RESEARCH PAPER
Adolescent and adult perceptions of the effects of larger size graphic health warnings on conventional and plain tobacco packs in India: A community-based cross-sectional study
Gaurang P. Nazar 1, 2  
,  
Monika Arora 1, 2
,  
Tina Rawal 1, 2
,  
Amit Yadav 3
,  
Nathan Grills 5
,  
 
 
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1
Health Promotion Division, Public Health Foundation of India, Gurugram, India
2
HRIDAY, New Delhi, India
3
Center for Tobacco Control Research and Education, University of California, San Francisco, United States
4
Indian Institute of Public Health, Hyderabad, India
5
Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
6
Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
CORRESPONDING AUTHOR
Gaurang P. Nazar   

Health Promotion Division, Public Health Foundation of India, Plot No. 47, Institutional Area, Sector 44, Gurugram, Haryana 122002, India
Publish date: 2019-10-01
 
Tob. Induc. Dis. 2019;17(October):70
KEYWORDS
TOPICS
ABSTRACT
Introduction:
We studied adolescent and adult perceptions of the effects of larger size, 85% versus 40%, Graphic Health Warnings (GHWs) on conventional and plain tobacco packs, in India.

Methods:
A cross-sectional survey was conducted with 2121 participants (aged ≥13 years), during the period 2015–16, in Delhi and Telangana, India. Four categories of GHWs on tobacco packs were shown: A – 40% existing (April 2013–April 2016), B – 40% new (April 2016–present), C – 85% new, and D – plain packs (85% new). Regression models tested percentage differences in choice of categories for eight outcomes, adjusted for gender, area of residence, socioeconomic status, age, and tobacco use.

Results:
Of the total 2121 participants, 1120 were from Delhi, 1001 from Telangana, 50% were males, 62% were urban residents, 12% were adolescents, and 72% had never used tobacco. Among packs shown, the majority of participants perceived the 85% size GHWs more effective than the 40% size GHWs across all outcomes. The perceived increase in noticeability of GHWs was 45% for category C (p<0.05) and 43.5% for category D (p<0.05) versus category B. In Delhi, participants perceived plain packs to be most effective in motivating quitting, preventing initiation and conveying the health message. In Telangana, adolescents believed GHWs on plain packs were most noticeable, most effective for quitting and preventing initiation.

Conclusions:
The larger size 85% GHWs were perceived to be more effective in increasing noticeability of warnings, motivating cessation, preventing initiation, and conveying the intended health message. Support for plain packaging was higher in Delhi and among adolescents in Telangana.

ACKNOWLEDGEMENTS
We acknowledge the contribution of G.V.S. Murthy, Director, Indian Institute of Public Health (Hyderabad) for overall direction and guidance with the implementation of the study in the state of Telangana. We also acknowledge the contribution of HRIDAY, a Delhibased NGO in data collection and data management in Delhi.
CONFLICTS OF INTEREST
The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.
FUNDING
This study was funded by The Nuffield Department of Population Health, University of Oxford. No external sources other than the research team were involved: in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit the manuscript for publication.
AUTHORS' CONTRIBUTIONS
M.A., N.G., P.W., A.Y. and G.P.N. contributed to developing the concept and design of the study. G.P.N. contributed to the planning and supervising data collection and management, data analysis, interpretation of results, and drafting and revising the manuscript. V.K.G. provided technical input on data analysis and interpretation of results. T.R. assisted with the data collection, field operations, and drafting components of the manuscript. A.Y. and S.S. contributed to drafting the manuscript and providing technical inputs on tobacco control policy aspects related to plain packaging and pack warnings. N.K.K. contributed towards leading the data collection efforts, training and data management in Telangana along with contributing to drafting and reviewing manuscript components from Telangana. P.W. contributed to guiding data analysis, interpreting the results and drafting the manuscript. P.W., M.A. and N.G. contributed to revising the manuscript critically for intellectual content. All the authors approved the final version of the manuscript and are responsible for the accuracy and integrity of the work.
PROVENANCE AND PEER REVIEW
Not commissioned; externally peer reviewed.
 
REFERENCES (38)
1.
Tata Institute of Social Sciences and Ministry of Health and Family Welfare, Government of India. Global Adult Tobacco Survey GATS 2 (GATS 2) India 2016-17 Report. New Delhi: Ministry of Health and Family Welfare, Government of India; 2017. https://mohfw.gov.in/newshighl.... Accessed May 10, 2019.
 
