|Year : 2016 | Volume
| Issue : 3 | Page : 148-153
Awareness of pictorial warning on cigarette packets and its impact on smoking cessation among smokers in Shimla, Himachal Pradesh: A cross-sectional study
Vinay Kumar Bhardwaj1, Shailee Fotedar1, Sunil Abbot2, Pravesh Jhingta3, Deepak Sharma3, Nishant Negi4
1 Department of Public Health Dentistry, H. P. Govt. Dental College and Hospital, Shimla, Himachal Pradesh, India
2 Dental Officer, Indian Army Dental Corps, India
3 Department of Periodontology, H. P. Govt. Dental College and Hospital, Shimla, Himachal Pradesh, India
4 Department of Orthodontics and Dentofacial Orthopaedics, H. P. Govt. Dental College and Hospital, Shimla, Himachal Pradesh, India
|Date of Web Publication||5-Aug-2016|
Dr. Vinay Kumar Bhardwaj
Department of Public Health Dentistry, H. P. Govt. Dental College and Hospital, Shimla - 171 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Background: Pictorial warnings are effective in promoting smoking cessation as shown by researches in the developed countries. The Government of India has also introduced pictorial warnings as one of the strategies among different tobacco control strategies. Objective: The objective of this study was to find the awareness of pictorial warnings present on cigarette packets and its impact on smoking cessation among cigarette smokers in Shimla, Himachal Pradesh. Materials and Methods: The study was conducted among 200 patients attending the outpatient department in the Department of Oral Medicine and Diagnosis from May 1, 2010 to August 31, 2010. Structured questionnaire consisted of demographic details, health-related issues of smoking, awareness about pictorial warning, and impact to quit smoking. Results: Among the study patients, maximum number of patients who were using any form of tobacco products were 35-44-year-old, and higher consumption was seen among the people from lower socioeconomic status. Younger age group, i.e., ≤25 years, those with higher socioeconomic status, urban residence, and literate were more aware about pictorial warning on cigarette packs and majority of them were about to quit smoking. Conclusion: Pictorial warning is an effective method to improve the awareness among smokers on the deleterious effects of smoking. The present study has shown significant results as the youngsters are less involved in the habit of smoking, aware about pictorial warning on the cigarette pack depicts, and motivated to quit smoking after knowing the harmful effects which the warning on packs reveals.
Keywords: Cigarette smoking, pictorial warning, smoking cessation
|How to cite this article:|
Bhardwaj VK, Fotedar S, Abbot S, Jhingta P, Sharma D, Negi N. Awareness of pictorial warning on cigarette packets and its impact on smoking cessation among smokers in Shimla, Himachal Pradesh: A cross-sectional study. Int J Health Allied Sci 2016;5:148-53
|How to cite this URL:|
Bhardwaj VK, Fotedar S, Abbot S, Jhingta P, Sharma D, Negi N. Awareness of pictorial warning on cigarette packets and its impact on smoking cessation among smokers in Shimla, Himachal Pradesh: A cross-sectional study. Int J Health Allied Sci [serial online] 2016 [cited 2021 Mar 6];5:148-53. Available from: https://www.ijhas.in/text.asp?2016/5/3/148/187802
| Introduction|| |
The World Health Organization Framework Convention on Tobacco Control (WHO FCTC), the world's first public health treaty, calls for warning labels to be displayed as large and clear health warnings which cover 30-50% of the package in the form of pictures, pictograms, or text. Every person should be informed of the health consequences, addictive nature, and mortal threat posed by tobacco use and exposure to tobacco smoke.  A research has established that pictorial warnings are effective in promoting smoking cessation among users,  informing people about the adverse health consequences of tobacco use,  and arousing negative emotions such as fear and disgust.  Tobacco use has been identified by the WHO as the leading cause of the preventable death  worldwide, and estimates that it currently causes 5.4 billion deaths/year.  Rate of smoking has declined in developed countries in comparison to developing countries where it is continuously rising. 
