An examination of the effectiveness of health warning labels on smokeless tobacco products in four states in India: findings from the TCP India cohort survey

Abstract

BackgroundIn 2009, after many delays and changes, India introduced a single pictorial health warning label (HWL) on smokeless tobacco (SLT) packing—a symbolic image of a scorpion covering 40% of the front surface. In 2011, the scorpion was replaced with 4 graphic images. This paper tested the effectiveness of SLT HWLs in India and whether the 2011 change from symbolic to graphic images increased their effectiveness.MethodsData were from a cohort of 4733 adult SLT users (age15+) of the Tobacco Control Project (TCP) India Survey from 4 states. The surveys included key indicators of health warning effectiveness, including warning salience, and cognitive, emotional, and behavioral responses to the warnings.ResultsThe HWL change from symbolic to graphic did not result in significant increases on any of the HWL outcome indicators. A substantial minority of SLT users were unaware that SLT packages contained HWLs (27% at both waves). Noticing the warnings was also remarkably low at both waves (W1 = 34.3%, W2 = 28.1%). These effects carried over to the cognitive and behavioural measures, where among those who noticed HWLs, about one-third reported forgoing SLT at least once because of the HWLs, and fewer than 20% reported that HWLs made them think about SLT risks or about quitting SLT. Even fewer reported avoiding HWLs (8.1 to 11.6%). Among those who quit using SLT by post-policy, awareness that SLT packaging contained HWLs was significantly greater at post-policy (86.8%) compared to pre-policy (77.8%, p = 0.02). Quitters were also significantly more aware of the post-policy HWLs compared to those who continued to use SLT (p < 0.001).ConclusionsHealth warnings on SLT packages in India are low in effectiveness, and the change from the symbolic warning (pre-policy) to graphic HWLs (post-policy) did not lead to significant increases of effectiveness on any of the HWL indicators among those who continued to use SLT products, thus suggesting that changing an image alone is not enough to have an impact. There is a critical need to implement SLT HWLs in India that are more salient (large in size and on the front and back of the package) and impactful, which following from studies of HWLs on cigarette packaging, would have strong potential to increase awareness of the harms of SLT and to motivate quitting.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3899-7) contains supplementary material, which is available to authorized users.

Public awareness of oral cancer among adults in Jakarta, Indonesia

“…Previous research has reported that there is a diminished effect of cognitive processing of graphic health‐warning labels on participants after 5 years, indicating the need for a regular refreshment of graphics . A study in India showed that graphics on cigarette packaging is strongly effective in increasing awareness, but not effective enough to motivate them to quit . Current health education is not sufficient to achieve behavioral changes.…”

“…31 A study in India showed that graphics on cigarette packaging is strongly effective in increasing awareness, but not effective enough to motivate them to quit. 32 Current health education is not sufficient to achieve behavioral changes. Interventional studies are needed using a primary healthcare approach focused on smokers, with adequate follow up.…”

Compliance with Tobacco Control Policies and Global Youth Tobacco Survey: A Cross-Sectional Comparison between GYTS 2000 and 2015 in Maharashtra, India

“…This study confirms low level of noticing and effectiveness reported in other Indian studies. 27,28 Additionally, change from the symbolic warnings (before COTPA) to graphics health warnings (after COTPA) did not lead to increase in noticing as well as effectiveness.…”

“…Tobacco control policies compliance decreased smoking prevalence. 19,[21][22][23]26,28 A policy on tobacco sale to minor was associated with lowering youth smoking. 22 Although the laws clearly prohibit the sale of tobacco products to young people <18 of age in India, 8 the current study shows initiation of tobacco use continues to starts as early as 9 years or younger.…”

The role of negative affect and message credibility in perceived effectiveness of smokeless tobacco health warning labels in Navi Mumbai, India and Dhaka, Bangladesh: A moderated-mediation analysis

“…Despite numerous delays in implementation (Arora, Tewari, Nazar, Gupta & Shrivastav, 2012; Oswal, Raute, Pednekar, & Gupta, 2011), in 2009, India became the first country in the world to require pictorial health warnings (a symbolic image of a scorpion) on smokeless tobacco packages. In 2011, the symbolic image of a scorpion was replaced with four different graphic images, but recent longitudinal evidence indicated that this change from a symbolic warning in 2009, to graphic warnings in 2011, did not result in significant increases in effectiveness (Gravely et al, 2016). However, India has committed to increasing warning size from the current 40% of the front surface to 85% of the principal display area (i.e., front and back).…”