Tobacco cues in India: An ecological momentary assessment
More details
Hide details
Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, USA
Submission date: 2015-09-03
Acceptance date: 2016-04-18
Publication date: 2016-05-04
Corresponding author
Dina L. G. Borzekowski   

Department of Behavioral and Community Health, School of Public Health, University of Maryland, #2364 SPH Building, Valley Drive, College Park, MD 20742, USA
Tobacco Induced Diseases 2016;14(May):16
Tobacco use in India is a major health concern; however, little is known about the influence of tobacco-related social and environmental cues on tobacco use. This study uses ecological momentary assessment (EMA) to examine real-time tobacco use and exposure to social and environmental cues.

In Hyderabad and Kolkata, participants were recruited, and an EMA application was installed on their mobile phones. Momentary prompts (MP) were randomly used to collect real-time information and end-of-day (EOD) prompts gathered retrospective information on daily basis. Besides personal tobacco use, the surveys asked about exposure to social (e.g., presence of others using tobacco) and environmental cues (e.g., visual and olfactory stimuli). Using the data aggregation approach, bivariate and multivariate analyses were performed to examine the association of tobacco use and cue exposure. Moderating roles of participants’ socio-demographic characteristics were also tested to gain an in-depth understanding of the relationship.

Among the 205 participants, around a third (MP, 33.7 %; EOD, 37.6 %) used tobacco at least once during the study period. Tobacco-related social and environmental cues related were commonly reported. In the bivariate models, tobacco use was associated with gender, age, and all the examined social and environmental cues except for seeing restrictions on tobacco use. In the multivariate models, tobacco use was associated with age, gender, seeing others using tobacco, and seeing restrictions on tobacco use. Seeing others in one’s immediate group using tobacco was the strongest predictor of tobacco use in both MP and EOD assessments. Gender and age did not moderate the relationship between cue exposure and tobacco use, although males reported higher tobacco use and cue exposure in general.

This research provides data on the ubiquity of social and environmental tobacco cues in India. The EMA approach was feasible and informative. Future cessation interventions and advocacy efforts should address the high prevalence of tobacco use and exposure to pro-tobacco use cues especially among Indian males. Health education campaigns for promoting tobacco use restrictions in private places as well as changing the norms of tobacco use in social settings are recommended.

