|Year : 2015 | Volume
| Issue : 1 | Page : 1-3
Anti-tobacco Messages on Tobacco Products in India: Do They Really Hit the Mark?
Srikrishna Sulgodu Ramachandra1, Srinivas Sulugodu Ramachandra2
1 Public Health Foundation of India, Indian Institute of Public Health, Hyderabad, Telangana, India
2 Faculty of Dentistry, SEGi University, Jalan Teknologi, Taman Sains Petaling Jaya, Selangor, Malaysia
|Date of Web Publication||17-Jun-2015|
Srinivas Sulugodu Ramachandra
Faculty of Dentistry SEGi University, Jalan Teknologi, Taman Sains Petaling Jaya, Selangor
Source of Support: None, Conflict of Interest: None
The Indian Government has recently introduced various fiscal and nonfiscal measures for tobacco control, including pictorial health warnings on tobacco packaging. Health warnings on tobacco products are arguably the most cost-effective tool for educating on the health risks of tobacco use. However, interventions are effective upon being transferred from one setting to another with appropriate adjustment to the local context. Authors argue that there is a need to strengthen and target the health messages in a better way to ensure that the warnings reach all smokers, including those buying loose cigarettes/bidis. Any measures that make anti-tobacco messages more meaningful in the Indian context will lead to significant contributions towards the fight against tobacco.
Keywords: Anti-tobacco messages, India, pictorial warnings, tobacco products
|How to cite this article:|
Ramachandra SS, Ramachandra SS. Anti-tobacco Messages on Tobacco Products in India: Do They Really Hit the Mark?. Indian J Oral Health Res 2015;1:1-3
|How to cite this URL:|
Ramachandra SS, Ramachandra SS. Anti-tobacco Messages on Tobacco Products in India: Do They Really Hit the Mark?. Indian J Oral Health Res [serial online] 2015 [cited 2020 Jan 18];1:1-3. Available from: http://www.ijohr.org/text.asp?2015/1/1/1/158900
| Introduction|| |
The use of tobacco and its products remains one of the most preventable causes of human morbidity and mortality globally.  "Tobacco impoverishes entire nations, just as it does individual families."  Facing strong opposition and stringent regulations in rich and developed countries, the tobacco industry and manufacturers have slowed their expansion in rich countries and are now focusing on developing countries.  Urgent action is required to prevent the inevitable health and social catastrophes linked to large scale tobacco consumption. Tobacco usage has a dual burden on the economy of the consumers: (a) Burden on the economy of the family from the money spent on tobacco products and (b) health burden or treatment costs which occur as a result of diseases attributed to tobacco usage.  Government, nongovernmental organizations (NGO's) and research groups are creating awareness among tobacco users about the ill-effects of tobacco usage through various strategies including, advocacy for an increase of taxes on tobacco products, ban on smoking in public places and mandatory printing of pictorial warning on packs of tobacco products. 
The Department of Health and Family Welfare, Government of India (GOI) has done a great deal toward fighting against usage of tobacco by introducing various fiscal and nonfiscal measures.  One such nonfiscal measure is the introduction of health warnings on packages (both smoked and smokeless forms of tobacco).  Health warning labels on tobacco products constitute the most cost-effective tool for educating smokers and nonsmokers alike about the health risks of tobacco use.  There is definite evidence from studies in many developed countries such as Australia, Canada, UK and USA, where health warnings on cigarette packaging are effective for tobacco control. Changes to increase the severity of health warnings are associated with increased effectiveness and text-plus-graphic warning labels are more salient and potentially more effective than word-only labels. , However, intervention measures may not always be as effective if directly transferred from one setting to another, without being tailored to the tobacco production and consumption context.
| Adoption of Pictorial Warnings|| |
India is a signatory of the World Health Organization (WHO) framework convention on tobacco control (FCTC). As per the guidelines in the article 11 of FCTC,  the Ministry of Health, GOI made pictorial warnings mandatory on smoked and smokeless forms of tobacco products effective from May 31, 2009.  This move by the government was a major step toward creating awareness among both tobacco consumers and nonconsumers. This feat was achieved through concerted pressure on the GOI from NGOs, research agencies and international agencies.  Studies in many countries have shown that pictorial warnings, when used appropriately, have resulted in decreased use of tobacco among consumers. ,, The pictorial warnings on packs of tobacco products in India have been primarily that of a scorpion, skull, pictures of oral cancer or a picture of lungs [Figure 1].
