Implementing the World Health Organization - Framework Convention on Tobacco Control Article 5.3: A qualitative study in 17 Indian states

India experiences a high degree of tobacco industry interference. The World Health Organization Framework Convention on Tobacco Control, in its Article 5.3, requires members to protect their policies from tobacco industry influence. Despite the global guidance, the implementation of the Article 5.3 of the convention remains far from desired. We study implementation processes concerning the Article 5.3 policies in 17 of the 19 Indian states that had adopted such policies by 2023. We first conducted an online survey to understand the nature and enforcement of Article 5.3 policies. We then conducted focus group discussions engaging representatives from governments and civil society. The inquiry focused on understanding the prevailing policies, perceived challenges, and good practices in policy implementation as well as the perceived policy impacts. We used reflexive thematic analysis of the qualitative data. There were 17 respondents for the survey, and a total of 258 participants in 17 focus group discussions across study states. Major perceived challenges in the implementation of Article 5.3 policies included limited dissemination/awareness about these policies, suboptimal functioning of the committees overseeing implementation, low priority accorded to these policies, and interference by the tobacco industry. Several government departments were perceived vulnerable to industry interference, with the departments of education, health, and municipal administration perceived as the most vulnerable. A few states adopted practices that facilitated Article 5.3 policy implementation, including display of policy signage/declarations, issue of policy orders/notifications by non-health departments, and setting up a complaints mechanism and norms to avoid sponsorships by private entities. These policies were perceived to have reduced visible interference from the industry and enabled some of the government agencies to refuse funding/partnerships with the tobacco industry. The sub-national Article 5.3 policies in India have a promise to reduce tobacco industry interference. However, implementation of these policies ought to be strengthened.