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  Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 54  |  Issue : 2  |  Page : 461-466
 

Impact of pictorial warning labels on tobacco products among patients attending outpatient department of a dental college in Bangalore city: A cross-sectional study


1 Department of Public Health Dentistry, Bangalore Institute of Dental Sciences, Bengaluru, Karnataka, India
2 Department of Public Health Dentistry, Rungta College of Dental Sciences and Research Centre, Bhilai, Durg, Chhattisgarh, India

Date of Web Publication21-Feb-2018

Correspondence Address:
Dr. R R Narayan
Department of Public Health Dentistry, Bangalore Institute of Dental Sciences, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_203_17

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 » Abstract 


AIM: The aim of this study is to assess the knowledge, attitude, and impact of pictorial warnings present on tobacco packets among patients attending outpatient department of a dental college of Bangalore city. MATERIALS AND METHODS: A cross-sectional study was conducted among 419 patients through convenience sampling, using a structured close-ended questionnaire containing 35 questions. The participants were approached and invited to participate voluntarily. The data obtained were analyzed using descriptive statistics, Chi-square test and ANOVA. RESULTS: Mean age of the participants was 28.1 ± 7.06 years. Out of total 419 participants, 62.8% were tobacco users. About 40.6% of the participants had average knowledge and only 22.9% had positive attitude regarding the pictorial warnings. Nearly 77.9% of tobacco users had previously attempted decreased frequency of tobacco use and 63.7% had tried quitting the habit. The difference was statistically significant (P < 0.05 Chi-square test and ANOVA). CONCLUSION: The present study revealed that most of study participants have noticed the warnings on tobacco products, and most of them believe that they could understand warning labels. This study also showed that most of study participants believed that pictorial health warnings create awareness about probable health hazards of tobacco use and that these pictorial presentations on tobacco packs positively assist in reducing or quitting tobacco smoking.


Keywords: Attitude, impact, knowledge, pictorial warning labels, tobacco


How to cite this article:
Vanishree N, Narayan R R, Naveen N, Bullapa D, Vignesh D, P Raveendran N M. Impact of pictorial warning labels on tobacco products among patients attending outpatient department of a dental college in Bangalore city: A cross-sectional study. Indian J Cancer 2017;54:461-6

How to cite this URL:
Vanishree N, Narayan R R, Naveen N, Bullapa D, Vignesh D, P Raveendran N M. Impact of pictorial warning labels on tobacco products among patients attending outpatient department of a dental college in Bangalore city: A cross-sectional study. Indian J Cancer [serial online] 2017 [cited 2019 Sep 16];54:461-6. Available from: http://www.indianjcancer.com/text.asp?2017/54/2/461/225789





 » Introduction Top


Tobacco has been the prime and most perilous killer of humanity probably since its discovery. Most of tobacco stakeholders, from caretakers, producers, and tobacco farmers, including most consumers, all suffer from multiple chronic health hazards – the ultimate outcome of which is a decreased life span and a premature miserable death.[1],[2] The physical consequences of using smoked or smokeless tobacco on the oral cavity range from the initial tobacco stains on tooth, periodontal diseases, and tooth loss to life-threatening oral cancer preceded by premalignant red and white lesions.[3] Tobacco use continues to be the leading global cause of preventable death. If current trends continue, by 2030, tobacco would kill more than 8 million people worldwide each year, with 80% of these premature deaths among people living in low- and middle-income countries.[4] India is among the countries with the highest tobacco use. According to the National Family Health Survey-3 conducted in 2005–2006, one-third (33.3%) of the men and 1.6% of women aged 15–49 years smoke while smokeless tobacco use was found among more than one-third (38.1%) of the men and one-tenth (9.9%) of the women.[5] As the first guiding principle for controlling the demand and supply of tobacco, Framework Convention on Tobacco Control states that “every person should be informed of the health consequences, addictive nature and mortal threat posed by tobacco consumption and exposure to tobacco smoke.”[6]

