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1960 Floyd Patterson knocks out Ingemar Johansson of Sweden in the fifth round at the Polo Grounds in New York to become the first fighter to regain the undisputed world heavyweight title. Johansson lies in a daze on the canvas for at least five minutes before he is helped back to his corner. Patterson had lost his title to Johansson a year earlier when the Swede knocked him down seven times in the third round..
SLT use remains a huge public health concern for other countries in the region as well. Priority areas for SLT control should include: constant monitoring, increasing taxes and price of SLT products, strengthening and strict enforcement of existing laws, integration of SLT cessation with all health and development programmes, banning of advertisement and promotion of SLT, increasing age of access to tobacco up to 21 years, introducing licensing for the sale of SLT, standardising of SLT packaging and preventing SLT industry interference in the implementation of SLT control policies besides a committed multistakeholder approach for effective policy formulation and enforcement.India has taken tobacco control steps both at national and subnational levels which has resulted in significant reduction in tobacco use between 2009 2010 and 2016 2017 but with wide regional variations.There is wide gap in existing SLT control policies and their enforcement due to lack of research, training, capacity and adequate resources.Several tobacco control policies applicable to smoking products hitherto did not apply to SLT products.High SLT burden countries including India, especially its 13 high SLT burden states, should adopt and implement comprehensive tobacco control policies in line with WHO Framework Convention for Tobacco Control (FCTC) and beyond to curb SLT use.Greater policy focus and multistakeholder commitment for SLT control research, training, capacity and resources will help high SLT burden countries meet their WHO FCTC obligations.IntroductionNearly 356million people use smokeless tobacco (SLT) in 140 countries while 82% of this burden lies in the Southeast Asia.1 Moreover, 29 of these countries have high SLT burden with 10% or more prevalence of SLT use at the population level or either among males or females.2 Unfortunately, more than 0.65million people die every year due to SLT use.3 Most of the SLT products are produced in the traditional markets in the unorganised sector and remain away from regulations, and therefore greatly vary in their composition and health risks.4 5 Most of these products contain extremely high levels of nicotine resulting in chronic dependence.6 Research over the period has definitively established that SLT use is responsible for several forms of cancers,7 is associated with cardiovascular deaths8 and poor birth outcomes.9Although 181 countries and the European Union have ratified the WHO Framework Convention for Tobacco Control (FCTC), the global focus has remained mainly on curbing cigarette consumption and with little progress on SLT prevention and control.2 SLT use is more common and replacing smoking as the most popular choice among tobacco users in Bangladesh, India and Nepal.10 There is an increase in SLT use, and the share of SLT use in overall tobacco use across the three countries has increased.10 With majority of its tobacco burden as SLT use, several countries from the region have taken some efforts to curb SLT use including a complete prohibition on manufacture, sale and import of SLT in Bhutan.11 However, a comprehensive response from all stakeholders is much needed to deal with the problem.12India leads the global efforts in prevention and control of SLT and has implemented several laws, even beyond the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COTPA), to curb its use.2 Although there is clear progress in SLT control in India that can be replicated in the region and other high SLT burden countries, enforcement and continuous monitoring and evaluation of several of these policy measures remains a challenge.13Recently, several academicians, civil society organisations and statutory bodies from Southeast Asia including India have joined a new initiative called Addressing Smokeless Tobacco and Building Research Capacity in South Asia (ASTRA).14 On behalf of ASTRA India, a policy review and analysis was conducted to identify the existing policies on SLT regulations and the challenges, opportunities and priorities to improve its control in the country and highlight the lessons for the other high SLT burden countries in the region. A comprehensive review of the existing literature to identify the prevailing policies and the gaps therein to control SLT use was undertaken.