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 Table of Contents  
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 39-43

Assessment of awareness about pictorial warnings on tobacco products in tobacco users in paonta sahib, Himachal Pradesh, India

1 Department of Periodontics, Himachal Institute of Dental Sciences, Paonta Sahib, Himachal Pradesh, India
2 Department of Oral Pathology, H. P. Government Dental College, Shimla, Himachal Pradesh, India
3 Department of Public Health Dentistry, Himachal Institute of Dental Sciences, Paonta Sahib, Himachal Pradesh, India

Date of Web Publication16-Jun-2017

Correspondence Address:
Parveen Dahiya
Department of Periodontics, Himachal Institute of Dental Sciences, Paonta Sahib - 170 325, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_83_16

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Aim: This is a hospital-based questionnaire survey to investigate the awareness of the pictorial warnings on tobacco products among the residents of Paonta Sahib, Himachal Pradesh. Materials and Methods: A total of 840 tobacco user subjects were enrolled in the study. Data were collected by a self-designed, close-ended structured questionnaire which comprised 15 questions related to demographic details, knowledge about tobacco products, practices of tobacco habits, etc., Results: Most of the study participants (69.9%) were aware of statutory and pictorial warnings present on the tobacco products. Majority of the subjects (48.3%) said pictorial representation on the tobacco packets does not help them in refraining from intake of tobacco. Conclusion: The recently updated pictorial warnings are helpful to some extent but requires more strengthening to make pictorial health warnings easier to comprehend to assess the deleterious effects of tobacco by its consumers and general public.

Keywords: Awareness, knowledge, smoking, tobacco

How to cite this article:
Dahiya P, Kamal R, Gupta R, Bhatt S, Didhra G, Bansal V. Assessment of awareness about pictorial warnings on tobacco products in tobacco users in paonta sahib, Himachal Pradesh, India. Arch Med Health Sci 2017;5:39-43

How to cite this URL:
Dahiya P, Kamal R, Gupta R, Bhatt S, Didhra G, Bansal V. Assessment of awareness about pictorial warnings on tobacco products in tobacco users in paonta sahib, Himachal Pradesh, India. Arch Med Health Sci [serial online] 2017 [cited 2020 May 31];5:39-43. Available from: http://www.amhsjournal.org/text.asp?2017/5/1/39/208209

  Introduction Top

The World Health Organization (WHO) has named tobacco as the world's single greatest cause of preventable death.[1] Estimated 100 million deaths were caused by tobacco in the 20th century. If current trends continue, there will be up to one billion deaths in the 21st century. Unchecked, tobacco related deaths will increase to >8 million a year by 2030, and 80% of those deaths will occur in the developing world.[2] This gory picture of future can be prevented by communicating the health risks of tobacco use to consumers.

Health warnings on tobacco products can be very strong and cost effective way of making people aware of hazardous effects of tobacco. Unlike many other products, tobacco packaging is not removed and discarded but is used as a container until the contents have been consumed; it thus provides high reach and frequency of exposure to users.[3] Tobacco packs left in public view between uses may help in curbing passive smoking as it serves as portable advertisement making nonsmokers aware of deleterious effects of inhaling tobacco smoke. Therefore, health warnings on tobacco packages that combine text and pictures are one of the most effective ways to increase public awareness of the serious health risks of tobacco use and to reduce its consumption. Moreover, in country like India, where most of the people are illiterate hailing from different cultural and linguistic background, pictorial warnings along with text can break cultural, regional, and language barriers.

