Why India’s Fight Against Smoking Needs A Behavioural Shift

Despite decades of policy action, however, India is the world’s second-largest consumer and producer of tobacco, and consequently faces a formidable public health and economic challenge.

The Global Adult Tobacco Survey (GATS) 2016-17 says that nearly 267 million Indian adults--about 29% of the adult population--use tobacco in some form. More recent estimates suggest there are around 253 million tobacco users in India as of 2022. The lack of updated national surveys since 2022 limits precise tracking of current trends, highlighting the need for frequent surveys to inform evidence-based policymaking.

While the ban under COTPA has led to reduced passive smoking, enforcement remains inconsistent across states, according to the Report on Tobacco Control in India 2022, by the Ministry of Health and Family Welfare.

Nicotine is among the most addictive substances in the world, with some researchers deeming it to be more addictive than cocaine and heroin. “The tobacco industry takes advantage of this by targeting young people through advertisements and behavioural strategies, aiming to create lifelong customers,” says Ravi Mehrotra, Program Lead at the India Cancer Research Consortium, affiliated with the Indian Council of Medical Research (ICMR). “A significant portion of tobacco users, including smokers, begin using tobacco products before age 18.”

One-third of all daily smokers aged 20-34 had started smoking tobacco on a daily basis before attaining the age of 18, the GATS survey found.

Every state has different enforcement policies, as a result of which India has no uniform evaluation metrics for the outcomes. In states with weaker enforcement, limited funding and inadequate training for enforcement officers hinder COTPA compliance. “Today, the cessation facilities available in India are very few, and there has been little to no scientific study or random clinical trials to see how many people have benefited and what the actual quit rate is due to these facilities,” says Mehrotra, who serves on the board of directors of the India Cancer Genome Atlas and is the founder of the Centre of Health Innovation & Policy (CHIP) foundation.

In India, smoking causes 930,000 deaths each year while smokeless tobacco leads to 350,000 deaths--together adding up to about 3,500 deaths every day, estimates suggest. In addition, over 200,000 people die from causes attributable to second-hand smoke exposure. The economic cost is staggering: tobacco use cost India nearly Rs 1.7 trillion in 2017-18, taking into account the healthcare expenses and lost productivity.

Geographical variations in smoking habits

The National Family Health Surveys suggest a decline in tobacco consumption. In 2019-21, 38% men aged 15 to 49 years reported using some form of tobacco, down from 57% in 2005-06. Among women, this number fell from 11% to 9%. Northeast Indian states report the highest prevalence of tobacco use.

Factors driving tobacco use

Several factors contribute to the widespread use of smoking tobacco in India. From a behavioural science perspective, a 2023 paper groups the reasons for tobacco use initiation into six categories based on the Capability, Opportunity, Motivation-Behaviour (COM-B) model.

Psychological capabilities play a role, as many individuals lack knowledge about the harmful health effects of tobacco, struggle with self-control, or face mental challenges. Many people start using tobacco believing it will relieve stress, anxiety, or improve mood. Individuals with mental health disorders are particularly vulnerable.

Pratima Murthy, director, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru and an expert in addiction psychiatry and tobacco cessation, points out the mental health links to smoking. “Research shows that the risk of smoking is doubled among people with depression, and those with depression are more likely to develop dependent patterns of tobacco use and experience more severe withdrawal symptoms.” Integrating tobacco cessation into mental health services at primary health centres could address higher relapse rates among individuals with depression or anxiety.

Physical opportunities, including the widespread presence of tobacco advertising, easy access to tobacco products, and seeing celebrities smoke on screen, create an environment that encourages smoking initiation. Social opportunities, like peer pressure, parental tobacco use, cultural traditions that normalise tobacco, and notions of masculinity, further reinforce the habit. For example, in Uttar Pradesh and elsewhere, the cultural practice of chewing paan with tobacco, often offered at social gatherings, normalises smokeless tobacco use, particularly among women.

One notable driver of physical opportunities is the widespread sale of single cigarettes. Nearly 75% of all cigarettes are sold as single sticks, estimates show, making them more affordable and accessible, especially to minors and low-income users. “This practice undermines the impact of health warnings and taxation, as single sticks do not display the mandated graphic warnings and evade higher taxes applied to full packs,” explains Mehrotra.