Of the 1.1 billion people who smoke worldwide, 182 million (16.6%) live in India. In fact, India is suffering a stage of tobacco epidemic.  In 2004, in an estimated population of 1065 million, 0.8-0.9 million Indians die annually from diseases associated with tobacco, which amounts to approximately around 2500 a day. It is predicted that by 2020, tobacco will account for 13% of all the deaths. Among these deaths, 50% are due to cancer and remaining are other health-related problems such as cardiovascular and lung disorders. 
Tobacco control legislation in India dates back to 1975, when the Cigarettes (Regulation of Production, Supply, and Distribution) Act, 1975, required the display of statuary health warnings on advertisements, cartons, and cigarette packages.  Communicating the hazardous effects of smoking remains a primary goal of the tobacco control policy. Section 7 of the Cigarettes and Other Tobacco Products Act (COTPA), 2003 (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, and Supply and Supply and Distribution) in India requires all tobacco products to bear pictorial warning, which must cover 40% of the principal display area of the front panel of tobacco pack. 
Article 11 of the FCTC recognized pictorial health warning on tobacco products as one of the proven strategies to inform consumers about the harmful effects of tobacco. 
The current health warning appearing on cigarette packs consists of a picture of diseased lungs or a radiograph of lungs with cancer for smoked tobacco.  Countries such as Brazil, Thailand, Singapore, Hong Kong, Chile, Australia, and Canada have effectively implemented pictorial warning on tobacco product packets. The effect of pictorial warning was found to be strongest on the people with low socioeconomic status. 
Limited literature exists which reveal the effectiveness of pictorial health warnings on tobacco products in India. No such study has been conducted in the state of Himachal Pradesh. Hence, this study has been taken up to evaluate the awareness of smokers about pictorial warnings on cigarette and impact of these warning in quitting smoking.
| Materials and Methods|| |
A hospital-based cross-sectional study was conducted among the tobacco-using patients, attending the outpatient department, Department of Oral Medicine and Radiology. Two hundred patients, who indulged in the habit of tobacco use, were included in the study, from May 1, 2010 to August 31, 2010. Persons younger than 17 years or those who were suffering from any systemic disease which may influence the oral mucosal status were excluded from this study. Verbal consent was obtained from all the participants. Ethical clearance for conducting the study was obtained from the Institutional Ethical Committee.
A pilot study was conducted 15 days prior to the original study with a sample of twenty individuals who were not part of the main sample. Questionnaire was modified based on the questions and suggestions that arose during the pilot study. The questions were asked by the investigator on sociodemographic characteristics, awareness about warnings and the effect of the warnings on the habit of using tobacco, and the responses were recorded. In India, for smoke form products, a picture of radiograph of chest with an arrow mark pointing at a lesion suggesting lung cancer is being used as a pictorial warning, and the people who had said picture depicts lung problems or lung cancer or injurious to health was taken as correct response to that pictorial warning. Similarly, for smokeless form, a picture of scorpion is being used as a pictorial warning, and the people who had said picture depicts injurious to health or poison or danger to our body was taken as correct response for that pictorial warning. To test the reliability of the questionnaire, Cronbach's alpha was performed and the value obtained was 0.85 for the given sample, thus showing a high degree of reliability.
The data were compiled and entered into Standard Microsoft Excel 2007. Statistical analysis was done using Statistical Package for Social Sciences version 15 (SPPS Inc., Chicago, IL, USA) where we first computed the proportion of tobacco consumers who had seen pictorial warning, and among them, we computed the proportion of tobacco consumers who interpreted correctly and the impact of the pictorial warnings on their habit. P < 0.05 and P < 0.01 were considered as statistically significant and highly significant, respectively.
| Results|| |
In this study, 200 participants were included. Nearly, 28% were in the age group above 35-44 years, and 61% were from urban area. Majority of them (82%) were literate and from upper lower class (34%) [Table 1]. In this study, we found that younger age group (<25 years), better educational status, people from urban area, upper socioeconomic class, and lesser duration (<5 years) of tobacco usage were observed to have a significant association with awareness about pictorial warnings on cigarette packs [Table 2]. These significant variables were subjected to multiple logistic regression analysis, and we found that younger age, urban locality, better education status, and better socioeconomic status are the important independent determinents of awareness about the pictorial warnings [Table 3]. In our study, we found that younger age group (<25 years), better educational status, people from urban area, and lesser duration (<5 years) of tobacco usage were found to have a significant association with the correct interpretation of the pictorial warnings on tobacco products [Table 4]. These significant variables were subjected to multiple logistic regression analysis and we found that better education status and younger people emerged as the important independent determents of correct interpretation of the pictorial warnings on tobacco products [Table 5]. Younger age group (<25 years), educated people from urban area, upper middle class, and with lesser duration of tobacco consumption were sensitive to pictorial warnings and they gave a thought/attempted to reduce/quit tobacco use. It was statistically not significant in people who belong to upper class [Table 6].
