India, where there are more than 300 million tobacco users, is facing a serious public health crisis due to addiction, disease and policy shortcomings.

Although the government has implemented tobacco control laws and initiatives under frameworks such as the Cigarettes and Other Tobacco Products Act (COTPA) and the National Tobacco Control Program (NTCP), the fight against tobacco remains ineffective.

Evidence from doctors, public health experts and India’s own reports highlights the structural and operational flaws undermining the country’s fight against tobacco.

Tobacco use in India kills 1.35 million people annually and causes economic loss of Rs 1,77,341 crore, which is more than 1 percent of GDP. Despite claims of success, including tobacco prevalence declining from 34.6 percent in 2009–10 to 28.6 percent in 2016–17, the absolute number of users remains elusive due to population growth.

As Professor Ravi Mehrotra of the National Institute of Cancer Prevention and Research explains, “One reason we have a higher number of tobacco users than many other countries is our huge population.” However, of greater concern is the persistence of high consumption among vulnerable groups, particularly rural populations and adolescents, underscoring the critical need for targeted interventions and sustained public health campaigns to curb this epidemic.

Health care professionals have identified another important gap in India’s tobacco control measures: cessation support. Dr. Pankaj Chaturvedi of the Tata Memorial Center points out that the current approach relies more on punitive deterrence rather than providing effective support to quit smoking, which he calls a major mistake. They highlighted the limited availability and prohibitive cost of nicotine replacement therapy (NRT), making it inaccessible to most people who need it.

Adding to the concern, others emphasize the inadequacy of the termination infrastructure. “Most people are ready to leave their jobs. But they can’t just leave. Quitting is difficult, so we have to support them,” explains Dr Star Pala, associate professor in the department of community medicine at the North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences and co-principal investigator of the Resource Center for Tobacco. Control (RCTC), a joint initiative of PGIMER Chandigarh and Central Government.

He acknowledges the government’s efforts to set up tobacco cessation centers and clinics in every district, but stresses the need to strengthen these facilities with dedicated manpower to ensure their effectiveness.

Dr Sonu Goyal, Pala’s colleague and principal investigator at RCTC, is more optimistic about the government initiative. Dr. Goyal, Professor, Department of CM-SPH, PGIMER, believes that India is making meaningful progress in supporting cessation efforts. He points to India’s status as home to the world’s largest tobacco quit line, which offers services in 18 languages.

This quit line provides support to users directly via phone, as well as a mobile quit app that sends customized messages to assist with quitting. Additionally, India now has four National Quit Line Hubs in Bengaluru, Guwahati, Noida and Mumbai, representing a significant step forward in providing accessible support to users across the country.

India has also taken a lead by introducing licensing for tobacco sellers in eight states. Vendors are required to be licensed and may only sell tobacco products, ensuring that specialty tobacco shops limit exposure to other items. This initiative is rare globally and indicates India’s innovative approach to tobacco control. Similarly, the Tobacco Free Educational Institutions (TOFEI) guidelines mandate compliance from all educational institutions. Recently, the government has directed all medical and dental colleges to set up tobacco cessation clinics, expanding the reach of these vital services.

“We were tasked by the Central Government to evaluate the effectiveness of quit-tobacco lines and we found that they have been quite successful in helping people quit tobacco,” says Dr Goyal. However, he argues That integrating these quit lines with a health management information system (HMIS) – a web-based platform for health data collection and analysis – will further increase their impact. “Over time, HMIS-derived output indicators will give us a clearer picture of our progress,” he added.

Dr Pratima Murthy of NIMHANS highlights another overlooked challenge: the stigma associated with tobacco addiction. She points out that for many low-income individuals, tobacco serves as a coping mechanism for poverty and stress, but current policies fail to address the underlying socio-economic causes of addiction. As Dr. Goyal says, socio-cultural factors present additional barriers: “Implementation is challenging due to the diversity of tobacco products and cultural practices. For example, traditional smoking methods such as hookah are deeply entrenched in some communities, making regulation and intervention more complex.

India’s tobacco control policies prioritize activity-based metrics such as awareness campaigns and number of inspections, rather than concrete outcomes such as quit rates. This bureaucratic focus obscures the real impact – or lack thereof – on tobacco consumption. “The work being done should not lead to success,” says Dr Pala.

Taxation, a key element of India’s tobacco control strategy, has had unintended consequences. High taxes on factory-made cigarettes have reduced their consumption, but also pushed users toward cheaper, more harmful alternatives such as beedis and smokeless tobacco, giving rise to a robust black market.

Paradoxically, only 8 percent of India’s tobacco consumption comes from legally manufactured cigarettes, despite the country being a major exporter of premium quality tobacco.

Globally, tobacco-related discussions primarily revolve around cigarettes. However, in India, the focus has shifted to smokeless tobacco, which is not only more affordable and widely available but also largely unregulated.

“When one neighbor produces smokeless tobacco and another consumes it, monitoring becomes almost impossible. Small-scale tobacco sales further complicates taxation,” explains Mehrotra.

India’s fight against tobacco is not just a public health challenge – it is a test of its commitment to saving lives and promoting equitable development. Without a radical change in policy, millions of people will remain trapped in the deadly grip of tobacco.