Effect Of Pictorial Health Warnings On Tobacco Usage –A Cross Sectional Study

Introduction

The tobacco epidemic is one of the biggest public health threats the world has ever faced, killing around 6 million people a year. Nearly 80% of more than 1 billion smokers worldwide live in low- and middleincome countries where the burden of tobacco-related illness and death is heaviest. Tobacco users who die prematurely deprive their families of income, raise the cost of health care and hinder economic development (3).

Graphic warnings can contribute to a break in the chain of disease transmission by persuading smokers to initiate steps not only to protect themselves but also to decrease the effect of passive smoking. Warning labels on tobacco products provide an effective way of communicating the consequences of tobacco use(4). It is a cost-effective way to disseminate information to the public on the dangers of smoking and benefits of quitting.

Display of pictorial warnings on tobacco products was one of the legislative measures taken under The Cigarettes and Other Tobacco Products Act (COTPA) enacted in 2003, intended to discourage the consumption of tobacco(5). 

The Government of India (GOI) launched the National Tobacco Control Programme (NTCP) in 2007. Nearly 8 - 9 lakh people die every year in India due to diseases related to tobacco use and as per the report of Indian Council of Medical Research (ICMR), nearly 50% of cancers in males and 25% cancers in females in India are directly attributed to tobacco use. India is party to the WHO Framework Convention on Tobacco Control (FCTC) and is hence committed to implementing all provisions of this international treaty(6).

Though the World Health Organization (WHO) in 2009 had urged the government to include pictorial warnings on all tobacco packages(7), only 42 countries, representing 19% of the world's population, have met the best practice for pictorial warnings, which includes the warnings in the local language and cover an average of at least half of the front and back of cigarette packs and most of these countries are interestingly low- or middle-income countries.

Limited literature exists which reveal the effectiveness of pictorial health warnings on tobacco products in India among the lower strata of society. Hence, this study has been taken up to determine the effect of pictorial warnings on tobacco products among smokers in our field practice area. Studies carried out after the implementation of pictorial package warnings in Brazil, Canada, Singapore and Thailand consistently show that pictorial warnings significantly increase people's awareness of the harms of tobacco use(8,9).

Materials And Methods

Study Design: A hospital based cross sectional study was carried out among patients attending the outpatient department of Rural and Urban health training centre under a Medical college teaching hospital in Karnataka. Only male patients aged between 20-80 years with atleast a six months’ history of smoking in the past were considered as the study population. Using the non probability sampling technique, a total of 200 patients (100 each from urban and rural)who attended the outpatient department in the month of November - December 2016 were selected and interviewed.

After obtaining verbal consent, data was collected through interview method using a semi-structured questionnaire. The Questionnaire comprised of 18 questions categorised into 4 areas namely sociodemographic details, details of tobacco use, awareness on pictorial warnings and support for implementation of pictorial warnings on tobacco packs.

Statistics

Statistical analysis was done using SPSS software v.20. Data were analysed using descriptive and inferential statistics.

Results

The study has attempted to reveal the awareness levels of 200 participants, 100 each from rural and urban area with respect to pictorial warnings on tobacco products. About 30% of the participants in rural area were in the age group of 20-40 years and 36% were in the age group > 40 years from urban area. The proportion of participants educated above tenth grade was more in the urban (52%) as compared to the rural area (31%). About 83% of these respondents were above the poverty line in urban area and the same was 45 % in the rural area.

Smoking was the most common form of tobacco use among both rural and urban population (89% and 93%). Among them, regular smokers were 79% and 65% respectively and about 46.5% of them were into the habit for more than 10 years. The most common reason given for being a chronic smoker was stress. The mean cigarettes smoked per day was 10.2 per day.

When enquired about pictorial warnings displayed on cigarette packets, only 7% of rural and 12% of urban smokers had not noticed the warnings. Around twenty seven percent of respondents, (34% rural and 21% urban smokers)had noticed the text displayed on pictorial warnings.However, only 49% of them who had noticed had understood the pictorial warning. Majority of the urban smokers (80%) understood the picture displayed to be related to lung cancer compared totheir counterparts (67%).More number of urban smokers said that red was the most attractive colour followed by black for use in these pictorial warnings.