As per article 11 of the WHO Framework Convention on tobacco control (2003) guidelines, health warnings must be large, clear, rotating, should cover at least 30% of the front and back of cigarette packages. Besides these minimum requirements it must cover at least 50% or more of a package's principal surface area and may include pictures.[4] So keeping this in mind according to section 7 of Cigarettes and Other Tobacco Products Act in India requires all tobacco products to bear pictorial warnings and its rule prescribe covering 40% of the principal display area of the front panel of the tobacco pack.[5]

India signed the WHO framework convention on tobacco control on September 10, 2003.[6] In July 2006, pictorial health warnings were notified which were field tested and were quite effective. However, under pressure from the tobacco industry, these warnings were replace by evasive, smaller in size and nonfield tested pictorial warnings that were introduced on May 31, 2009. The government notified a set of new pictorial health warnings on May 27, 2011. These warnings introduced from December 1, 2011 [Figure 1] were stronger than previous ones [Figure 2] but were not field tested so their effectiveness needs to be researched.[5]
Figure 1: Revised pictorial health warnings displayed on all tobacco product packs in India since December 1, 2011

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Figure 2: Previous pictorial health warnings displayed on all tobacco product packs in India since May 31, 2009

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Hence, this study was conducted to investigate the awareness about the pictorial warning on tobacco products in tobacco users in Paonta sahib, Himachal Pradesh.

  Materials and Methods Top

The present interview based questionnaire study was conducted in the Department of Periodontics, Himachal Institute of Dental Sciences from November 2014 to January 2015. 840 tobacco user subjects were recruited from the universal sampling method. Only systemically health individual with good mental health and those who willing want to participate in the study were enrolled in the study.

Data were collected by the means of a self-structured questionnaire including 15 questions based on demographic details, knowledge about tobacco products, practices of tobacco habits, etc., Suggestions regarding improvement in pictorial warning on tobacco products were also welcomed from the participants.

The validity of questionnaire was checked by conducting a pilot study 1 month before the original study with the sample size of 50 individuals. The study was approved by the Ethical Committee of Himachal Institute of Dental sciences and Research Center. A written consent form was signed by all the participants of the study. For illiterate the consent form was read and explained by the investigator and their thumb impression was taken as their consent. An investigator was trained to explain the questionnaire to the study subjects and to record the data accurately.

  Results Top

Among 840 participants, 94.4% were males and 5.6% were females. Participants of the study were in the age group of 17–71 years, with a mean age of 32.45 ± 10.69. Education status was categorized as primary (up to 5th class), secondary (5th to 10th class) and above secondary (10 + 2 and above) [Table 1].
Table 1: Distribution of subjects according to sociodemographic variables

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Among them, 49.3% were cigarette smokers followed by 23% bidi, 14.4% smokeless tobacco and rest 13.3% were consuming multiple forms of tobacco [Table 2]. Majority of participants 36.5% found bidi more harmful followed by 25.8% cigarette, 24.8% smokeless tobacco, and still 12.8% had no opinion [Table 3].
Table 2: Distribution of subjects according to the tobacco habits

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Table 3: Participant's knowledge regarding harmful effects of tobacco products

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More than 1/3rd of participants were aware of warning signs on tobacco products. 64.2% found warnings on tobacco products readable whereas 35.8% disapproved the same [Table 4]. Regarding the readability of text, statistical significant (P < 0.05) differences were found between younger and older individuals [Table 5]. Similar statistical significant results were recorded with individual with highly qualified and less qualified individuals [Table 6].
Table 4: Participant's perception regarding the warning signs on tobacco products

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Table 5: Participant's age and perceptions about warning signs

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Table 6: Participant's education and perceptions about warning signs

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In terms of satisfaction with pictorial warnings, statistically significant differences were found between least qualified (up to 5th class) and highly qualified individual (10 + 2 and above) [Table 6].

On role of warnings in reduction of habit, 42.7% individuals of younger age group agreed that it has positive impact in reducing the habit and rest 57.3% felt it had no effect. Statistically significant (P < 0.05) results were recorded between younger and older age group individuals regarding the impact of health warning in quitting the habit [Table 5].

Nearly 59.4% of participants found no impact of skull and bone pictorial warnings on tobacco products, whereas 40.6% individuals had contrary opinion [Table 4].