Automatic motivation, such as using tobacco to manage emotions, seeking temporary pleasure, or engaging in risk-taking, and reflective motivation, which includes beliefs about perceived benefits, underestimating risks, and coping with stress--also drive people to start smoking or to persist with the habit.

India has implemented strict tobacco control measures, including large pictorial health warnings covering 85% of tobacco packaging. However, as Mehrotra points out, “They have been shown to have some effectiveness, but the impact can diminish over time. Many young people become desensitised to the current warning labels.” Regularly updating and strengthening warning labels and combining them with other anti-tobacco campaigns is therefore essential. The Ministry of Health and Family Welfare announced new packaging and labelling rules in December 2024, introducing stronger warnings and a national quitline number, effective from June 2025.

According to the World Health Organization, the most effective way to discourage tobacco smoking has been to increase the taxes on it and other smoking products. “The single best way of increasing the effectiveness of tobacco control is increasing the taxes. In countries like Australia, where the cigarette tax is as high as 69%, there has been a significant decline in smoking in the past decade,” said Mehrotra. While India’s cigarette taxes, reaching 53% of retail price, are high, they fall short of WHO’s 75% benchmark, limiting their impact on reducing affordability.

Cessation efforts

The government has made several efforts for individuals seeking to quit smoking. The National Tobacco Control Programme (NTCP) focuses on establishing Tobacco Cessation Centres (TCCs) in district hospitals, offering free behavioural counselling, medication, and nicotine replacement therapy. This also reflects in the data: About 32% of people who use tobacco reported trying to quit in the 12 months prior to the 2019-21 NFHS survey.

With only 600 TCCs nationwide, however, India has roughly one cessation center per two million people, with rural areas particularly underserved.

The National Tobacco Quit Line provides community-based counselling through a toll-free number, and the m-cessation initiative uses text messaging to support quitting. Specialised institutes like NIMHANS in Bengaluru and Tata Memorial Centre in Mumbai offer tobacco cessation services. AI-powered apps like QuitNow, tailored for Indian users, could complement m-cessation by offering personalized quitting plans.

Need to strengthen community-based programmes

There is an urgent need to strengthen community-based programmes and implement effective screening initiatives, especially in rural and underserved areas. Mehrotra urges the community leaders and social workers to focus on their level with the help of technology. “Leveraging the widespread availability and affordability of mobile devices and internet connectivity, community health workers can use smartphones and tablets to conduct screenings, maintain records, and ensure that no one is left out of follow-up care.”

Mehrotra stresses the need for early screening and cancer detection to minimise the burden on healthcare and personal expenses. “Early screening is essential because many individuals, especially women from lower-income groups who are busy with daily work, may not recognise the importance of getting checked for early signs of disease. By making screening accessible, affordable, and trusted, health systems can detect health issues in asymptomatic individuals and improve outcomes across communities.”

Rakesh Gupta, president, Strategic Institute for Public Health Education and Research, and a tobacco control advocate, tells IndiaSpend how the model was established by the National Tobacco Control Program (NTCP) in Punjab, a state that has seen a significant decline in tobacco consumption. “We had a state-level coordination committee, which included most of the stakeholder ministries, like the health department, the education department, and the home department under which they have the police. All the stakeholders are part of the state-level coordination committee, and meetings were held every three months.” There are enforcement squads at the state level, district level and block level with similar bodies to ensure cooperation on the ground.

These enforcement squads are responsible for raiding premises which violate the tobacco laws frequently. “The NTCP in the state earned enough through challans (fines) in these squares to regulate its tobacco enforcement. This framework is being replicated in states like Rajasthan, Bihar, Uttar Pradesh and Karnataka, though ensuring these are enforced properly is a challenge. It depends on the state programme officer, state nodal officer, and the political will in the state.”

India needs to find a collective will to eradicate smoking from its public places, through community-led interventions that prevent the initiation altogether, and take inspiration from model states to establish policies tailored to their regions.

IndiaSpend reached out to the health ministry for comments. We will update this story when we receive a response.

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