Awareness and attitude toward pictographs on tobacco products: A population-based study in field practice area.

BACKGROUND: Tobacco use is a major global public health threat for all countries and no form of tobacco use is safe. Pictorial warnings covering 40% area of tobacco products are made mandatory from May 31, 2009 in India. The present study was aimed to investigate the awareness and attitude toward pictorial warnings on tobacco products among age 15 years and above population in field-practice area.
MATERIALS AND METHODS: A total of 1064 individuals were selected by systematic random sampling. A model containing the pictorial warnings were shown to the study subjects, and data were collected by semi-structured questionnaire. Data was analyzed using SPSS 20 and statistical tests used were Chi-square test. Significance level set at P ≤ 0.05.
RESULTS: Of the 1064 individuals participated in the study, 53.9% were male and the mean age of the study population was 31.24 ± 5.8. Nearly 45.8% reported using tobacco in some form and all of them were males. 51.3% of both males and females reported that they never came across antitobacco messages (pictorial warnings). 71.2% believed that the size and position of pictorial warnings on tobacco products were not sufficient to understand the harmful effects of tobacco. There was statistically significant difference between different age groups in their responses to the aforementioned questions.
CONCLUSION: The results of present study demonstrate that the need for pictorial warnings on tobacco products to be more clear and explanatory since there is little point in having pictorial warnings when the prime purpose of having them is not being served.

INTRODUCTION

Tobacco use in the Indian context imposes a huge burden for public health and being emerged as a major cause for premature deaths.[1] Considering the public health thrust, there is a need of visible effort to increase awareness regarding the health risks of tobacco use to consumers. Tobacco packages provide high reach and frequency of exposure and also serve as portable advertisements providing a provision for Health warnings which have emerged as an efficient medium for communicating the health risks, as the frequency of exposure through pack a day, smokers are potentially exposed to the warnings over 7000 times per year.[2]

In India, the new pictorial warnings notification was issued on October 15, 2014, but mandatory display of new health warnings covering 85% of the principal display area on all tobacco products was notified on September 24, 2015, making India 3rd among countries with largest pictorial warnings on tobacco products. This initiation to drive home the point of prevention was implemented by Health Ministry, from April 1 2016, on all forms of tobacco products.[34]

A successful image is about communication as most of the information transmitted to the brain is visual; it must tell the viewer the intended story, through an entirely and solely visual means of communication. The visual portion has much more immediate impact than the text because text requires conscious processing and images do not, which facilitate to empower people to make strong associations between health messages and their perceptions. Majority of the researchers presume that the knowledge and attitude are related to each other where attitude is further linked to the behavior. The assumption believes on “if people become more knowledgeable about the tobacco and its associated diseases, they will, in turn become more aware of the tobacco and its problems and thus, be more motivated to act toward the tobacco and its related diseases in more responsible and vigilant ways.”[56]

The present study was done from the Department of Public Health Dentistry, in a renowned dental college that is located in Takkellapadu Village, Guntur, Andhra Pradesh, India. Since Guntur is a major district in production and consumption of tobacco, the public in this area are more prone to get habituated to various forms of tobacco. Hence made an attempt to study the awareness, attitudes and impact of current pictorial warnings in the field practice area, which is with in 15 kilometers radius from the institution.

MATERIALS AND METHODS

Study design

A cross-sectional, semi-structured, self-administered, validated questionnaire-based study was done with ethical clearance obtained from the Institutional Ethics Review Board, where study aim, objectives and confidentiality on their personal information, and responses were well described to the study contestants whilst an informed written consent was obtained from all the participants before the start of the study.

Selection criteria

Inclusion criteria

Males and females of age 15 years and above were included in the study

Tobacco users, nonusers, and past users were included in the study

Persons who are permanent residents of the study area are only included in this study.

Exclusion criteria

Mentally challenged and who are unable to answer.

