|Year : 2015 | Volume
| Issue : 3 | Page : 250-253
A study on adolescents to assess the impact of pictorial and textual warnings on panels of smoked and smokeless tobacco products in Western Maharashtra, India
Anand Thakur1, KM Shivakumar1, Snehal Patil1, KV Suresh2, Vidya Kadashetti3
1 Department of Public Health Dentistry, School of Dental Sciences, Krishna Institute of Medical Sciences University, Karad, Maharashtra, India
2 Department of Oral Medicine and Radiology, School of Dental Sciences, Krishna Institute of Medical Sciences University, Karad, Maharashtra, India
3 Department of Oral Pathology, Microbiology and Forensic Odontology, School of Dental Sciences, Krishna Institute of Medical Sciences University, Karad, Maharashtra, India
|Date of Web Publication||14-Sep-2015|
K M Shivakumar
Department of Public Health Dentistry, School of Dental Sciences, Krishna Institute of Medical Sciences University, Karad - 415 110, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Various pictorial and textual warnings are depicted with a hope that they will deter the individuals from using tobacco and inform them regarding the risks of tobacco. Yet there is lack of information regarding the comprehension of these signs by the adolescents. Aims: The aim was to explore the perception of the adolescents regarding the pictorial and textual warnings on tobacco packs. Materials and Methods: A cross-sectional study was conducted among 500 adolescents of Satara district using simple random sampling technique. A specially designed questionnaire was administered to assess understanding, credibility and persuasiveness of the pictorial and textual warnings on panel of smoked and chewable tobacco. A model containing the pictorial and textual warnings on panel of smoked and smokeless tobacco products were shown to the study subjects. Chi-square test was used for intergroup comparisons based on gender and age of the participants. The statistical analysis of data were done using SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). Results: Nearly one-third of the study participants had often noticed warnings on tobacco packs in the last month, had sometimes read or looked closely at the warnings on tobacco packs in the last month and had rarely talked with anyone about these warnings. About more than two-third of the study participants had found the warning related pictures as not easy to understand, not believable and that these images did not deter them from the likely use of tobacco, and it did not stop them from using tobacco.
Conclusion: We can infer that the textual and pictorial warnings failed to have desired deterrent impact on the adolescent who tend to initiate or continue the tobacco use despite the warning.
Keywords: Adolescents, perception, pictorial warnings, tobacco
|How to cite this article:|
Thakur A, Shivakumar K M, Patil S, Suresh K V, Kadashetti V. A study on adolescents to assess the impact of pictorial and textual warnings on panels of smoked and smokeless tobacco products in Western Maharashtra, India. J Indian Assoc Public Health Dent 2015;13:250-3
|How to cite this URL:|
Thakur A, Shivakumar K M, Patil S, Suresh K V, Kadashetti V. A study on adolescents to assess the impact of pictorial and textual warnings on panels of smoked and smokeless tobacco products in Western Maharashtra, India. J Indian Assoc Public Health Dent [serial online] 2015 [cited 2020 Jan 17];13:250-3. Available from: http://www.jiaphd.org/text.asp?2015/13/3/250/165243
| Introduction|| |
Tobacco in smoke and smokeless form is a leading cause of preventable morbidity and mortality worldwide. With over 8 million deaths projected to be attributable to smoking by the year 2020, smoking has been described as a major public health scourge of modern times. 
Government of India has been taking initiative with regards to the ban of sale of tobacco products, placing pictorial warnings on the tobacco packets, advertising related to the vices of tobacco use and also has been contemplating about raising the taxes on tobacco products. These combined efforts have been instrumental in raising awareness among the masses regarding the ill effects of tobacco consumption and have been discouraging people from adopting this habit. 
The World Health Organization explains that consumers have "fundamental right to accurate information" about the risks of smoking, with warnings on tobacco packaging as a simple means of communicating these risks.  More than 60 countries now require pictorial health warnings on packs and in five countries they cover 75% or more of the principal surfaces (Canada, Brunei, Uruguay, Sri Lanka, Australia). In India too, a mandate on the display of such warnings has been implemented. Three different pictorial and many textual warnings on rotation basis are used. These warnings usually state "smoking is injurious to health" and "chewing tobacco causes oral cancer" in local languages to make it more effective. 