Many approaches and strategies are being tried to prevent control and cease tobacco use both at individual and community level.[1] Communicating the hazardous effects of tobacco remains a primary goal of the tobacco control policy. Studies have shown that warning labels on tobacco products can help in communicating the consequences of tobacco use and bring about behavioral changes such as quitting and reducing the tobacco consumption.[7] 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 remains frequently exposed to users (and others).[8] The introduction of pictorial health warnings is perhaps the most notable regulatory development in product labeling. They are meant to help users visualize the nature of tobacco-related diseases and are among the six MPOWER strategies declared by the WHO to combat tobacco use.[6]

To date (2016), more than 40 countries have implemented pictorial warnings on cigarette packages.[9] As far as India is concerned, implementation of the pictorial warnings has taken a rather long time, notified first in 2006, and was to be enforced on May 31, 2009, under Section 7 of The Cigarettes and Other Tobacco Products (Prohibition of Advertisement & Regulation of Trade & Commerce, Production, & Supply and Distribution) Act, 2003.[10] The government notified a set of new pictorial health warnings on May 27, 2009. Although the implementation times and specifications of these pictorial warnings were varied and there were many changes made to the pictorial requirements, from April 1, 2015, new warnings will be required to cover 85% of the front and back of the pack, with different warnings for smoked and/or smokeless tobacco product.[9]

Studies have shown that despite existing tobacco control policies, not only does the number of juvenile and young tobacco users continues to rise unabated, but also those diseases, disabilities, and deaths attributed to tobacco use, upped considerably.[7] Although previous graphic pictorial warnings proved an effective method to improve the awareness among smokers, the size, area covered, and position of the pictures on cigarette packets now need to be researched to provide evidence of improvement in the quit rate.[11]

An analysis of the awareness of the presence of warning messages among tobacco users is important as little is known about its impact on people's behavior. Hence, the present study was conducted with the objective to assess the knowledge, attitude, and impact of pictorial health warnings on tobacco products among the outpatient department (OPD) patients attending a dental college in Bangalore city.


 » Materials and Methods Top


This is an observational cross-sectional study conducted among the patients attending the OPD of Bangalore Institute of Dental Sciences, Bangalore city for 3 months. Patients who could read English or Kannada language and those willing to participate in the study were included in the study. Data were collected from the patients attending the OPD of Bangalore Institute of Dental Sciences, Bangalore city. Permission to conduct the study was obtained from the Principal of Bangalore Institute of Dental Sciences. The study proposal was submitted for approval, and clearance was obtained from the Ethical Review Board of Bangalore Institute of Dental Sciences and Hospital and postgraduate research center.

A self-structured pretested and validated questionnaire containing 35 questions was used. Kannada translation of English version of the self-structured questionnaire was undertaken to have a clear and easy to read and express questionnaires in local language. The final version of Kannada translated questionnaire was back translated to English by two independent bilingual translators who were fluent in English and Kannada. Two experts fluent in both languages and with no prior knowledge of the study compared the back-translated English version with original English version. The two English versions proved nearly identical. The content validity was assessed by a panel of subject experts.

A pilot study was conducted on thirty participants who were selected randomly, to pretest the data collection methods and for the clarity and meaning of the questions. The panel of experts recommended modifying the wording of the questions and addition of options in others. The Cronbach's alpha value for the questionnaire was found to be 0.75, which indicated a very good reliability.

A total of 419 adult patients were obtained by convenience sampling. Implicit verbal consent was obtained from the patients by disclosing the purpose of the study and only those who satisfied the inclusion and exclusion criteria were given the questionnaire. 8–10 min was given to fill the questionnaire and it was on the same day.

The questionnaire was divided into five parts containing demographic details, history of tobacco use, knowledge and attitude regarding the pictorial warnings on tobacco products as well as impact of pictorial warning on tobacco products packets among the tobacco users. Demographic details of the study participants were recorded which included name, age, gender, education, family income, and occupation.

For selected variables, associations were studied using Chi-square test. Group-wise comparison was done using ANOVA. Pearson's correlation was done to check any relation between the parameters. IBM® SPSS Statistics version 19 was used. P ≤ 0.05 was considered to be statistically significant.