|Figure 1: Image showing the pictorial warnings on tobacco products. A hazy schematic picture of the lungs, schematic picture of scorpion and warning in English "tobacco causes cancer" may not be comprehended by the illiterate population|
Click here to view
However, the use of pictorial warnings in India would be better served by a stronger evidence base to inform the design of the campaign. Some key issues that need to be researched further arise from broader population issues of access to tobacco and purchasing and distribution patterns, as well as education and interpretation of warning images specifically.
| Full Cigarette and Bidi Packs versus Loose Cigarettes and Bidis|| |
In India, cigarettes and bidis are purchased loose as well as in packs. , Ambika Srivastava, in her paper commissioned by the WHO, mentions that as much as 65% of cigarette sales in India occurs from single cigarettes sold by paan-bidi outlets and not in packs.  The reasons for purchasing loose cigarettes rather than packs range from "affordability" among low income smokers and students to the "fear of being caught" among school children if carrying cigarettes in large quantities.  There is also a perception among smokers that, if they buy too many cigarettes at a time, they smoke at a faster rate than if they had bought one or two.  So, even though purchase of loose or single cigarettes may be a strategy to cut down on the cigarette consumption, the pictorial warning on the pack remains with the vendor and the consumer is not exposed to the warning.
The Global Adult Tobacco Survey Report For India (2009-2010) states that 71% of cigarette smokers, 62% of bidi smokers and 63% of smokeless tobacco users noticed health warnings on packages of the respective products.  This reflects that not all smokers see the packaging and that even when they do, the impact is questionable. Authors argue that there is a need to strengthen and target the health messages in a better way to ensure that the warnings reach all smokers including those buying loose cigarettes/bidis. This will have more impact on those consumers who see the packaging. We also need to ensure that the health warnings reach those who buy loose cigarettes/bidis.
| Pictorial Warnings|| |
Although pictorial warnings are particularly useful in communicating health information to populations with low literacy rates, it is very important to ensure proper care is to be taken in the selection of pictures for use in low literacy populations.  As mentioned by Fong et al., "without supporting text, pictures of smoking could inadvertently suggest approval rather than warning of its harms. Although pictures may say 1000 words, it is critical to select those that say the correct 1000 words."  This is especially true in India. Some degree of prior education on the causal links between the pictures shown (diseased lungs and oral cancer) and morbidity and mortality from smoking is needed for clear comprehension. More research on the comprehension of pictorial warnings on tobacco packaging is necessary.
| Statutory Warnings|| |
The sign "not for sale to minors" on the cigarette packs is written on the sides of the foldable top of the cigarette packs and is not immediately visible to the consumers and can only be read by those who are literate. Although the literacy rate in India (which is defined as the ability to read, write and understand in any language for a person who is older than 7 years of age) is around 65%,  the literacy rate for English language is likely to be much lower and needs to be quantified. A 2005 report claims that the English literate population in India is just 5%.  Current written statutory warnings are printed predominantly only in English or English and Hindi (India's National Language) [Figure 1]. In many states in India, the majority of people only know the local dialect and cannot read or write in either English or Hindi.
| Conclusions and Recommendations|| |
In reviewing the implementation of tobacco warnings in India, we have identified some possible ways to further strengthen the campaign and ensure maximum impact of anti-tobacco messaging on tobacco products:
- Printing pictorial warnings on both front and back surfaces of the packaging along with relevant text material
- Printing the warning in English and Hindi or even better, in the local language (dialect) of the state where the packs are marketed (i.e. if a cigarette is being marketed in Tamil Nadu state, the warning should also be in Tamil)
- Evaluation of pictorial warnings (scorpion, lungs etc.,) to ensure that the message from the pictures is clearly understandable by the whole population, regardless of literacy levels
- Investigate whether the statutory warning "smoking injures health" could be printed on the paper wrap of the cigarettes or the filter area and hence that, even if people buy a single cigarette, they have a chance to see the warning.