2.
Ministry of Health and Family Welfare Government of India, World Health Organization, Centers for Disease Control and Prevention, Tata Institute of Social Sciences. GATS 2: Global Adult Tobacco Survey: Fact sheet: India 2016-17. New Delhi: Ministry of Health and Family Welfare, Government of India; 2017. https://www.who.int/tobacco/su.... Accessed May 10, 2019.
 
3.
University of Waterloo. Experts predict 1.5 million smoking deaths in India by 2020. https://uwaterloo.ca/news/news.... Published September 12, 2013. Accessed October 10, 2017.
 
4.
Arora M, Gupta VK, Nazar GP, Stigler MH, Perry CL, Reddy KS. Impact of tobacco advertisements on tobacco use among urban adolescents in India: results from a longitudinal study. Tob Control. 2012;21(3):318-324. doi:10.1136/tc.2010.040733.
 
5.
Ministry of Law and Justice, Government of India. The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003. New Delhi: Government of India Press; 2003. http://legislative.gov.in/acts.... Accessed May 10, 2019.
 
6.
Ministry of Health and Family Welfare. Notification - GSR 727(E) Cigarettes and Other Tobacco Products (Packaging and Labelling) Amendment Rules, 2014. http://164.100.154.238/NTCP/Ac.... Published 2014. Accessed April 5, 2015.
 
7.
Tobacco Labelling Resource Centre. India: Health Warnings. https://tobaccolabels.ca/count.... Accessed October 15, 2018.
 
8.
Campaign for Tobacco-free Kids. India: South East Asia Region. https://www.tobaccofreekids.or.... Published 2015. Accessed January 5, 2018.
 
9.
Arora M, Bhaumik S. Trade versus health: an old argument with new hope for tobacco control in India. http://blogs.bmj.com/bmjgh/201.... Published February 2, 2018. Accessed February 25, 2018.
 
10.
The Hindu. Karnataka HC strikes down rule on stringent tobacco pack warnings. http://www.thehindu.com/news/n.... Published December 15, 2017. Accessed January 12, 2018.
 
11.
Hindustan Times. The Supreme Court is correct in restoring the size of pictorial warnings on cigarette packs. http://www.hindustantimes.com/.... Published January 10, 2018. Updated January 11, 2018. Accessed January 12, 2018.
 
12.
Campaign for Tobacco-free Kids. Implementation Summary. In: Standardized or plain tobacco packaging: International developments. https://www.tobaccofreekids.or.... Updated February 11, 2019. Accessed March 29, 2019.
 
13.
Department of Health, Australian Government. Post-Implementation Review Tobacco Plain Packaging 2016. http://ris.pmc.gov.au/sites/de.... Accessed January 5, 2018.
 
14.
Australia India Institute. Report of the Australia India Institute Taskforce on Tobacco Control-Plain Packaging of Tobacco Products. Australia India Institute; 2012. https://www.aii.unimelb.edu.au.... Accessed January 8, 2018.
 
15.
Arora M, Tewari A, Grills N, et al. Exploring Perception of Indians about Plain Packaging of Tobacco Products: A Mixed Method Research. Front Public Health. 2013;1. doi:10.3389/fpubh.2013.00035.
 
16.
Panda B. The cigarettes and other tobacco products (prohibition of advertisement and regulation of trade and commerce, production, supply and distribution) Amendment Bill, 2014. http://164.100.47.4/billstexts.... Accessed January 5, 2018.
 
17.
Campaign for Tobacco-free Kids. Plain packaging of tobacco products toolkit: Guide 2.3. Stakeholder input/Public consultation. https://www.tobaccofreekids.or.... Accessed November 9, 2018.
 
18.
Office of the Registrar General & Census Commissioner, India. Population Enumeration Data (Final Population). http://www.censusindia.gov.in/.... Accessed January 9, 2018.
 
19.
Gajalakshmi V, Kanimozhi CV. A Survey of 24,000 Students Aged 13-15 Years in India: Global Youth Tobacco Survey 2006 and 2009. Tob Use Insights. 2010;3:23-31. doi:10.1177/1179173x1000300001.
 
20.
Bostoen K, Chalabi Z. Optimization of household survey sampling without sample frames. Int J Epidemiol. 2006;35(3):751-755. doi:10.1093/ije/dyl019.
 
21.
Parr V, Tan B, Ell P, Miller K. Market Research to Determine Effective Plain Packaging of Tobacco Products. Sydney: GfK Blue Moon; 2011.
 