 » Results Top


A total of 419 participants in the age group of 18–58 years took part in the study, among whom maximum (62.1%) were in the age group of 18–28 years, while least number (0.9%) in the age group of 49–58 years with the mean age of 28.1 ± 7.06 years. Males were in the majority (75.4%) while females made up the remaining 24.6%. Furthermore, 62.8% were tobacco users and the minority were past tobacco users (32 representing 7.6%) [Table 1].
Table 1: Demographic details of the participants

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Knowledge regarding the pictorial warnings

Among the study participants, the maximum (40.6%) of them had average knowledge while only 0.2% had excellent knowledge. About 17.4% had a good knowledge, 27.7% had below average knowledge, while 14.1% had poor knowledge (P = 0.003) [Table 2]. Among the study participants, majority of them (76.1%) correctly identified lung cancer while 41.8% of the participants correctly identified oral cancer and 29.8% correctly identified cancer [Table 3].
Table 2: Distribution of participants according to knowledge and attitude

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Table 3: Identification of pictorial warnings among study participants

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When asked regarding the government legislation on pictorial warnings, very less number of participants (7.6%) answered correctly regarding percentage of tobacco packet to be covered by pictorial warnings as 85%. Only 3.1% of participants answered correctly regarding the presence of pictorial warning on both sides [Table 4].
Table 4: Awareness regarding implementation of the government legislation on pictorial warnings

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Attitude regarding the pictorial warnings

Among the study participants, 22.9% had positive attitude regarding pictorial warning, whereas 4.3% had negative attitude and 72.8% were uncertain (P = 0.026) [Table 5].
Table 5: Distribution of participants according to attitude

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The mean knowledge is maximum among tobacco users (2.69 ± 0.925) followed by nontobacco users (2.40 ± 0.978) and past tobacco users (2.91 ± 0.734) (<i>P = 0.003). No statistically significant difference was found in the mean values for attitude among the participants [Table 6].
Table 6: Mean scores for knowledge and attitude

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Impact of pictorial warnings on the tobacco users

Among the tobacco users, a very less number of participant (8.4%) always tried to decrease frequency of tobacco use, 3.8% always tried to quit habit of tobacco use, and 9.9% always advised others to quit habit of tobacco use (P = 0.029) [Figure 1]. When knowledge and attitude was correlated with history of tobacco use, it was found that study participants with a longer history of tobacco use had better knowledge and more positive attitude. Furthermore, it was seen that as the knowledge increases, there is more positive attitude toward pictorial warnings [Table 7].
Figure 1: Impact of pictorial warnings on the tobacco users

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Table 7: Correlation between history of tobacco use, attitude, and knowledge

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 » Discussion Top


Health warnings on tobacco packages have a broad population reach and represent a direct and prominent means of communicating the risks of tobacco use. The present study revealed that most of study participants had noticed the warnings on tobacco products and could understand them. Furthermore, most of study participants believed that it created awareness about probable health hazards due to tobacco use and positively assisted in reducing or quitting tobacco smoking.

About 92.6% of the participants in the present study had noticed the pictorial warnings. This result was similar to the study conducted on study participants from professional colleges of Barwala, Panchkula that suggested that more than 90% of study participants had noticed tobacco warning labels.[7] Almost similar results were found in the study conducted on tobacco users residing in the urban slums of Ahmedabad city in Gujarat which showed that 72.3% had noticed warning signals over the tobacco product and in Bellary that mentioned that 72.5% of total participants had seen the pictorial warnings.[2],[12]

In the present study, maximum participants (39.85%) had an average knowledge regarding pictorial warnings. Most of study participants had noticed the warnings on tobacco products and believed that they could understand warning labels. However, when they were asked to assess the pictorial warning labels, many of them were not able to assess them correctly. Similar results were seen in the study conducted on tobacco users residing in the urban slums of Ahmedabad city in Gujarat in which 74% of the respondents had already seen the pictorial warning on the cigarette packet used in India.[2] Findings of this study also corroborate with those of an earlier study conducted in five different states, which suggested that pictorial warnings that existed on tobacco packs are perceived to be ineffective by the Indian population.[10] Thus, the mandated warnings do not serve the desired purpose since they are not properly understood.