Urgent action is required in order to put a stop to the inevitable health and social catastrophes linked to large scale tobacco consumption in the developing world. Measures to make anti-tobacco messages on packaging of tobacco products meaningful in the Indian context will be a small, but significant additional step in the fight against tobacco.
| References|| |
Murthy P, Saddichha S. Tobacco cessation services in India: Recent developments and the need for expansion. Indian J Cancer 2010;47 Suppl 1:69-74.
Saouna I. Poor countries: The new "Eldorado" of smoking addiction. Promot Educ 2005;Suppl 4:22-4, 56.
Reddy KS, Gupta PC. Ministry of Health and Family Welfare, Government of India. Report on Tobacco Control in India. New Delhi: Ministry of Health and Family Welfare; 2004. Available from: . [Last accessed on 2010 Aug 08].
Fong GT, Hammond D, Hitchman SC. The impact of pictures on the effectiveness of tobacco warnings. Bull World Health Organ 2009;87:640-3.
Hammond D, Fong GT, Borland R, Cummings KM, McNeill A, Driezen P. Text and graphic warnings on cigarette packages: Findings from the international tobacco control four country study. Am J Prev Med 2007;32:202-9.
O′Hegarty M, Pederson LL, Nelson DE, Mowery P, Gable JM, Wortley P. Reactions of young adult smokers to warning labels on cigarette packages. Am J Prev Med 2006;30:467-73.
Supreme Court of India Order dated 6 th
May 2009, Record of Proceedings: Pack Warnings to be Implemented from 31 st
May 2009. Resource Center for Tobacco Free India. Available from: http://www.rctfi.org/press_statement4.htm
. [Last accessed on 2010 Aug 08].
Reddy KS, Arora M. Pictorial health warnings are a must for effective tobacco control. Indian J Med Res 2009;129:468-71.
Nimbarte A, Aghazadeh F, Harvey C. Comparison of current U.S. and Canadian cigarette pack warnings. Int Q Community Health Educ 2005;24:3-27.
Nascimento BE, Oliveira L, Vieira AS, Joffily M, Gleiser S, Pereira MG, et al.
Avoidance of smoking: The impact of warning labels in Brazil. Tob Control 2008;17:405-9.
Germain D, Wakefield MA, Durkin SJ. Adolescents′ perceptions of cigarette brand image: Does plain packaging make a difference? J Adolesc Health 2010;46:385-92.
Salomi Shah, Shailesh Vaite. Pavement dwellers in Mumbai, India: Prioritizing tobacco over basic needs. In: Efroymson D, editor. Tobacco and Poverty: Observations from India and Bangladesh. Canada: PATH; 2002. Available from: . [Last accessed on 2015 Feb 24].
Nichter M, Nichter M, Van Sickle D. Popular perceptions of tobacco products and patterns of use among male college students in India. Soc Sci Med 2004;59:415-31.
Srivastava A. The Role and Responsibility of Media in Global Tobacco Control. Paper Commissioned by and Produced for World Health Organization, Geneva; presented at the WHO International Conference on Global Tobacco Control Law: Towards a WHO Framework Convention on Tobacco Control, 7-9 Jan 2000, New Delhi, India. Available from: . [Last accessed on 2010 Aug 08].
Thrasher JF, Villalobos V, Dorantes-Alonso A, Arillo-Santillán E, Cummings KM, O′Connor R, et al.
Does the availability of single cigarettes promote or inhibit cigarette consumption? Perceptions, prevalence and correlates of single cigarette use among adult Mexican smokers. Tob Control 2009;18:431-7.
International Institute of Population Sciences (IIPS), Mumbai and Ministry of Health and Family Welfare (MOHFW), Government of India (GOI). Global Adult Tobacco Survey (GATS): India Report; 2009-2010. Available from: . [Last accessed on 2010 Aug 08].
Registrar General of India. Number of Literates and Literacy rate for India; Census of India, 2001. New Delhi: Registrar General and Census Commissioner, Ministry of Home Affairs, Government of India, New Delhi - 110011. Available from: . [Last accessed on 2010 Dec 08].