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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Health Promotion Division, Public Health Foundation of India, Gurugram, India
HRIDAY, New Delhi, India
Center for Tobacco Control Research and Education, University of California, San Francisco, United States
Indian Institute of Public Health, Hyderabad, India
Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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
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.

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.

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.

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.

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.
The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.
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.
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.
Not commissioned; externally peer reviewed.
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