About 48% urban and 52% rural smokers had attempted to quit smoking in the past and the desire to quit further improved after reading the pictorial warnings. Sixty percent of urban and 44% rural smokers opined that the warnings should be more powerful. The proportion of smokers who felt that it was mandatory by law to display pictorial warnings on tobacco products were 58% among urban and 46% among rural smokers. Also, overall 60% of respondents acknowledged that such powerful warning were a necessity.

In this study conducted among 200 smokers, multivariate analysis was attempted to explore whether there was influence of smoker’s age, literacy, socioeconomic status and duration of smoking on awareness about pictorial warnings on tobacco usage. It was found that there was no statistical significance between the mentioned factors and knowledge about pictorial warnings on tobacco usage.

Discussion

The present study was conducted to elicit the awareness regarding pictorial warnings on tobacco packs among tobacco consumers who availed the services of rural and urban health centres areas. Majority (64%) of the participants were in their middle age with 46.5% of them having a history of smoking for more than 10 years. Majority of them used tobacco in smoked form. Similar findings were observed in a study conducted in India by Raute et al and Shastri (10,19,20). Similar results have also been reported from a study conducted among the smokers in Shimla (10). 

A recent experimental research study conducted in Canada had found that increasing the size of pictorial warnings from the current size of 50% of the principal display area to 75%, 90% and 100% enhanced their impact among adult smokers, youth smokers, as well as ‘vulnerable’ youth non-smokers (11,12).The same observations were made from a study in Australia, where pictorial warnings currently cover 90% of the front and 30% of the back of packs (13). Here in our study, 30% rural participants opined that coverage of warning label should be 50% whereas 40% urbanites felt it should be 80%.

In a randomised control trial conducted by Schneider et al. (2011), one group of 44 adult smokers were made to view only the written warnings and another similar group were made to view corresponding pictorial warnings (14). This study reported that pictorial warnings were associated with a significantly higher motivation to quit. Pictorial warnings were also associated with higher fear intensity. Here, in our study also the effect of pictorial warnings (43% among urban and 51% among rural smokers) on intention to quit was higher than for plain text messages (14% among urban and 10% among rural smokers). A combination of text and picture messages were said to be a must and some participants suggested text in red as red represented danger whereas literature says that contrasting colours such as black lettering on white background were the easiest to read and increased comprehension (15,16). Our study also showed that red colour would be more ‘eye catching’. Further, 45% of urban smokers and 40% of rural smokers wished that the warning label should be two-sided.

A study conducted in China in 2008 had found that smokers were significantly more likely to rate pictorial warnings as more effective than text warnings for motivating smoking cessation and for preventing smoking among youth (17). The current study also supported the evidence that 52% urban smokers and 48 % rural smokers were willing to reduce the habit and quit. Almost all the study participants had noticed the pictorial warning but only one third of them had observed the text and among them only 50% had actually understood it. The present study rules out the influence of socio-demographic factors on awareness of pictorial warnings. A study in Davangere city, Karnataka, among people aged 15 years and above had also showed that there was no statistical significance between education of the person and awareness about addiction and impact of pictorial warnings on tobacco products to quit the habit (18).

However, since the study was hospital based and had been carried out in a small population for a short period of time, the results obtained could have occurred by chance, and cannot be applied to the whole population. In the future, population-based surveys should be done in rural areas of India where knowledge about the illeffects of tobacco are most needed.This will help identify other factors which can improve the awareness of effects due to smoking.

Conclusion

The present study revealed that the youngsters in the selected sample were less habituated to smoking and majority of the middle-aged participants were smokers from urban and rural areas. Health warnings on cigarette packages provide smokers with universal access to information on the risks of smoking. Our study showed that people from the lower strata of society are still lagging behind in understanding these health warnings and the intention to quit smoking is positive among those who understood it.It is time for both the government and health professionals to work together and address these factors among the public, especially among the growing citizens of India.