scaling up the model to more villages, as planned, will be crucial to create a ripple effect not just in Meghalaya but across the states in the region. The existence of similar social community-led institutions among different communities in the region is an advantage which should be leveraged to emulate the "Meghalaya Model" and innovate their own models for curbing tobacco use in other states. Strict enforcement of the Prohibition of Electronic Cigarettes Act (PECA), 2019, which prohibits the production, manufacture, import, export, transport, sale, distribution, storage and advertisement of electronic cigarettes and related devices, is of paramount importance to sustain the achievement in the 264 villages in Meghalaya. The communities must be made aware of the myths spread about e-cigarettes being safer and that they help smokers to quit tobacco consumption. The Indian Council of Medical Research, in a white paper on Electronic Nicotine Delivery Systems (ENDS) of e-cigarettes, warned that e-cigarette use adversely affects the cardiovascular system, impairs respiratory immune cell function and airways in a way similar to cigarette smoking and is responsible for severe respiratory disease. It also poses a risk to foetal, infant, and child brain development. It also states that studies have found that youths using ENDS or e-cigarettes are more likely to use regular cigarettes later. E-cigarettes increase the likelihood of experimenting with regular tobacco products and increase the intention to indulge in cigarette smoking. Official data shows that 470 stocks of e-cigarettes were seized in Arunachal Pradesh, and three stocks of e-cigarettes were seized in Assam over the past four years, which speaks volumes about the rising demand and smuggling of e-cigarettes in the region despite the ban, which is cause for grave concern. The ICMR warned that e-cigarettes can open a gateway for new tobacco addiction, which is a potential threat to the country's tobacco control laws and tobacco control programmes. This makes it imperative for the TfV programme to empower the community institutions spearheading the tobacco-free programmes to keep a strict vigil against e-cigarette vaping. As public health is a state subject, the state governments supporting the community-led institutions and strengthening the enforcement of the COTPA and PECA provisions is vital to ensure a ripple effect of the Meghalaya Model of tobacco control in the region.