According to the United Nations (UNICEF 2011), adolescent are the people in the age group of 11-19 years.  As we know it is the age of experimentation which often is instrumental in the initiation of tobacco related habits. The individuals in this age group are very much inquisitive and want to try different things so the chances of being a tobacco addict are very high among them. According to the global youth and adult tobacco survey it has been found that initiation of tobacco habits starts at an average age 17.9 years in males and 21.0 years in females. 
Government of India as a part of its campaign against tobacco use has mandated the presence of pictorial warning on the packs of tobacco: Smoked and smokeless. These warnings are depicted with a hope that they will deter the individuals from using tobacco and inform them regarding the risks of tobacco. Yet there is lack of information regarding the comprehension of these signs by the adolescents. Such information will give an insight into the thinking process of the adolescents regarding these warnings. This is the first study of its kind in Western Maharashtra exploring the other side of the scenario of tobacco free initiative. In our study, Satara district was chosen as the study area as Maharashtra is one of the leading states in tobacco consumption and it has been observed on a national and state level survey that age of initiation of tobacco habits is quite young in these state inhabitants. Hence, this study was conducted with the aim to assess the understanding, credibility and persuasiveness of the adolescents regarding the pictorial and textual warnings on reverse panel of smoked and chewable tobacco packages.
| Materials and methods|| |
A cross-sectional study was conducted among adolescents group of Satara district from May to June 2014. The study population was the adolescents belonging to the age group of 11-19 years attending the educational institutions of Satara district in Western Maharashtra. It is inhabited by 74,335 people with an average literacy rate of 76%, which is higher than the national average.  An Ethical Clearance was obtained from the Institutional Ethics Committee to initiate the study. Informed consent was obtained from all the study participants. All necessary permissions were obtained from the concerned authorities.
A pilot study was conducted among 30 adolescents to assess the feasibility of the study. As per the results of the pilot study, the sample size was determined 500 study subjects with the probability of 90% and error of 5%. The questionnaire used for this study was translated to Marathi which is the local language and back translated to English by a bilingual expert and the face and content validity was assessed. The reliability of the questionnaire was assessed in pilot study by measuring Cronbach's alpha and inter-item correlations. The internal consistency reliability coefficient (Cronbach's alpha) for the questionnaire was 0.71. The item-scale correlations of all the items of questionnaire ranged from 0.52 to 0.60, in which none was less than the minimum acceptable level of 0.4.
A list of institutions was obtained and from them the schools and colleges were selected by using simple Random sampling techniques. Of the 120 institutions listed, 18 institutions' were selected for the study and among them 27 students were selected by simple random sampling technique. Inclusion criteria were people who were willing to participate, who were present on the day of examination.
A specially designed questionnaire was administered to assess understanding, credibility and persuasiveness of the pictorial and textual warnings on the reverse panel of smoked and smokeless tobacco. The questionnaire consisted of 6 questions 4 dealing with the comprehension of the warnings and other two dealt with the perceived seriousness of the warnings. The responses were "never," "sometimes," "rarely," "very often" and last two questions responses were dichotomized as "yes" or "no." The questionnaire assessed the salience (noticing, looking closely at warnings), depth of processing (thinking about warnings, discussing them with others), comprehension and credibility (warning comprehensibility, believability, and truthfulness), unaided recall, persuasiveness (warnings as a deterrent to smoking), avoidance techniques (e.g., hiding packs), and a behavioral indicator (forgoing cigarettes due to warnings) of the participants.  A model containing the pictorial and textual warnings on panel of smoked and smokeless tobacco products were shown to the study subjects. This model was displayed in the rooms where the participants were supposed to see them and then complete the questionnaire.
The recorded data were transferred to the computer in Microsoft Excel worksheet and was subjected to statistical analysis by using SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). Chi-square test was used for intergroup comparisons based on gender and age of the participants. P value was set at < 0.05.
| Results|| |
Majority 251 of the population belonged to the age group of 11-15 years of age in that 197 were males and 54 were females, 249 subjects were in the age group of 16-19 years, in that 176 were males and 73 were females [Table 1]. In the age group of 11-15 years the mean age of the participants was 13 ± 2.8 years and that of age group of 16-19 years 17.5 ± 2.12 years (P < 0.001). The sample consisted of total 373 males and 127 females (P < 0.001).