Study procedure

A house-to-house survey was conducted on 1064 participants aged 15 and above in the field practice area located in Pedakakani Mandal (Mandal is a sub-district administrative area), South coastal Andhra Pradesh, India, spreading over 16.60 km2 comprising 12 suburban localities with population of 64,693 residing in 14,944 houses.[7] From each of these, 12 localities a quota of 50 houses selected using systematic random sampling technique.

The data on attitude and awareness on pictorial warnings of tobacco products were obtained using a self-administered, semi-structured questionnaire along with a model-contained a panel of empty packets having pictorial warnings of smoked and smokeless tobacco products stuck on it.

The questionnaire was developed on the basis of the perceptions of authors with Master's degree in the subject of Public Health Dentistry. While framing the questionnaire the context of the study subjects and their usage of tobacco products were taken into consideration. The perceptions were converted to sentences to frame the questionnaire. These questions were then organized in a systematic order and then were translated to Telugu, mother tongue of study participants and then back translated to English by a bilingual expert, the face and content validity of the questionnaire were assessed while the content validity of the questionnaire is 0.80. For illiterates, the questions were read out and the reliability of the questionnaire was assessed in the pilot study, which was conducted on 90 individuals (Cronbach's alpha = 0.88). The final questionnaire contained semi-structured questions after considering minor corrections.

The questionnaire consisted of sociodemographic details such as age, gender, education and occupation; tobacco use practices and questions on awareness along with attitudes in regard to pictorial warnings on tobacco products. Data thus obtained were analyzed using Chi-square test with IBM SPSS version 20.0 (IBM Corp., Armonk, NY, USA) and P ≤ 0.05 was considered to be statistically significant.

RESULTS

Out of 1064, 53.9% were male with mean age group of 31.24 ± 5.8 and majority of the participants (54%) belonged to the age group of 25–34 years with 26.9% (n = 287) of the study participants had primary school education. Regarding occupation, majority of the study participants, i.e., 31.4% are clerical, shop-owner or farmer. Nearly 46% of the study participants are tobacco users and all the tobacco users are only males, thus gender-wise shift to one side could be due to social stratification bias [Table 1].

Table 1

Frequency distribution of the study population

In total population, 91% of tobacco users and 14% of nonusers responded that they came across antitobacco pictorial warning signs while this difference was statistically significant (P = 0.001). Nearly 56% of tobacco users and 6% of nonusers agreed that textual warning on tobacco products are sufficient and clear to understand the harmful effect and this difference was statistically significant (P = 0.002) [Figure 1].

Figure 1

Responses of the participants

There was also a significant difference (P = 0.001) in the opinions of 69% tobacco users and 15% of nonusers about changing the textual warnings on tobacco products to regional language, while 2% of tobacco users and 83% of nonusers were not aware about the colors that should be used on pictorial warnings of tobacco products (P = 0.008). Mandated pictorial warnings do not serve the desired purpose since they are not properly understood, people would like to see the warnings mainly in regional language with more clarity in picture [Figure 1]. Further, the respondent's attitudes toward tobacco are measured through an open-ended question and were converted to typical statements and presented.

DISCUSSION

Despite the fact that state has taken enormous measures, none have served in getting the desired result as to properly communicate the ill effects of tobacco consumption to the general public. Hence, the present study states the current level of knowledge on harmful effects of tobacco consumption among the mainstream population. Nearly 57.3% of illiterates and 54.2% of the present study population in the age group of 25–34 years were not aware of pictorial warnings on tobacco products as compared to 40.6% illiterates and 32.6% of people aged 25–34 years in a study done by G. N Karibasappa et al.[8] Tobacco use has been found inversely proportion to literacy and directly proportional to age which is similar to a study done by Bhawna, Global Adult Tobacco Survey, India.[9]

Awareness among the people on warning labels was inadequate. These labels were ineffective in conveying the adverse effects of tobacco use on health which was on par with the studies done by Rani et al.,[10] Oswal et al.,[11] Arora et al.[12]

The perceptions on the effectiveness of pictorial warnings on tobacco products were found to be inadequate among tobacco users (44%) and nonusers (13%), respectively. Dissimilar results were observed in the studies done by Thakur et al. and Arora et al. where 71.5% of users and 62.75% of nonusers opined that the effectiveness of pictorial warnings to be inadequate.[1213]

The following are the statements of the study participants that are organized based on their colloquial, which reflects the study population's attitudes toward the tobacco usage and pictorial warnings.