Sauvaget C, Ramadas K, Thomas G, Vinoda J, Thara S, Sankaranarayanan R. Body mass index, weight change and mortality risk in a prospective study in India. Int J Epidemiol. 2008;37(5):990–1004. doi:10.1093/ije/dyn059.
Bhawna G. Burden of smoked and smokeless tobacco consumption in India-results from the global adult tobacco survey India (GATS-India)-2009-2010. Asian Pac J Cancer Prev. 2013;14(5):3323–9.
Sarkar BK, Reddy KS. Priorities for tobacco control research in India. Addiction. 2012;107(12):2066–8.
GATS. WHOGATS. Fact sheet, India: 2009-2010. Mumbai: Ministry of Health and Family Welfare, Government of India; 2010.
Shiffman S, Gwaltney CJ, Balabanis MH, Liu KS, Paty JA, Kassel JD, et al. Immediate antecedents of cigarette smoking: an analysis from ecological momentary assessment. J Abnorm Psychol. 2002;111(4):531.
Shiffman S. Relapse following smoking cessation: a situational analysis. J Consult Clin Psychol. 1982;50(1):71.
McDermut W, Haaga DA. Effect of stage of change on cue reactivity in continuing smokers. Exp Clin Psychopharmacol. 1998;6(3):316.
Warren CA, McDonough BE. Event-related brain potentials as indicators of smoking cue-reactivity. Clin Neurophysiol. 1999;110(9):1570–84.
Perkins KA, Gerlach D, Vender J, Meeker J, Hutchison S, Grobe J. Sex differences in the subjective and reinforcing effects of visual and olfactory cigarette smoke stimuli. Nicotine Tob Res. 2001;3(2):141–50.
Dunbar MS, Scharf D, Kirchner T, Shiffman S. Do smokers crave cigarettes in some smoking situations more than others? Situational correlates of craving when smoking. Nicotine Tob Res. 2010;12(3):226–34.
Carter BL, Tiffany ST. The cue-availability paradigm: the effects of cigarette availability on cue reactivity in smokers. Exp Clin Psychopharmacol. 2001;9(2):183.
Thewissen R, van der Meijden VA, Havermans RC, van den Hout M, Jansen A. From the office to the pub: The role of smoking-relevant contexts and cue-elicited urge to smoke. Eur Addict Res. 2008;14(4):198.
Dietz NA, Sly DF, Lee DJ, Arheart KL, McClure LA. Correlates of smoking among young adults: The role of lifestyle, attitudes/beliefs, demographics, and exposure to anti-tobacco media messaging. Drug Alcohol Depend. 2013;130(1):115–21.
Song AV, Ling PM. Social smoking among young adults: investigation of intentions and attempts to quit. Am J Public Health. 2011;101(7):1291.
Sayette MA, Hufford MR. Effects of cue exposure and deprivation on cognitive resources in smokers. J Abnorm Psychol. 1994;103(4):812.
Niaura R, Abrams DB, Pedraza M, Monti PM, Damaris JR. Smokers’ reactions to interpersonal interaction and presentation of smoking cues. Addict Behav. 1992;17(6):557–66.
Lazev AB, Herzog TA, Brandon TH. Classical conditioning of environmental cues to cigarette smoking. Exp Clin Psychopharmacol. 1999;7(1):56.
Bansal-Travers M, Fong GT, Quah AC, Sansone G, Pednekar MS, Gupta PC, et al. Awareness of pro-tobacco advertising and promotion and beliefs about tobacco use: Findings from the Tobacco Control Policy (TCP) India Pilot Survey. J Epidemiol Glob Health. 2014;4(4):303–13.
Martino SC, Scharf DM, Setodji CM, Shadel WG. Measuring exposure to protobacco marketing and media: a field study using ecological momentary assessment. Nicotine Tob Res. 2012;14(4):398–406.
Shah PB, Pednekar MS, Gupta PC, Sinha DN. The relationship between tobacco advertisements and smoking status of youth in India. Asian Pac J Cancer Prev. 2008;9(4):637–42.
Viswanath K, Ackerson LK, Sorensen G, Gupta PC. Movies and TV influence tobacco use in India: findings from a national survey. PLoS One. 2010;5(6):e11365.
Wakefield MA, Chaloupka FJ, Kaufman NJ, Orleans CT, Barker DC, Ruel EE. Effect of restrictions on smoking at home, at school, and in public places on teenage smoking: cross sectional study. BMJ. 2000;321(7257):333–7.
Bradburn NM, Rips LJ, Shevell SK. Answering autobiographical questions: The impact of memory and inference on surveys. Science. 1987;236(4798):157–61.
Shiffman S, Stone AA, Hufford MR. Ecological momentary assessment. Annu Rev Clin Psychol. 2008;4:1–32.
Shiffman S. Ecological momentary assessment (EMA) in studies of substance use. Psychol Assess. 2009;21(4):486.
Businelle MS, Ma P, Kendzor DE, Reitzel LR, Chen M, Lam CY, et al. Predicting quit attempts among homeless smokers seeking cessation treatment: An ecological momentary assessment study. Nicotine Tob Res. 2014;16:1371–8. ntu088.
