Date of Award

Fall 2023

Document Type

Open Access Dissertation


Health Promotion, Education and Behavior

First Advisor

Daniela Friedman

Second Advisor

James Thrasher


Background: Sale of loose cigarettes and bidis (loosies) is widely accepted as a key factor in promoting the tobacco epidemic in India. This mixed-methods study aimed to broaden understanding around the sale and purchase of loosies addressed three aims: 1) To determine the prevalence and correlates of loosies purchase in India; 2) To examine the association between purchase behavior and health warning labels (HWLs) exposure and responses, and 3) To conduct a stakeholder analysis regarding the ban on the sale of loosies in India. Methods: Data from the 2018-19 Tobacco Control Policy (TCP) India survey (643 current cigarette users and 730 current bidi users) and 82 in-depth interviews with smokers (n=28), tobacco vendors (n=28), and policymakers and implementers (n=26) from two Indian cities, Mumbai (where ban on the sale of loosies was implemented) and Delhi (without the ban) were analyzed. Ordinal and logistic regression models were used to analyze the survey data and open and axial coding was done to analyze the interview data. Results: Survey findings suggest that about 75% of cigarette smokers and 12% of bidi smokers bought loose cigarettes and bidi, respectively, at their last purchase. Those with low education levels, unemployed, from urban neighborhoods, occasional smokers, and unsuccessful quitters were significantly more likely to purchase loosies. Those who purchased loosies less often noticed HWLs on cigarette packs. Interview findings suggest that financial and social restrictions, and limiting cigarette consumption, were the main reasons for purchasing loosies. Awareness regarding the ban was poor among smokers, vendors, and implementers in Mumbai. Participants described that the ban would reduce their cigarette consumption and assist in quitting. Policymakers and implementers discussed potential barriers, such as unclear implementation guidelines and lack of a monitoring and evaluation mechanism, and facilitators for effective policy implementation, such as need for tobacco vendor licensing, and effective coordination between multiple stakeholders. Conclusion: Loose tobacco prevalence remains widespread in India. Poor awareness of the policy among stakeholders signals inadequate implementation of the ban. Banning loose cigarettes will promote cessation and prevent initiation and should be included as part of the overall approach to tobacco control in India.


© 2024, Mayank Sakhuja