[Table 4] depicts that 58.8% tobacco users claimed that double sided pictorial representation is more impactful. 71% of individuals wished to contribute to the society by active participation in tobacco cessation program. Further, 56.9% of younger age group participants were satisfied by the steps laid down by the government of India to educate the population regarding harmful effects of tobacco whereas 43.1% individuals said that still a lot needs to be done by the government to make the citizens aware of harmful effects of tobacco [Table 5].

  Discussion Top

“Sell the sizzle not the steak” is a commonly used sales aphorism which can be applied judiciously in the form of health warnings on tobacco products to spread awareness of inimical effects of tobacco to the generations as in to promote cessational behaviors among its consumers and feeling of disgust in nonconsumers.

In the present study, the prevalence of cigarette was found to be higher than bidi smoker. It could be explained on the fact that Paonta sahib is a semi-urban area and bidi smoking is usually more prevalent in rural area. Cigarette smoking was the highest among study participants that were in concordance with study done by Rahman et al.,[7] Karinagannanavar et al. (2011)[8] and Chopra et al.[9]

Regarding the harmful effect of tobacco products, it was found that the bidi smoking is more harmful as compared to cigarette. People believe that due to the presence of filters and more refined form of tobacco, cigarettes have less harmful effect.

More than two-third of the respondent were aware of the statutory and pictorial warnings. This finding is comparable to the previous studies done to assess the awareness of health warnings which were found to be 89.9%, 74%, and 73.4% according to study done by Raute et al.,[10] Bhat and Kumar [11] and Karibasappa et al.[12] respectively.

About 58.2% respondents could understand pictorial warnings but found them ineffective in shunning the habit. The results of our study was found to be concordance with the study conducted in Mumbai by Oswal et al.,[13] Arora et al.,[5] Chopra et al.[9] which suggest that pictorial warnings that exist on tobacco packs are perceived to be ineffective by the Indian population.

A very high percentage (71%) people indulge in tobacco habit wish to contribute to the society by participating in anti-tobacco and tobacco cessation programs. It shows that if we plan to organize some anti-tobacco programs in future, it will be have great success.

During this study, we came to know about a disappointing but realistic fact that 48.3% of tobacco users believe that presence of pictorial and text warnings had no impact on them. It made us realize that our responsibility regarding anti-tobacco programs should not be just limited to adding pictures and text warnings on tobacco products.

Continued use of ineffective warning pictures and signs on tobacco products puts light on the missed opportunities as the government has failed to effectively and efficiently utilize this evidence-based strategy to amplify knowledge about the tobacco health hazards among the people, in addition to another educational interventions, for example anti-tobacco advertising employed by the ministry of health and family welfare in India.

The whole objective is to communicate not only with tobacco users but also with prospective quitters and probable initiators. If the anti-tobacco policy is further refined, young people and illiterate who initiate tobacco use without knowledge of its health impact will benefit the most.

Majority of the participants in this study felt that they could understand the warning labels but when asked to interpret the pictorial figures, many of the participants failed to interpret them correctly. One of the participants even misjudged the current warning label on cigarette packs of lung cancer as a man wearing a black jacket. From this, we can assume the level of unawareness still present in our society regarding tobacco products, the warning labels on them and the associated health hazards with it.

We suggest a specific design and certain modifications in warning labels which we feel can impart more impact on smokers:

  • Front and the back of tobacco product should contain pictorial warnings with a specific text covering the entire face of the box or covering at least 70%–80% of the front and back with remaining about 20%–30% space to be utilized for the company's name and price texts
  • The brand and the price of the tobacco product should be written on the sides of the tobacco product
  • The pictorial warning on either side should be different as in one side showing the health hazard on one organ system and the other showing the health hazard on the other organ system
  • We also feel that on one side either front or back, the warning text should be written in Hindi, as it being the language understood by almost every Indian
  • India consists of a large section of population that is illiterate and cannot read or speak English. Hence for awaring that section of the society it is inadverant that pictorial warning should be specific, self-explanatory and not at all attractive to the sight
  • The advertisement hoardings outside tobacco selling shops/vendors should also contain a big specific pictorial warning sign
  • Strict action should be taken against the vendors who sell tobacco products to minors below 18 years of age, violating the law already laid down by the government
  • “Habits attained while growing up remain till the end.” Anti-tobacco awareness programs should be made mandatory in all the schools, colleges and universities and one to one counseling should be done with the help of audio-visual aids showing case reports of people harmed by tobacco use
  • Health warnings should be integrated with mass media campaigns and tobacco cessation helpline numbers should be printed on one of the sides of tobacco products.