Only 168 (33.6%, P < 0.05) had often "noticed warnings on tobacco packs in the last month," 137 (27.4%, P > 0.05) had "sometimes" read or looked closely at the warnings on tobacco packs in the last month, 131 (26.2%, P > 0.05) had "rarely" thought about what warnings on the tobacco packs are telling them with the pack in sight/out of sight in the last month, 155 (31%, P > 0.05) had rarely "talked with anyone about these warnings" [Table 2].
|Table 2: Distribution of participants based on the response of the questions |
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In the last month, majority 415 (83%, P > 0.05) found these "pictures were not easy to understand," 421 (84.2%, P > 0.05) found these "images were not believable," 403 (80.6%, P < 0.05) found these "images were not truthful in respect to the health risks associated with tobacco use," 432 (86.4%, P < 0.05) found these "images did not deter them from the likely use of tobacco," 446 (89.2%, P > 0.05) found it "did not stop them from using tobacco" [Table 3].
|Table 3: Distribution of participants based on the response of the questions |
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| Discussion|| |
This study was conducted to assess the adolescent response to pictorial and textual warnings on a reverse panel of tobacco products. In this study, it was observed that very small portion of the study sample hardly ever thought about the warnings or discussed about it. Such a finding points toward the lack of seriousness or lack of sensitization of the adolescents regarding such habits.
Similarly, majority of the study participants found these warnings as unbelievable, not easy to understand or truthful and that these warnings did not deter them from using tobacco. This study is first of its kind to be conducted in India. Most of the studies have been conducted regarding the prevalence of tobacco usage but none about the impact of warnings on the individuals. These findings are similar to those observed by Moodie et al.  that these warnings have negligible impact on daily users of tobacco and are contrary to findings in a study by Callery et al. 
Attractiveness of the packaging and small display areas of the warnings have always been considered to the reasons for the initiation of the tobacco as most of the adolescents mistook it as a mouth freshener and once they initiated the habit it was difficult to stop the same. This fact definitely highlights the importance of stopping the initiation of the tobacco habit. Government of India has come up with measures to reduce the attractiveness of the packages by mandating plain packaging in years to come.  Yet definitively awareness among the students regarding the seriousness of the warnings can be a definitive step toward our goal. ,
Through the preliminary observation we can infer the textual and pictorial warnings fail to have desired deterrent impact on the adolescent who tend to initiate tobacco use despite the warning. Drawback can be the lack of inclusion of school dropouts in the study sample. Further research with a larger sample and inclusion of adolescents from diverse social demographic profiles are needed to come up with measures to enhance the comprehension of them regarding the pictorial and textual warnings. The study was an attempt to understand the perceptions of adolescents regarding the health risk warning on tobacco packs. Furthermore, it is recommended to sensitize adolescents by including vices of tobacco use as part of education system.
| Conclusions|| |
Based on the findings of this study, it can be concluded that there is need for more attention in educating and sensitizing the adolescents of this region to the seriousness of the textual and pictorial warnings, so that they can make responsible decisions regarding the initiation or continued use of tobacco products.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. WHO Report on the Global Tobacco Epidemic: Warning about the Dangers of Tobacco. Geneva, Switzerland: World Health Organization; 2011. Available from: http://www.who.int/tobacco/global_report/2011/en/
. [Last accessed on 2015 Feb 05].
World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: WHO; 2003.
Ministry of Health and Family Welfare. The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 and Related Rules and Regulations. New Delhi: Government of India Press; 2009.
Government of India, Ministry of Health and Family Welfare and WHO Global Adult Tobacco Survey (GATS): India; 2009-2010.
Census of India 2011: Data from 2011 Census Including Cities Villages and Towns. Census Commission of India; 2011.
Moodie C, Mackintosh AM, Hastings G. Adolescents′ response to pictorial warnings on the reverse panel of cigarette packs: A repeat cross-sectional study. Tob Control 2015;24:e93-7.
Callery W, Hammond D, O′Connor RJ, Fong GT. Impact of health warning messages on smokeless tobacco products. Nicotine Tob Res 2012;13:373-83.
Bhaumik S. Private member′s bill proposes plain packaging of tobacco products in India. BMJ 2013;346:F953.
World Health Organization. WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER Package. Geneva: World Health Organization; 2008.
World Health Organization. Guidelines for Controlling and Monitoring the Tobacco Epidemic. Geneva: World Health Organization; 1998. p. 76-80.
[Table 1], [Table 2], [Table 3]