WCTOH

Global Health

Background:
Over 100 million Indian adults use tobacco. India enhanced tobacco warning label requirements as of 2016; a HWL should now cover 85% of the 2 principal displays. Smokers make up a smaller proportion of Indian tobacco users; smokeless users tend to be less educated and live in more rural areas. We assess HWL compliance and product appeals conveyed on packs of cigarettes, bidis and various forms of smokeless tobacco.

Methods:
We purchased tobacco products (cigarettes, bidis and smokeless) according to a systematic protocol in four cities (New Delhi, Mumbai, Chennai and Bangalore) during November-December 2016. Within each city, we constructed a purposive sample of 12 diverse neighborhoods and data collectors followed a walking protocol to select sales outlets, from which they purchased one of each unique pack (all products). Two independent coders assessed each pack using product and country specific HWL law codebooks, and a standardized codebook for product appeals.

Results:
We collected 226 unique packs; 94 cigarettes, 47 bidis and 85 smokeless. For cigarettes, 59% (N=55) had a current HWL; of these, 53% (n=29) were compliant with size, placement and warning label components. For bidis, 91% (N=43) displayed the current HWL, but none were compliant with all aspects of the law. For smokeless products, 85 packs were collected of which 64% (n=54) displayed the correct HWL, but only 1 was compliant by our indicators. We discuss challenges in assessing HWL compliance for non-cigarette products and compare marketing appeals between products, including cultural and religious symbolism, and depiction of individual manufacturers.

Conclusions:
India has a progressive health warning label law, but compliant implementation differs between tobacco products. Our discussion of HWL compliance and appeals on packs suggest areas for attention to ensure that India continues to see rates of tobacco use decline and protect all Indians from harm from all forms of tobacco.