In the present study, 22.9% of the participants had a positive attitude regarding the pictorial warnings present on tobacco products. In the present study, it was seen that larger warnings with pictures are significantly more effective than smaller, text-only messages. This can be due to the fact that they are eye-catching, informative, add on as an additional motivation in quitting tobacco consumption. Furthermore, 40.3% of the participants thought that larger pictures are needed while 37.5% thought that the use of local language was needed. About 57.1% of participants thought that the present colorful form of pictorial warnings is more effective than the earlier black and white pictures. Similar results were found by study conducted on health-care professionals in tertiary referral centers in Pakistan which showed 56% of the participants thought that instead of black and white pictures, colored pictures would be more effective and the picture should cover more pack area to convey the health information, which was similar to our study results.[13] The present study also found that pictorial warnings were found to be more effective than text warnings, which is in accordance with the study conducted on study participants from professional colleges of Barwala, Panchkula.[7] Similar studies conducted in Australia and in Bangalore city showed that text-only packs were not considered as effective in conveying the potential negative health consequences of smoking as the graphic pack alternatives which were comparable to our study.[14],[15]

More than 70% believe that warnings create awareness about health hazards of tobacco and help in reducing or quitting tobacco. Given their great reach, these may be one of the few tobacco control policies that can have the potential to reduce the communication inequalities across groups. Policies that establish strong pictorial warning labels on tobacco packaging may be instrumental in reducing the toll of the tobacco epidemic, particularly within vulnerable communities. Four countries suggested that more prominent health warnings are associated with greater levels of awareness and perceived effectiveness among smokers.[8] Similar results were found in study conducted in Thane that showed though pictorial warning is an effective method to improve the awareness among smokers on the ill effects of smoking, the size, area covered, and the position of the picture on cigarette packets need to be reviewed to improve the quit rate.[16]

In the present study, among those who were aware about warning signals, 77.9% said that they had reduced the quantity after seeing the warning labels sometimes, whereas 63.7% had sometimes thought to quit tobacco and 67.2% had sometimes advised others to quit the habit, which was similar to some studies.[2],[7] In the present study, as the level of education increases, number of tobacco users with positive impact and positive attitude regarding warning labels increases. This was in accordance with the study conducted in Bellary mentioned that awareness and impact of pictorial warnings was highest among graduates.[12] This is due to the fact that better education of the participants made them more aware of the ill effects of tobacco usage.

The present study showed that pictorial health warnings on tobacco products do not provide enough motivation to quit tobacco or prevent its initiation as 39.7% of the respondents who were tobacco users would continue to use tobacco and would not contemplate quitting even after observing the warnings.

Furthermore, it is seen that tobacco users have better knowledge compared to the past tobacco users and nontobacco users. This is in consistent with the study conducted in Mumbai which showed that participants with an income of less than Rs. 10000 and education lower than professional degree had lower health knowledge about the ill effects caused by smoking.[16] However, it is in contrast with the study conducted in Canada revealed that knowledge to be substantially lower among the majority of the world's smokers, particularly those living in low- and middle-income countries where resources for tobacco control are nonexistent or lower by orders of magnitude.[8] This can be because majority of the population in the present study was from middle- and upper-income groups having good education level.

There are certain studies that also suggest that health warnings can promote smoking cessation and discourage youth uptake.[2],[5],[7] Considerable proportions of smokers report that warning labels increase their motivation to quit and help them to sustain abstinence after quitting.[17] However, the impact of health warning labels depends on their design; obscure text-only warnings appear to have little impact, in contrast to larger pictorial warnings on the front and back of packages in other jurisdictions.

The present study has some limitations. The self-reported questionnaire that was used may cause several biases including recall and social desirability bias. Furthermore, the convenience sampling method used may also have added to the bias. Further studies can be done with a longer duration as time interval for the present study is very small for assessment of a sustained effect to reduce tobacco product use among tobacco user.

