Case Study 2

Knowledge synthesis – Tobacco-related NCDs and plain packaging policies, India

Knowledge synthesis on plain packaging to assess existing evidence to promote the selection of evidence-based policies and interventions for implementation in India

Why this case study?

This showcases knowledge synthesis in preparation for the implementation of tobacco plain packaging policies and interventions in India.

The case study also illustrates that, although there may be evidence for a policy or intervention’s effectiveness, it is important to take account of local context.


Knowledge synthesis on plain packaging to assess existing evidence to promote the selection of evidence-based policies and interventions for implementation in India


Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia

Health issue

Respiratory diseases and other NCDs caused by tobacco



Target population

Individuals who use tobacco products


Tobacco is responsible for 25% of deaths from respiratory diseases in India,(42) which is the world’s second largest consumer of tobacco (smoking and smokeless forms).(43) The prevalence of tobacco use is 48% in males and 20% in females, with many others exposed to second-hand smoke.(44, 45) Tobacco attributable deaths in India are expected to rise to 1.5 million annually by 2020.(46) It has been suggested that the cost of respiratory diseases attributable to tobacco in India in 2011 was US$ 600 million(47)

In 2003 the Indian government, consistent with the WHO Framework Convention on Tobacco Control (FCTC),(48) passed The Cigarettes and Other Tobacco Products Act (COTPA). This prohibited tobacco-related advertising and sponsorship and specified health warnings on tobacco packs.(49) However, the impact of these measures was limited,(50) prompting the Indian Government to consider larger, more effective pictorial health warnings.(4, 51-56) The next step would be plain packaging, for which there is growing international evidence.

Description of policy or intervention

Plain packaging entails the removal of all branding (colours, imagery, corporate logos and trademarks), with brand names mandated a uniform size and font and placed together with current or enhanced graphic health warnings on the tobacco packaging.

Plain packaging would apply to packaging of all forms of tobacco; in India this includes beedis and chewed forms of tobacco as well as conventional cigarettes.

The aim of plain packaging is to decrease the attractiveness of the package, enhance the effect of pictorial health warnings on the package, increase thoughts about quit- ting and promote negative attitudes towards tobacco use.

Plain packaging of tobacco products has a significant evidence base from a number of countries(54, 57-60) – especially from Australia where it was first introduced. However, evidence on such packaging in rapidly developing countries such as India is relatively scant.(61, 62)

What took place?

A joint Indian and Australian taskforce was convened with support from a small grant from the Australia India Institute. Following a comprehensive knowledge synthesis project, the taskforce produced a report on the possibility of plain packaging in India.(60)

The report included evidence from other jurisdictions, local market research on plain packages(63) and results from a stakeholder analysis undertaken with legal experts, policy-makers and tobacco control experts. It summarized all the behavioural, political and legal evidence and provided graded recommendations as to the way forward.

The report was launched at a high level event attended by politicians from India, WHO representatives, leading tobacco control experts and legal experts. In response, a private members bill on plain packaging was introduced to the Indian parliament in 2013 and a follow up international conference was also held at which the Indian health minister and health secretary gave presentations.

However, a number of contextual barriers have slowed progress on plain packaging. These include a change of government and health ministers, a demand for local evidence and opposition from a significant tobacco farming industry in India. Further research is planned to respond to these concerns and produce additional local evidence.

What have we learnt?

While external (international) evidence and the input of international experts is a helpful start in formulating policies, it is not sufficient for successful policy change.

To increase the chances of the knowledge synthesis leading to a change in policy, the following points are useful:

  • It is important to know the specific audience for whom the knowledge synthesis is being undertaken.
  • Research needs to take account of the policy-making timetable – e.g. regulatory committee meetings or election cycles.
  • A mechanism is needed to ensure the knowledge synthesis is fed to the appropriate groups to inform debate and policy. In particular, a clear communication strategy is needed to reach decision-makers.
  • The knowledge synthesis team need to involve credible figures to maximize the likelihood of evidence reaching decision-makers. (In this example, two coinvestigators sat on government advisory committees).
  • Contextual information can often result in a need to include and/or produce unique evidence in addition to that available from other jurisdictions. (For example, in this case the tobacco products and industries of Australia and India were very different, so further information was needed).

Finally, note that while the stages of knowledge synthesis outlined above will help to identify policies and interventions that may be pursued in the prevention and control of NCDs, they may not provide information about transferability of these to new and different contexts. Approaches to the assessment of suitability and adaptation of policies and interventions to new contexts are discussed later in the guide.