SW033291 India is the second largest consumer and third

India is the second largest consumer and third largest producer of tobacco in the world. The Indian Government has been significantly engaged in addressing the tobacco problem. A major policy, the Cigarettes and Other Tobacco Products Act (COTPA) was implemented in 2003, followed by WHO\'s Framework Convention on Tobacco Control (FCTC) ratification in 2004. The Indian Government also initiated the National Tobacco Control Programme, which is aimed at tobacco cessation efforts and capacity building at the state level. Despite these stringent efforts, cigarette and bidi consumption rates continue to increase with deceasing social class gradient. These trends reflect the lack of substantial increase in tobacco excise taxes to decrease affordability, as also highlighted by Barua and colleagues. Another suggestion of Barua and colleagues was the adoption of an alcohol retail sales model for tobacco products in India to reduce accessibility of tobacco products to adolescents—a provision already covered under the existing tobacco laws in India. This strategy would help reduce unorganised or unaccounted sale of tobacco products in India. Given the SW033291 dynamics in India, raising taxes to reduce adolescent smoking might work by decreasing affordability of tobacco products for adults thus indirectly reducing adolescents\' access. But we have reservations about tobacco-specific regulated retail outlets—including the feasibilty of establishing such outlets— and simulation models are warranted in this direction.
The Article by Nicolas Menzies and colleagues (November, 2016), based on a modelling approach, concludes that most tuberculosis control interventions in South Africa, China, and India are highly cost-effective. In this regard, I have a different viewpoint.
In his Correspondence on our paper, Sachin Atre describes factors that could reduce the impact of intensified tuberculosis control, and questions the usefulness of mathematical modelling that ignores these challenges. On these points we wholeheartedly agree. As part of this modelling collaboration, we took steps to ensure that modelled strategies reflected real-world constraints—to the extent possible, assumptions about uptake, retention, quality, and other factors influencing policy outcomes were based on empirical programme experience, and stakeholders from national tuberculosis control programmes were involved throughout to define realistic policy scenarios and review modelled results. These steps are detailed in our supplementary information and the related impact paper.
David Osrin and Tim Colbourn (November, 2016) uphold a recommendation to restrict use of chlorhexidine to “infants born at home in environments with high neonatal mortality rates” and assert that “Cochrane reviews, a meta-analysis, and these two new trials have not supported an effect after hospital births”. We do not think it is clear how one could come to such a conclusion from the evidence in the cited papers. The 2013 Cochrane review cited included the three large community-based trials of chlorhexidine 4% solution in which application to the cord was done at home, although in the two largest of the studies, participants included both home and facility births. The review concluded that chlorhexidine reduces risk of both omphalitis (ranging from 27% to 65% depending on severity of infection) and death (risk ratio [RR] 0·77, 95% CI 0·63–0 ·94). A German trial of 669 healthy newborn babies was also included, with those in the intervention arm receiving chlorhexidine 1% powder applied to the cord after every diaper change, initiated in hospital and continued at home until 3 days after cord separation (and could therefore be seen as a hybrid hospital-based and community-based study). “Cord-related adverse events” (the main endpoint other than cord separation time)—including “erosion, irritation, lesion, omphalitis, erythema, umbilical granuloma, purulence, bleeding, discharge or weeping”—were seen in 29% of those receiving dry cord care and 16% receiving chlorhexidine (p=0·001). Omphalitis, as defined in the study, was seen in seven of 332 receiving dry cord care and two of 337 receiving chlorhexidine (p=0·1). This trial did not use mortality as an endpoint. The review came to no conclusions about differences in effectiveness by place of birth.