Implementation of tobacco control policies in India: a realist evaluation

Tobacco use is a major risk factor for non-communicable diseases and 28.6% of Indian adults consume tobacco, making this research on implementation of tobacco control policies highly relevant. This research study aims to describe, analyse and evaluate the implementation of select tobacco control policies in India. Owing to the complex nature of the policy under study we chose the realist evaluation method to answer our research questions. The findings highlight the diversity of implementation of tobacco control policies across Indian states and associate the implementation of tobacco control policies in India with tobacco use and underlying mechanisms to explain the implementation process in diverse settings. An initial program theory was developed based on existing implementation theories and frameworks, policy and program documents and the researcher's experience of supporting policy implementation at subnational levels in India. This was followed by a systematic review of literature through a realist synthesis to refine the initial programme theory. The program theory explains mechanisms working under four main strategies of awareness, enforcement, intersectoral coordination, and tobacco industry interference. This was followed by a realist evaluation through case studies of three contrasting Indian states. Here mechanisms that are facilitating or hindering the implementation of tobacco control policies in different Indian settings were identified. The major mechanisms include collective action, felt accountability, individual motivation, fear of enforcement, and prioritization.