22.
CRÉATEC +. Quantitative Study of Canadian Adult Smokers: Effects of Modified Packaging Through Increasing the Size of Warnings. Canada: Health Canada; 2008.
 
23.
CRÉATEC +. Quantitative study of Canadian youth smokers and Vulnerable non-smokers: Effects of modified packaging Through increasing the size of Warnings on cigarette packages. Canada: Health Canada; 2008.
 
24.
Sharma R. Revised Kuppuswamy's Socioeconomic Status Scale: Explained and Updated. Indian Pediatr. 2017;54(10):867-870. doi:10.1007/s13312-017-1151-x.
 
25.
Wakefield M, Coomber K, Zacher M, Durkin S, Brennan E, Scollo M. Australian adult smokers' responses to plain packaging with larger graphic health warnings 1 year after implementation: results from a national cross-sectional tracking survey. Tob Control. 2015;24(Suppl 2):ii17-ii25. doi:10.1136/tobaccocontrol-2014-052050.
 
26.
Wakefield MA, Hayes L, Durkin S, Borland R. Introduction effects of the Australian plain packaging policy on adult smokers: a cross-sectional study. BMJ Open. 2013;3(7). doi:10.1136/bmjopen-2013-003175.
 
27.
White V, Williams T, Faulkner A, Wakefield M. Do larger graphic health warnings on standardised cigarette packs increase adolescents' cognitive processing of consumer health information and beliefs about smoking-related harms? Tob Control. 2015;24(Suppl 2):ii50-ii57. doi:10.1136/tobaccocontrol-2014-052085.
 
28.
Gallopel-Morvan K, Moodie C, Hammond D, Eker F, Beguinot E, Martinet Y. Consumer perceptions of cigarette pack design in France: a comparison of regular, limited edition and plain packaging. Tob Control. 2012;21(5):502-506. doi:10.1136/tobaccocontrol-2011-050079.
 
29.
Beede P, Lawson R. The effect of plain packages on the perception of cigarette health warnings. Public Health. 1992;106(4):315-322. doi:10.1016/s0033-3506(05)80425-1.
 
30.
McCool J, Webb L, Cameron LD, Hoek J. Graphic warning labels on plain cigarette packs: will they make a difference to adolescents? Soc Sci Med. 2012;74(8):1269-1273. doi:10.1016/j.socscimed.2011.12.043.
 
31.
Munafo MR, Roberts N, Bauld L, Leonards U. Plain packaging increases visual attention to health warnings on cigarette packs in non-smokers and weekly smokers but not daily smokers. Addiction. 2011;106(8):1505-1510. doi:10.1111/j.1360-0443.2011.03430.x.
 
32.
Hughes N, Arora M, Grills N. Perceptions and impact of plain packaging of tobacco products in low and middle income countries, middle to upper income countries and low-income settings in high-income countries: a systematic review of the literature. BMJ Open. 2016;6(3):e010391. doi:10.1136/bmjopen-2015-010391.
 
33.
White V, Williams T, Wakefield M. Has the introduction of plain packaging with larger graphic health warnings changed adolescents' perceptions of cigarette packs and brands? Tob Control. 2015;24(Suppl 2):ii42-ii49. doi:10.1136/tobaccocontrol-2014-052084.
 
34.
Drovandi A, Teague PA, Glass B, Malau-Aduli B. A systematic review of the perceptions of adolescents on graphic health warnings and plain packaging of cigarettes. Syst Rev. 2019;8(1):25. doi:10.1186/s13643-018-0933-0.
 
35.
D'Alonzo KT. Evaluation and revision of questionnaires for use among low-literacy immigrant Latinos. Rev Lat Am Enfermagem. 2011;19:1255-1264. doi:10.1590/s0104-11692011000500025.
 
36.
Bernal H, Wooley S, Schensul JJ. The challenge of using Likert-type scales with low-literate ethnic populations. Nurs Res. 1997;46(3):179-181. doi:10.1097/00006199-199705000-00009.
 
37.
Singh A, Arora M, English DR, Mathur MR. Socioeconomic Gradients in Different Types of Tobacco Use in India: Evidence from Global Adult Tobacco Survey 2009-10. Biomed Res Int. 2015;2015. doi:10.1155/2015/837804.
 
38.
Yadav A, Nazar GP, Rawal T, Arora M, Webster P, Grills N. Plain packaging of tobacco products: the logical next step for tobacco control policy in India. BMJ Glob Health. 2018;3(5):e000873. doi:10.1136/bmjgh-2018-000873.
 
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