“Is it wrong to consume tobacco? If tobacco is really wrong and harmful to our health then why government is allowing to grow the crop and also allowing it for consumption.”

“Consumption of tobacco decreases only when government bans the tobacco completely and government should more concentrate on educating people about risks of tobacco.”

“We don’t have the habit and never saw the pictorial warnings.”

“Though pictorial warnings are printed on tobacco products, it has less impact on behaviours as people will consume tobacco products no matter what and they aren’t going to stop now even though it is bad for health”

“As I am a farmer, I work at midnights in the field so, in order to stay awake I consume tobacco”

“We will discuss about this topic (tobacco consumption) outside the house”

Consumption of tobacco is sin, god punishes them those who consume it.

“I have been a smoker for the past 15 years and have always known the risks of health, as I have to work continuously I smoke”.

“My favorite hero smokes on screen so as I”

Attitudes of the study population

The present study, however depicts exact understanding of ill effects caused by tobacco among the residents of our selected field area and the only possible shortcoming might be due to the under response of female participants. Although Indian women right away trying to adapt themselves to the modern habits besides maintaining their ancient culture and traditions, occasionally they don’t like to express their inner feelings, tastes, and habits to the outside world.[141516]

It also said that the packaging rules are drastic and impractical as this may lead to increase smuggling of illegal cigarettes, even the Beedi industry are against the new rules saying that they would bring the industry to “Grinding Halt” and “cause grave and irreparable harm and loss” as 8 million people and their families were surviving on this industry. Farmer groups and industrial entrepreneurs are among those taking out large advertisements in newspapers protesting and criticizing the legislation.[17]

Keeping in mind the ethical standards everyone has right to know the truth about harmful effects of tobacco consumption, as pictorial warnings helps to communicate not only with tobacco users but also with prospective quitters and probable initiators, young people and illiterates who initiate tobacco use without knowledge of its health impact will benefit the most, as a picture is worth a thousand words.

CONCLUSION

Although photographic psychology explores the impact that pictures have on behaviors, the present study depicted mandated pictorial warnings on tobacco products do not serve the desired purpose since they are not in a way that can be easily understood by the target population. Hence, there required an implementation of robust and effective pictorial health warnings along with regional language on all tobacco products with immediate effect. Health professionals can play a decisive role by making use of every opportunity in the fight against the tobacco that can be considered as weapon of mass destruction as today's teenage beginner is tomorrow's potential regular user.

Limitations

For the illiterates, the questions were read out by the investigator, which could have influenced the answers

All female subjects said that they do not have the habit of tobacco either in smoke or smokeless form, as the possibility of social stratification bias cannot be ruled out as none of the female subjects reported of having the habit

Traditional tobacco products like “chutta” do not have pictorial warnings

Cross-sectional studies only reflect the time period when the data were collected.

Implications for policymakers and public

Toll free numbers of rehabilitation cells should be provided on packaging to aid in quitting the habit

Needed stronger implementation of COTPA Act (cigarettes and other tobacco products act), 2003

Regional languages along with English should be printed on tobacco products to make the general population realize about the harmful effects of tobacco

Loose sale of tobacco products should be avoided, as the purpose of pictographs cannot be served

Establishment of authoritative committees is required to organize the local sale of indigenous tobacco products such as Chutta with proper pictorial representation

While making the policies plain packaging of the tobacco products should be encouraged worldwide

Alternative crops cultivation should be encouraged among the tobacco farmers

Lower the nicotine content in conventional cigarettes to nonaddictive levels suggested by US Food and Drug Administration

The close interconnection between tobacco use and psychopathological profiles accentuate the importance of interdisciplinary cooperation among professionals working in treatment programs for nicotine dependence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.