Vigilance is necessary to ensure that legislation is backed up with implementation. Furthermore, compliance by tobacco manufacturers in showing the truth about health hazards of tobacco through the medium of tobacco packages is important as it is universal in reach and hence can help in overcoming the illiteracy and language barriers.[5] Some recommendations can be considered to make pictorial warning on tobacco products more effective. Pictorial warning should be clearer and more glorified. More influential warning labels are required to achieve the goal set for tobacco control. In addition to text message in English, local or regional languages in India should also be considered. Having the warnings on each cigarette piece can also be considered.


 » Conclusion Top


Warning labels on tobacco packs may effectively inform people about adverse health effects of tobacco. However, mandated warnings do not serve the desired purpose since they are not properly understood. People would like to see warnings with scarier picture, textual warning in native language, and mentioning about more ill effects of tobacco. It created awareness about probable health hazards due to tobacco use and positively assisted in reducing or quitting tobacco smoking. The tobacco epidemic is devastating but preventable. This study has shown that effective and field-tested health warnings displayed on tobacco product packages can address all the issues related to increasing the awareness and motivation to quit tobacco consumption among all the folks. This serves as an important lesson for India and other developing countries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

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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 study. Indian J Stomatol 2011;2:227-32.  Back to cited text no. 1
    
2.
Shah VR, Dave VR, Sonaliya KN. Impact of anti-tobacco warning labels on behaviour of tobacco users in one of the cities of Gujarat, India. J Prev Med Hyg 2013;54:109-13.  Back to cited text no. 2
    
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Lopez AD, Mathers CD, Ezzati M, Murray CJ, Jamison DT, editors. Global Burden of Disease and Risk Factors. New York: Oxford University Press; 2006. p. 45-240.  Back to cited text no. 3
    
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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. 5
    
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Fong GT, Hammond D, Hitchman SC. The impact of pictures on the effectiveness of tobacco warnings. Bull World Health Organ 2009;87:640-3.  Back to cited text no. 6
    
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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. 7
    
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Hammond D, Fong GT, Borland R, Cummings KM, McNeill A, Driezen P. Communicating risk to smokers: The impact of health warnings on cigarette packages. Am J Prev Med 2007;32:202-9.  Back to cited text no. 8
    
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World Health Organization. Framework Convention on Tobacco Control. Elaboration of Guidelines for Implementation of Article 11 of the Convention. World Health Organization; 2008. www.who.int/fctc/guidelines/adopted/article_11/en/. [Last accessed on 2015 May 03].  Back to cited text no. 9
    
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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. 10
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Thejus T, Jayakrishnan T. Pictorial warnings on tobacco products: How delayed and diluted in India? Indian J Med Ethics 2009;6:105-6.  Back to cited text no. 11
    
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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. 12
    
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Raute LJ, Pednekar MS, Gupta PC. Pictorial health warnings on cigarette packs: A population based study findings from India. Tobacco Use Insights. 2009 Jan 1;2:11.  Back to cited text no. 13
    
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Cantrell J, Vallone DM, Thrasher JF, Nagler RH, Feirman SP, Muenz LR, et al. Impact of tobacco-related health warning labels across socioeconomic, race and ethnic groups: Results from a randomized web-based experiment. PLoS One 2013;8:e52206.  Back to cited text no. 14
    
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Bhat PK, Kumar A. Perception of pictorial warning present on cigarette packet used in India among graduating dental students of. Bangalore city, JIAPHD 2009;14:158-68.  Back to cited text no. 15
    
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Rajeswary K, Kumar PD, Shivakumar.M, Lenin K.R. Role of pictorial warning on cigarette packets in tobacco cessation- A questionnaire survey among cigarette smokers in Chennai. Int J Pharm Biol Res. 2012; 3:183–6.  Back to cited text no. 16
    
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Heydari GR, Ramezankhani A, Talischi F. The impacts of cigarette packaging pictorial warning labels on smokers in the city of Tehran. Tanaffos 2011;10:40-7.  Back to cited text no. 17
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]

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