BACKGROUND: Approximately 300 million people in over 120 countries use smokeless tobacco (SLT), with the highest burden concentrated in South Asia. In Bangladesh and India, variation in SLT pack shape, size, and material is associated with low compliance with health warning label (HWL) requirements, leaving room for attractive industry branding. Other countries may face similar challenges. Standardizing the shape, size, and material of SLT packs could improve HWL compliance and reduce pack attractiveness.
METHODS: We conducted 28 focus group discussions (FGDs) in Bangladesh in February 2021 and 24 FGDs in India in March 2023. Groups were stratified by SLT use status. Each participant was given a set of (a) current SLT packs and (b) standard SLT packs (tin cylinder in Bangladesh; paper sachet and tin cylinder in India). Trained facilitators led FGDs on the perceived attractiveness and harm of current versus standard packs. Data were collected in local languages, translated into English, and thematically analyzed.
RESULTS: Groups across both countries and SLT use status discussed the limited HWL visibility on existing packs, noting that images were missing, small, or distorted. These factors contributed to lower perceived harm of existing SLT packs. In contrast, all groups discussed how the standard packs appeared more harmful than existing packs due to the size and clarity of the standard pack HWLs, particularly the paper sachet in India. Several groups in both countries discussed how the standard cylinders seemed higher quality because of the ‘durable’ tin.
CONCLUSIONS: Results suggest that implementing a standard SLT pack may be an innovative strategy to reduce product attractiveness and increase perceived harm at a population level. Bangladesh, India, and other countries with high SLT use should consider implementing standard packs alongside complementary regulations that enhance HWL compliance and reduce appeal, such as requiring a lower quality standard pack material.