|TOBACCO CONTROL ISSUE - ORIGINAL ARTICLE
|Year : 2014 | Volume
| Issue : 5 | Page : 13-18
Influence of tobacco industry advertisements and promotions on tobacco use in India: Findings from the Global Adult Tobacco Survey 2009-2010
DN Sinha1, KM Palipudi2, K Oswal3, PC Gupta4, LJ Andes2, S Asma2
1 World Health Organization, South-East Asia Regional Office, New Delhi, India
2 US Centers for Disease Control and Prevention, Atlanta, GA, USA
3 Terna Dental College and Hospital, Mumbai, Maharashtra, India
4 Healis Sekhsaria Institute for Public Health, Mumbai, Maharashtra, India
|Date of Web Publication||19-Dec-2014|
D N Sinha
World Health Organization, South-East Asia Regional Office, New Delhi
Source of Support: None, Conflict of Interest: None
Introduction: The developing world, including countries like India, has become a major target for the tobacco industry to market its products. This study examines the influence of the marketing (advertising and promotion) of tobacco products on the use of tobacco by adults (ages 15 and over) in India. Method: Data from Global Adult Tobacco Survey 2009-2010 was analyzed using methods for complex (clustered) sample designs. Multivariate logistic regression was employed to predict the use of different tobacco products by level of exposure to tobacco marketing using adults who have never used tobacco as the reference category. Odds ratios (ORs) were adjusted for education, gender, age, state of residence, wealth index, and place of residence (urban/rural). Results: Adults in India were almost twice as likely to be current smokers (versus never users) when they were exposed to a moderate level of bidi or cigarette marketing. For bidis, among adults with high exposure, the OR for current use was 4.57 (95% confidence interval [CI]: 1.6, 13.0). Adults were more likely to be current users of smokeless tobacco (SLT) with even a low level of exposure to SLT marketing (OR = 1.24 [95% CI: 1.1, 1.4]). For SLT, the ORs showed an increasing trend (P for trend < 0.001) with greater level of exposure (moderate, OR = 1.55 [95% CI: 1.1, 2.2]; high, OR = 2.05 [95% CI: 0.8, 5.1]). The risk of any current tobacco use rose with increasing level of exposure to any marketing (minimum, OR = 1.25 [1.1-1.4]; moderate, OR = 1.38 [1.1-1.8]; and high, OR = 2.73 [1.8-4.2]), with the trend highly significant (P < 0.001). Conclusion: Exposure to the marketing of tobacco products, which may take the form of advertising at the point of sale, sales or a discounted price, free coupons, free samples, surrogate advertisements, or any of several other modalities, increased prevalence of tobacco use among adults. An increasing level of exposure to direct and indirect advertisement and promotion is associated with an increased likelihood of tobacco use.
Keywords: Adults, Global Adult Tobacco Survey, India, promotion and marketing, tobacco advertising, tobacco use
|How to cite this article:|
Sinha D N, Palipudi K M, Oswal K, Gupta P C, Andes L J, Asma S. Influence of tobacco industry advertisements and promotions on tobacco use in India: Findings from the Global Adult Tobacco Survey 2009-2010. Indian J Cancer 2014;51, Suppl S1:13-8
|How to cite this URL:|
Sinha D N, Palipudi K M, Oswal K, Gupta P C, Andes L J, Asma S. Influence of tobacco industry advertisements and promotions on tobacco use in India: Findings from the Global Adult Tobacco Survey 2009-2010. Indian J Cancer [serial online] 2014 [cited 2020 Apr 9];51, Suppl S1:13-8. Available from: http://www.indianjcancer.com/text.asp?2014/51/5/13/147424
| » Introduction|| |
Around the world, tobacco companies are employing sophisticated campaigns to market their products to men, women, and children from different socioeconomic groups, and in recent years they have shifted their efforts toward the developing world, including India. ,, The tobacco industry places advertisements in stores (point of sale), on TV, on the radio, on billboards, and through posters. Advertisements for tobacco are also seen in newspapers/magazines, in cinemas, on the internet, on public transportation, on public walls, and in various other places. Furthermore, the tobacco industry uses a variety of strategies for promoting its products, including discounts and sales, clothing or other items with brand logos, coupons, free samples, surrogate advertising and free gifts.