|Table 2: Univariate analysis (a one-way Chi-square goodness-of-fit test) showing awareness about the pictorial warnings on tobacco products |
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|Table 3: Multivariate analysis showing awareness about pictorial warning on tobacco products |
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|Table 4: Univariate analysis showing interpretation about the pictorial warning on tobacco products |
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|Table 5: Multivariate analysis showing interpretation about the pictorial warning on tobacco products |
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|Table 6: Univariate analysis impact of tobacco pictorial warning to quit or reduce |
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| Discussion|| |
Health warnings on cigarette packages provide smokers with a universal access to information on the risks of smoking.  Smoking is a big health hazard not only to the smokers but also to the people in their surroundings through passive smoking. Government through regulatory approach has made it mandatory to print the pictorial warning for public awareness.
The present study conducted among the smokers in Shimla reveals that majority of the participants are from the middle age group and from urban area and were literate. Almost half of the study participants are those having longer duration of smoking more than 10 years.
While answering the question related to whether pictorial warning is seen on the cigarette pack, majority of the youngest age group has seen it. The participants who were residing in urban area, with higher socioeconomic status and those who were literate, have seen the pictorial warnings as compared to the participants among similar participants in the same subgroup. Statistically, this difference was highly significant. Similar results were found in the study conducted on an Indian population by Raute et al. and Shastri. , However, Kees et al.  revealed contrasting results.
Multivariate analysis taking into consideration different variables, i.e., age group, locality of residence, level of education, and socioeconomic status shows a significant association among these variables.
As far as correct identification of the pictorial warning is concerned, the majority of the participants in the younger age group have correctly identified the pictorial warning. Among other group's smoker's participants living in urban area, higher socioeconomic status and those who were literate have correctly identified the warnings on cigarette packs as compared to their counterparts in the same subgroup. Difference among youngsters and other participants in the different age group and different participants living in separate localities were statistically highly significant. Nascimento et al.  and Fong et al.  in Brazil and China, respectively, have obtained similar results in their studies on respective population whereas studies conducted by Strasser et al.  and Borland et al.  have revealed contrasting results. The difference could be due to different demographical and legislative interventions. However, the difference in the correct identification of pictorial warning among participants of different socioeconomic status groups was statistically not significant.
Multivariate analysis among younger age group and literate participants has shown a significant association. Effect of seeing pictorial warning and ease to reduce or quit smoking have also shown significant results among different age groups. Almost three-fourth of the younger participants as group smokers want to quit or reduce smoking as compared to the other age groups, although this difference was statistically insignificant. Smokers residing in the urban area, literate, and upper middle socioeconomic status were more motivated to quit smoking as compared to the other participants in the same subgroup. Statistically, the difference was not significant. Studies , have revealed the identical results.
| Conclusion and Public Health Significance|| |
The present study revealed that the youngsters are less involved in the habit of smoking, know what the pictorial warning on the cigarette pack depicts, and motivated to quit smoking after knowing the harmful effects which the warning on packs reveals. Majority of the middle-aged participants are smokers. Awareness has to be created among these people about the harmful effects of tobacco and explaining them what are all the problems health wise or economically can happen to them and can weaken the society and nation. This study is conducted on a smaller sample. In future, more studies should be conducted involving more participants from the rural area. Awareness must be created among masses by health professionals with the help of local bodies and also to the school children through teachers as children are involved in purchasing of cigarettes for their parents.
I thank all the participants, who agreed to participate in this study, statistician, and administrator of H. P. Govt. Dental College and Hospital, Shimla, for permitting me to conduct this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]