Warthen MW, Tiffany ST. Evaluation of cue reactivity in the natural environment of smokers using ecological momentary assessment. Exp Clin Psychopharmacol. 2009;17(2):70.
Gwaltney CJ, Bartolomei R, Colby SM, Kahler CW. Ecological momentary assessment of adolescent smoking cessation: A feasibility study. Nicotine Tob Res. 2008;10(7):1185–90.
Robertson BM, Piasecki TM, Slutske WS, Wood PK, Sher KJ, Shiffman S, et al. Validity of the hangover symptoms scale: Evidence from an electronic diary study. Alcohol Clin Exp Res. 2012;36(1):171–7.
ITU World Telecommunication/ICT Indicators Database. Geneva SITUI. Key statistical highlights: ITU data release. 2012.
Shadel WG, Martino SC, Setodji C, Scharf D, Corporation R. Momentary effects of exposure to pro-smoking media on college students’ future smoking risk. Health Psychol. 2012;31(4):460–6. doi:10.1037/a0027291.
Shiffman S, Paty JA, Gnys M, Kassel JA, Hickcox M. First lapses to smoking: within-subjects analysis of real-time reports. J Consult Clin Psychol. 1996;64(2):366.
Rani M, Bonu S, Jha P, Nguyen S, Jamjoum L. Tobacco use in India: prevalence and predictors of smoking and chewing in a national cross sectional household survey. Tob Control. 2003;12(4):e4. e.
Mathur P, Shah B. Evidence building for policy: Tobacco surveillance/surveys and research in India. Indian J Public Health. 2011;55(3):177.
Soong A, Chen JC, Borzekowski D. Using ecological momentary assessment to study tobacco behavior in urban india: There’s an App for that. JMIR Res Protoc. 2015;4(2):e76.
SPSS I. IBM SPSS statistics 22. Algorithms. Chicago: IBM SPSS Inc; 2013.
Shiffman S, Li X, Dunbar MS, Ferguson SG, Tindle HA, Scholl SM. Social smoking among intermittent smokers. Drug Alcohol Depend. 2015;154:184–91.
Reddy KS, Gupta PC. Report on tobacco control in India, vol. 5. New Delhi: Ministry of Health and Family Welfare, Government of India; 2004. p. 589–94.
Soong A, Chen JC, Borzekowski DL. Using Ecological Momentary Assessment (EMA) to study tobacco behavior in urban India: There’s an app for that. JMIR Res Protoc. 2015;4:e76. SRNT 2015 Conference.
Setodji CM, Martino SC, Scharf DM, Shadel WG. Friends moderate the effects of pro-smoking media on college students’ intentions to smoke. Psychol Addict Behav. 2013;27(1):256.
Gilpin EA, White MM, Messer K, Pierce JP. Receptivity to tobacco advertising and promotions among young adolescents as a predictor of established smoking in young adulthood. Am J Public Health. 2007;97(8):1489.
Dube SR, Arrazola RA, Lee J, Engstrom M, Malarcher A. Pro-tobacco influences and susceptibility to smoking cigarettes among middle and high school students—United States, 2011. J Adolesc Health. 2013;52(5):S45–51.
Rai A. India had third largest smartphone base with 117M users in 2013; to grow 45 % in 2014: Mary Meeker Report. TechCircle.In, TechCircle.In. 2014. Accessed 28 Jan 2014.
India TRAo. Highlights on Telecom Subscription Data as on 30 September 2014. TELECOM REGULATORY AUTHORITY OF INDIA. 2014;Press Release No. 73/2014.
Hammersley R. A digest of memory phenomena for addiction research. Addiction. 1994;89(3):283–93.
Heron KE, Smyth JM. Ecological momentary interventions: incorporating mobile technology into psychosocial and health behaviour treatments. Br J Health Psychol. 2010;15(1):1–39.
Rodgers A, Corbett T, Bramley D, Riddell T, Wills M, Lin R-B, et al. Do u smoke after txt? Results of a randomised trial of smoking cessation using mobile phone text messaging. Tob Control. 2005;14(4):255–61.
Wetter DW, McClure JB, Cofta-Woerpel L, Costello TJ, Reitzel LR, Businelle MS, et al. A randomized clinical trial of a palmtop computer-delivered treatment for smoking relapse prevention among women. Psychol Addict Behav. 2011;25(2):365.
Pro-tobacco advertisement exposure among African American smokers: An ecological momentary assessment study
Cendrine D. Robinson, Christine Muench, Emily Brede, Romano Endrighi, Edwin H. Szeto, Joanna R. Sells, John P. Lammers, Kolawole S. Okuyemi, Grant Izmirlian, Andrew J. Waters
Addictive Behaviors
A systematic review report on tobacco products and its health issues in India
Samprit Padhiary, Dibyaranjan Samal, Pratima Khandayataray, Meesala Murthy
Reviews on Environmental Health
Telehealth interventions for substance use disorders in low- and- middle income countries: A scoping review
Margaret Ojeahere, Sarah Kiburi, Paul Agbo, Rakesh Kumar, Florence Jaguga, Valentina Lichtner
PLOS Digital Health
Journals System - logo
Scroll to top