Research has shown that cigarette marketing in the form of advertisements and promotions are causally related to increased prevalence of smoking. , Unfortunately, the majority of studies to date on the relations between advertising and tobacco use have been undertaken in developed countries, and generally they have focused on just one form of tobacco use: Cigarette smoking.
In India, evidence strongly suggests that exposure to marketing for tobacco leads to the initiation and progression of tobacco use among children and adolescents. ,,, Moreover, it appears that young people often differ from one another in their response to advertising, and thus information about such responses among both youths and adults should increase our understanding of how to combat the tobacco problem worldwide. For example, in a study that relied on longitudinal data for more than 10,000 adolescents who were never smokers, cognitive susceptibility to smoking (having "high-risk cognitions") was found to double the risk of future smoking.  In addition, various studies have found that receptivity to advertisements for cigarettes was associated with smoking behavior among adolescents. ,,
India has a wide spectrum of forms in which tobacco is consumed encompassing smoking as well as smokeless tobacco (SLT) use. The easy availability of both SLT and smoked products renders Indian people in all age groups vulnerable to tobacco use. In a study, which was conducted from 2004 to 2006, exposure to tobacco advertising was significantly related to higher rates of tobacco use among students, with a clear dose-response relationship.  To the best of our knowledge, the impact of the marketing of tobacco products on the use of tobacco among adults, however, has not been reported for India.
The Global Adult Tobacco Survey (GATS), India during 2009-2010 provided some background on the issue of tobacco marketing. In the previous 30 days, two of every seven adults (28.4%) had noticed a cigarette advertisement or promotion; almost half (47.0%) noticed a bidi advertisement or promotion; and more than half (54.7%) noticed a SLT advertisement or promotion.  Using the same dataset, the present study examines the influence of the marketing of tobacco products on tobacco use among adults aged 15 years and above. ,
| » Methodology|| |
GATS, India 2009-2010 was conducted in 29 states and two union territories covering 99% of the country's population. A multistage cluster design was employed in this nationally representative in-person survey; the detailed methodology for GATS has been described elsewhere.  In this study, exposure to marketing was assessed by using 51 questions in GATS India about advertisements and promotions for cigarettes, bidis, and SLT [Table 1]. Public use data were used for statistical analysis. 
|Table 1: List of questions about tobacco advertising and promotions in India, GATS 2009- 2010 |
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Participants who reported smoking daily or less than daily, but who did not use SLT were defined as current smokers. Similarly, participants who reported use of SLT on a daily or less than daily basis, but who did not smoke were defined as current SLT users. Participants who were classified as both current smokers and current users of SLT were defined as current dual users. Thus, all present tobacco users were classified in one of three categories: Current smoker only, current SLT user only, or current dual user. Never tobacco users were those who had never used either smoked or SLT.
Tobacco industry marketing for cigarettes, bidis, and SLT was assessed separately, as indicated by the questions in [Table 1]. For each type of product, respondents were asked whether they had noticed 11 types of advertising and six types of promotions in the last 30 days. An answer of "yes" was coded as 1, and "no" was coded as 0. A response of "yes" to any of the advertising or promotions questions was considered to be exposure to such activity, and a tobacco marketing index was created based on the number of categories with exposure (none = 0, low = 1-2, moderate = 3-4, and high = 5-17) [Figure 1].
|Figure 1: Percentage distribution of levels of exposure to tobacco advertising and promotions by type of tobacco product among adults aged ≥15 years in India, Global Adult Tobacco Survey 2009-2010|
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Statistical Package for the Social Sciences (version 21; SPSS Inc., Chicago, IL, USA) was used to analyze the data. Bivariate analyses were employed to calculate the prevalence of exposure to different forms of tobacco marketing among four classifications of current users (smokers only, users of SLT only, dual users, and all tobacco users) and non-users [Table 2]. In addition, logistic regression analysis was performed with tobacco use status as the dependent variable and the tobacco marketing index as the independent variable to determine the influence of exposure to tobacco advertisements and promotions [Figure 1]. Separate logistic regressions were conducted to predict four categories of current use (smoker only, SLT user only, dual user, and tobacco user) versus never users. The odds ratios (ORs) were adjusted for gender, age, education, wealth index, state of residence, and place of residence (urban/rural); an OR was considered as significant if the P < 0.05 for the difference between the OR and the referent (OR = 1.00).
