Background:
In 2014, the Government of India's Ministry of Health & Family Welfare constituted an expert group for development of pictorial health warnings for tobacco products. Accordingly, six prototypes were developed with warnings displayed on the front and back occupying 85 percent of the space. The packs visually showed the adverse impact of tobacco consumption.
The prototypes were pretested. The objective of the pretest was to assess the effectiveness of the health warnings and messages on different target groups in terms of noticeability, comprehension, informativeness, credibility, legibility, clarity of color & design, and intention to change behavior. The main task of the study was to exhibit six types of pack warnings developed separately for cigarette, bidi, and smokeless tobacco users and non-users and rank them based on their reactions to each of the attributes listed above.

Methods:
The pre-testing was undertaken in one district each of the three states of India. In all, the study area covered 28 locations. The total number of respondents was 300 comprising of tobacco users and non-users. The sample included adult women and men. The study used qualitative methodology for pre-testing the pack warnings on cigarette, bidi and smokeless tobacco packs. It conducted: 28 focus group discussions and 20 in depth interviews.

Results:
The study concluded that the image on cigarette, bidi or smokeless tobacco packs is the main source of information. Pack warnings which showed damage on the face or a disease were more impactful and understood. Cigarette/ Bidi are often bought loose, especially by those who are in the age group 18-25 years. Hence, the likelihood of noticing the pack warning is much lower by this age group.

Conclusions:
The study recommended that the image and the written warning on the pack must match and must be in English and an Indian language.