India faces a significant public health and economic challenge due to its status as the world’s second-largest consumer and producer of tobacco. Despite the ban on smoking in public places 25 years ago, initiated by a landmark judgement of the Kerala High Court and formalized by the Cigarettes and Other Tobacco Products Act (COTPA) in 2003, tobacco use remains widespread. According to the Global Adult Tobacco Survey (GATS) 2016-17, nearly 267 million Indian adults (approximately 29% of the adult population) use tobacco in some form; more recent estimates from 2022 suggest around 253 million tobacco users. The lack of current national surveys hinders the precise tracking of ongoing trends and highlights the critical need for regular, updated surveys to inform evidence-based policymaking.

Although COTPA has reduced passive smoking, enforcement inconsistencies persist across states. Nicotine's highly addictive nature, deemed by some researchers as more addictive than cocaine and heroin, is exploited by the tobacco industry, which targets young people through strategic advertising to cultivate lifelong customers. Ravi Mehrotra of the India Cancer Research Consortium (ICMR) notes that many tobacco users start before age 18, with one-third of daily smokers aged 20-34 beginning daily tobacco use before reaching this age. The absence of uniform evaluation metrics across states, compounded by weaker enforcement, limited funding, and inadequate training for enforcement officers, impedes COTPA compliance.

Mehrotra also points out the scarcity of cessation facilities in India and the lack of comprehensive scientific studies to evaluate their effectiveness. Smoking causes 930,000 deaths annually in India, while smokeless tobacco contributes to 350,000 deaths, totaling approximately 3,500 deaths daily. Additionally, over 200,000 deaths result from second-hand smoke exposure. The economic burden is substantial, with tobacco use costing India nearly Rs 1.7 trillion in 2017-18, considering healthcare expenses and lost productivity.

National Family Health Surveys indicate a decline in tobacco consumption, with 38% of men aged 15-49 reporting tobacco use in 2019-21, 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 contributing to tobacco use are categorized using the Capability, Opportunity, Motivation-Behaviour (COM-B) model. Psychological factors include a lack of awareness about health risks, difficulties with self-control, and mental health challenges. Many individuals use tobacco for stress relief or mood improvement, making those with mental health disorders particularly vulnerable. Pratima Murthy of NIMHANS highlights the doubled risk of smoking among people with depression, who are also more likely to develop dependent patterns and experience severe withdrawal symptoms. Integrating tobacco cessation into mental health services at primary health centers could help to address relapse rates.

Physical opportunities, such as widespread advertising, easy access to products, and media portrayals of smoking, promote initiation. Social opportunities, like peer pressure, parental use, cultural norms, and notions of masculinity, reinforce the habit. The practice of chewing paan with tobacco, particularly among women in Uttar Pradesh, normalizes smokeless tobacco use. The sale of single cigarettes, comprising nearly 75% of all cigarette sales, increases affordability and accessibility, especially among minors and low-income users, undermining health warnings and taxation.

Automatic motivations, like emotional management and risk-taking, and reflective motivations, including perceived benefits and stress coping, also drive tobacco use. India has implemented strict control measures, including large pictorial health warnings on packaging. However, Mehrotra notes that the impact of these warnings diminishes over time as young people become desensitized. Regularly updating and strengthening warning labels and combining them with other anti-tobacco campaigns is essential. The Ministry of Health and Family Welfare announced new packaging and labeling rules in December 2024, introducing stronger warnings and a national quitline number, effective from June 2025. The World Health Organization identifies increased taxes as the most effective way to discourage tobacco use, citing Australia's 69% cigarette tax as an example of significant decline in smoking. While India’s cigarette taxes reach 53% of retail price, they fall short of WHO’s 75% benchmark.

The National Tobacco Control Programme (NTCP) establishes Tobacco Cessation Centres (TCCs) in district hospitals, offering counselling, medication, and nicotine replacement therapy. Approximately 32% of tobacco users reported trying to quit in the 12 months prior to the 2019-21 NFHS survey. However, with only 600 TCCs nationwide, India has about one cessation center per two million people, with rural areas underserved. The National Tobacco Quit Line offers community-based counselling via a toll-free number, and the m-cessation initiative uses text messaging to support quitting. Specialised institutes like NIMHANS and Tata Memorial Centre offer tobacco cessation services, and AI-powered apps like QuitNow could complement m-cessation by offering personalized quitting plans.

Strengthening community-based programmes and implementing effective screening initiatives, especially in rural areas, is critical. Mehrotra advocates leveraging mobile devices and internet connectivity for community health workers to conduct screenings and maintain records. He stresses the need for early screening and cancer detection to minimize healthcare burdens. Rakesh Gupta of the Strategic Institute for Public Health Education and Research highlights the successful model established by the NTCP in Punjab, which involves a state-level coordination committee and enforcement squads at various levels. This framework is being replicated in other states, though proper enforcement remains a challenge. India needs to find a collective will to eradicate smoking from its public places through community-led interventions and tailored policies, drawing inspiration from model states.