|Table 2: Percentage of adults aged ≥ 15 years who were exposed to different types of tobacco advertisements and promotions in India, GATS 2009- 2010 |
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| » Results|| |
Exposure to tobacco advertisements and promotion varied by modality for all categories of adults by usage status [Table 2]. The 10 specified locations covered almost all marketing venues and exposure to marketing "anywhere else" was <1%. With "anywhere else" excluded, among non-users, the rates for exposure to cigarette marketing ranged from 0.9% for free gifts and "on the internet" to 10.3% at the point of sale (i.e. in stores). The comparable range (i.e. excluding "anywhere else") among non-users for exposure to the marketing of bidis was somewhat narrower, with a low of 0.9% for free gifts and a high of 7.9% for the point of sale. For the marketing of SLT, the comparable lows and highs for non-users were 1.0% for free gifts and 10.2% at the point of sale/in stores. Among those who were tobacco smokers only, the comparable estimates for exposure to cigarette marketing ranged from a low of 1.0% for free gifts to 14.1% for cigarette advertising at the point of sale, while for the marketing of bidis the corresponding range was from 1.1% for free gifts to 10.9% at the point of sale. Among users of SLT only, the comparable estimates varied from a low of 1.1% for free gifts to 10.5% at the point of sale. For dual users, as for other categories, the highest estimates for each type of marketing (cigarettes, bidis, and SLT) were for the point of sale. The single highest individual rate of exposure was 15.5% in stores for SLT marketing among dual users.
For cigarettes, bidis, and SLT, the estimated level of non exposure to marketing always exceeded 70%, and the percentage of adults exposed decreased as the level of exposure rose [Figure 1]. Regarding the relationship between tobacco use and marketing exposure, there was no clear dose-response relationship, but for cigarettes those with no exposure had the lowest estimate for smoking, with a significant difference between this category and the other three levels of exposure. This pattern did not hold for bidis or SLT when considering single users. Among dual users, however, those with no exposure had a significantly lower prevalence of SLT use than did those with low or moderate exposure. There was no significant difference between those with no exposure and the high exposure group.
In a logistic regression analysis [Table 3], with no exposure serving as the referent, adults exposed to even a low level of cigarette marketing were more likely to smoke, with the OR 1.25 (95% confidence interval: 1.1, 1.5). The OR rose with greater exposure (moderate, OR = 1.91 [1.2, 3.0]; high, OR = 2.35 [0.9, 6.3]). The trend analysis was significant (P < 0.001).
|Table 3: Influence of tobacco industry marketing on tobacco use: OR with 95% CI developed from logistic regression |
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Similarly, adults with low exposure to the marketing of bidis were more likely to smoke bidis than those with no exposure (OR = 1.49, [1.3, 1.8]), and the association was stronger when individuals were moderately exposed to bidi marketing (OR = 1.84 [1.2, 2.7]). Individuals were most likely to smoke bidis when there was high exposure (OR = 4.57 [1.6, 13.0]). The trend analysis for bidis was significant (P < 0.001).
[Table 3] also shows that individuals were more likely to consume SLT if they had low exposure (versus no exposure) to the marketing of this product (OR = 1.24 [1.1, 1.4]). The OR with moderate exposure was 1.55 (1.1, 2.2); for high exposure it was 2.05 (0.8, 5.1). The trend analysis for SLT was significant (P < 0.001).
The prevalence of dual users was significantly higher when exposed to even a low level of marketing for cigarettes (OR = 1.48 [1.2, 1.8)]); bidis (OR = 1.49 [1.2-1.8]), or SLT (OR = 1.76 [1.5-2.1]). An increasing trend with greater levels of exposure was evident (P < 0.001).
