Institutional tensions, corporate social responsibility and district-level governance of tobacco industry interference: analysing challenges in local implementation of Article 5.3 measures in Karnataka, India

Introduction Accelerating progress on tobacco control will require Article 5.3 of the WHO Framework Convention on Tobacco Control to be systematically integrated into policies and practices of sectors beyond health at diverse government levels. However, no study has explored implementation challenges of Article 5.3 within multilevel systems such as India, where political decisions on tobacco control occur at diverse government levels, which may constrain action at local level. Methods Based on 33 semi-structured interviews with diverse government and civil society stakeholders across four districts in Karnataka, India (Mysore, Mangalore, Bengaluru (rural) and Udupi), this study examines challenges to implement Article 5.3 arising from competing agendas and policies of different actors at multiple levels. Results Our analysis reveals generally low levels of awareness of Article 5.3 and its guideline recommendations, even among those directly involved in tobacco control at district level. Efforts to implement Article 5.3 were also challenged by competing views on the appropriate terms of engagement with industry actors. Scope to reconcile tensions across competing health, agriculture and commercial agendas was further constrained by the policies and practices of the national Tobacco Board, thereby undermining local implementation of Article 5.3. The most challenging aspect of Article 5.3 implementation was the difficulties in restricting engagement by government officials and departments with tobacco industry corporate social responsibility initiatives given national requirements for such activities among major corporations. Conclusions Promoting effective implementation of Article 5.3 in Karnataka will require policymakers to work across policy silos and reconcile tensions across India's national health and economic priorities.