There are certain limitations in the present study. First, the cross sectional design limits the assessment of reduction of tobacco habits among study sample. Second, this study is single hospital based than being population based which hinders the better understanding of the problem. Keeping all these limitations in mind we should plan some more studies on varied sample in future. The results of those studies would be more informative and helpful in making preventive anti-tobacco programs.

  Conclusion Top

Authors feel that further refinement of pictorial health warnings should be done which are more disturbing and bring about the negative emotion of fear in the smoker when he/she first looks at it. Findings in our study also provide us with an important lesson to ensure effective and field-tested pictorial health warnings to be displayed on the tobacco products and not to let the government succumb to tobacco industry pressures; which result in milder and ineffective health warnings.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER Package. Geneva: World Health Organization; 2008. Available from: http://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf. [Last accessed on 2015 Mar 15].  Back to cited text no. 1
World Health Organization. WHO Report on the Global Tobacco Epidemic. The MPOWER Package; 2008. Available from: http://www.who.int/tobacco/mpower/tobacco_facts/en/. [Last accessed on 2015 Mar 15].  Back to cited text no. 2
Wakefield M, Letcher T. My pack is cuter than your pack. Tob Control 2002;11:154-6.  Back to cited text no. 3
World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003. Available from: http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf. [Last accessed on 2015 Mar 15].  Back to cited text no. 4
Arora M, Tewari A, Nazar GP, Gupta VK, Shrivastav R. Ineffective pictorial health warnings on tobacco products: Lessons learnt from India. Indian J Public Health 2012;56:61-4.  Back to cited text no. 5
  [Full text]  
WHO Framework Convention on Tobacco Control. Geneva; 21 May, 2003. Available from: https://www.treaties.un.org/pages/ViewDetails.aspxsrc=TREATY&mtdsg_no=IX-4&chapter=9&lang=en. [Last accessed on 2015 Mar 15].  Back to cited text no. 6
Rahman M, Nurullah Awal AS, Fukui T, Sakamoto J. Prevalence of cigarette and bidi smoking among rickshaw pullers in Dhaka city. Prev Med 2007;44:218-22.  Back to cited text no. 7
Karinagannanavar A, Raghavendra B, Hemagiri K, Goud TG. Awareness about pictorial warnings on tobacco products and its impact on tobacco consumers in Bellary, India. Asian Pac J Cancer Prev 2011;12:2485-9.  Back to cited text no. 8
Chopra A, Rao NC, Gupta N, Vashisth S. Communicating tobacco health risks: How effective are the warning labels on tobacco products? Niger Med J 2014;55:411-6.  Back to cited text no. 9
[PUBMED]  [Full text]  
Raute LJ, Pednekar MS, Gupta PC. Pictorial health warnings on cigarette packs: A population based study findings from India. Tob Use Insights 2009;2:11-6.  Back to cited text no. 10
Bhat PK, Kumar A. Perception of pictorial warning present on cigarette packet used in India among graduating dental students of Bangalore city. J Indian Assoc Public Health Dent 2009;14:158-68.  Back to cited text no. 11
Karibasappa GN, Nagesh L, Usha GV, Prakash S. Assessment of awareness about pictorial warnings on tobacco products among 15 years and above age in Davangere city, Karnataka, India – A cross sectional survey. Indian J Stomatol 2011;2:227-32.  Back to cited text no. 12
Oswal KC, Raute LJ, Pednekar MS, Gupta PC. Are current tobacco pictorial warnings in India effective? Asian Pac J Cancer Prev 2011;12:121-4.  Back to cited text no. 13


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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