When any current tobacco use was considered, results were similar. Even those with low exposure to marketing for any tobacco product (cigarettes, bidis, or SLT) were more likely to consume tobacco (OR = 1.25 [1.1-1.4]), and the association showed a rising trend with increasing level of exposure to marketing of any tobacco product (moderate exposure, OR = 1.38 [1.1, 1.8]; and high exposure, OR = 2.73 [1.8, 4.2]). The trend analysis was significant (P < 0.001).
| » Discussion|| |
The findings of this paper clearly point to a strong relationship between exposure to advertisements and promotions for tobacco products and the use of tobacco among adults aged 15 years and over in India. In fact, we found a highly significant trend (P < 0.001) for an increasing likelihood of tobacco use with greater level of exposure to any marketing of tobacco products.
Findings from the present study indicate that, in India, exposure to direct advertisements is relatively high in stores (overall estimates of 10.7% for cigarettes, 10.8% for SLT, and 8.2% for bidis), on billboards (6.1-9.5% by product), on posters (7.4-9.5%), and on public transportation (6.2-8.9%). However, India has a nearly comprehensive ban on direct and indirect advertisements of tobacco while still allowing advertising that is at the point of sale, "in pack", or "on pack."  The tobacco industry is taking advantage of this weakness and using point-of-sale advertising in a most explicit manner in India.  In fact, the point-of-sale advertising of tobacco products has mushroomed since the implementation of the Indian tobacco control law in 2004.  Clearly, bans on point-of-sale advertising and promotion would be an important policy intervention. Point-of-sale retail settings have become increasingly important for (tobacco advertising, promotion, and sponsorship) activities  and, as in India, in many countries people are more aware of tobacco advertising in stores than through any other advertising channel.  It is important, therefore, to ban point-of-sale advertising, including product displays and signage, in retail stores.  Both Ireland  and Norway have enacted a ban on tobacco displays at the point of sale, which has diminished the value of branding in the purchasing choices made by consumers.  In the United Kingdom, cigarette sales declined by 3% in those retail stores that had covered up or removed product displays in advance of an announced ban.  India may take lessons from these countries and adopt the policy of completely banning the advertisement of tobacco products at the point of sale.
The study has at least three limitations. First, measures of tobacco use and exposure to tobacco marketing are based on self-reports which may be biased. Second, all channels of advertising and/or promotion are given equal weight in the creation of the tobacco marketing index, although different channels might be more important, that is, advertising on television might be more influential than free samples. Third, the effects of cigarette and bidi marketing are analyzed separately, although the influence of the two may be inter-related. However, the present study shows a significant dose-response relationship in the form of an increasing likelihood of tobacco use with increasing level of exposure to marketing strategies for tobacco.
India might consider strengthening its policy on banning tobacco advertisements, especially at the point of sale, and enforce the (cigarettes and other tobacco products act)  provisions more strongly to reduce tobacco use among adults and prevent initiation among youth and young adults.
| » Conclusion|| |
The tobacco industry continues to use diverse means of promoting and marketing its products, but such a strategy, while helping to meet the aims of tobacco companies, is no doubt very harmful to the public health. Marketing strategies, which may take the form of advertisements, discounted prices, free gifts, point-of-sale advertisements, free coupons, or other initiatives, seem to work synergistically with each other, causing the prevalence of tobacco use to increase with exposure to higher numbers of marketing strategies. A clear implication of the findings in the present study is that there should be an all-encompassing, clear definition of the promotion of tobacco products, and any legislation enacted should use that definition to effectively ban all marketing and promotion of tobacco products by the industry. The findings of the present study also show that the industry makes effective use of any weakness or exception in the law to continue to promote its products, as illustrated by the fact that the highest exposure is to point-of-sale advertising. India could learn from the experiences of other countries, where comprehensive bans on marketing of tobacco products have been effectively implemented and followed by decreasing tobacco use.
| » Acknowledgment|| |
Contributions from ministry of health and family welfare, government of India, New Delhi, and bloomberg philanthropies are appreciated.
The author alone is responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.
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[Table 1], [Table 2], [Table 3]