Effectiveness of Pictorial Health Warnings in Tobacco Control Program in India

Effectiveness of Pictorial Health Warnings in Tobacco Control Program in India S.K. Singh 1 Professor, International Institute for Population Sciences, Govandi Station Road Donor Mumbai, 400088, India, Email:sksingh31962@gmail.com Introduction Tobacco is the foremost cause of preventable deaths in the world. In the 20th century, 100 million people died from tobacco use, and the situation has only worsened in the 21st century, as tobacco-related deaths are projected to grow to one billion (WHO, 2011). It has been estimated that 70 percent of the death toll will occur in low and middle-income countries, where the tobacco epidemic has not yet peaked but where tobacco-related deaths will accelerate to more than 10 million deaths a year by 2025. To combat the looming disaster, 160 countries have pledged to implement tobacco control policies as part of the world first health treaty - the World Health Organization Framework Convention on Tobacco Control (FCTC). The FCTC has provided guidelines for the packaging and labelling of tobacco products and called upon countries to adopt and implement, in accordance with their national laws, effective measures to ensure that tobacco product packaging and labelling do not promote a tobacco product (Lalit, Mangesh, Pednekar & Gupta, 2009). India signed the WHO Framework Convention on Tobacco Control on September 10, 2003. It was ratified on February 5, 2004 (Lalit, Mangesh, Pednekar & Gupta, 2009). Comprehensive tobacco control legislation, the Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, (COTPA) 2003 came into force on May 1, 2004 (Mathur & Shah, 2012). COTPA was a law to prohibit the advertisement of, and to provide for the regulation of trade and commerce in, and production, supply and distribution of, cigarettes and other tobacco products and for matters connected therewith or incidental thereto. The law, intended to protect and improve public health, encompasses a wide array of evidence based strategies to reduce tobacco consumption. This legislation brings the entire range of tobacco products under the jurisdiction of the Central Government and is enforceable across all states and union territories and for all tobacco products, including cigarettes, cigars, cheroots, bidis, cigarette tobacco, pipe tobacco, hookah tobacco, chewing tobacco, gutka, tobacco toothpowder, paan masala or any chewing material with tobacco as one of the ingredients (Kaur & Jain, 2012). One approach to reducing demand is to promote better awareness of the health concerns associated with tobacco use. Globally as well as in India, research shows that many people remain unaware about the extent of harm caused by tobacco use. Several studies have revealed that many smokers still do not know that tobacco causes disease and premature death, while many others, even in developed countries such as the USA have only a vague notion that smoking is bad (World Health Organization, 2002). The situation is worse for developing countries and for non-smoking forms of tobacco use (Teo, Ounpuu, Hawken,

Pandey, Valentin, Hunt, & Zhang, 2006). It is important to convey information about the harmful effects of tobacco use through effective ways to alert tobacco users about tobaccorelated health risks associated with all forms of tobacco use as well as the benefits of quitting (World Health Organization, 2013) Mass communication efforts to convey information on health risks of tobacco include messages delivered through radio/television media, social media, posters, and text and pictorial images on tobacco products (Hall, Ribisl & Brewer, 2013). Research on text versus pictorial images suggests that text messages are less effective in reaching and influencing behaviour than pictorial warnings. One fundamental neuroscience based explanation for the greater efficacy of pictorial warnings suggests that pictures rather than words drive the activity of specialised brain networks affecting attitude and behaviour (PAHO, 2009 and Lalit, Mangesh, Pednekar & Gupta, 2009). Most tobacco related pictorial warnings rely on fear based messaging, assuming that the greater the viewers knowledge of the negative effects of tobacco, the more likely they are to avoid or to reduce their consumption or quit altogether (Emery, 2014; Kang & Lin, 2015). There is some evidence to suggest that fear based messages, even those which do not convey negative effects completely clearly or consistently, do have an effect. However, newer studies those try to disaggregate effects of fear from other influences, show that without belief in self-efficacy or the ability to quit or reduce use, observers actually avoid fear based messages and continue or even increase their use (Wong & Cappella, 2009). Thus the combination of fear based on concern over health, and belief in capacity to quit tobacco use are both required in order for messages to be effective (Peters, Ruiter, & Kok, 2013). India has made great efforts since 2006 to link pictorial warnings to tobacco products, especially cigarettes. In July 2006, the government issued a notification of the specific pictures to be used by tobacco companies within seven months. However, tobacco companies sought more time and the government extended the deadline to June 2007. Nevertheless, pictorial healthwarnings notified by the government during 2006 and 2007 mandated that cigarette and bidi packs should carry pictorial healthwarnings such as depictions of cancer or a child dying due to the effects of passive smoking. The pictorial health warning needed to cover 50 percent of both surfaces of the tobacco package. There was further delay and the Court fixed a revised deadline, that of December 1, 2007 for pictorial warnings to be implemented, followed by another extension till March 17, 2008 which was accompanied with an amendment to the prior notification. In March 2008, the government notification stated that the pictures should be either of a lung or a scorpion and that the size of the pictorial warnings should cover 40 percent of the package (National Cancer Institute, 2008). When the first national study of tobacco use was conducted in 2009-2010, these pictorial warnings had been placed on cigarette packages and on commercial packaged smokeless tobacco products. Subsequently researchers have paid close attention to whether tobacco users have paid attention to these warnings, and what effect if any, observation of the pictorial healthwarnings had on their behavior. In this paper, based on GATS 2010, we explore to what extent noticing pictorial health warnings influences 30 day quit attempts following the observation. We also explore the degree to which a combination of fear,

indicated by concern over the health effects of smokeless tobacco, and tobacco cessation selfefficacy, measured by previous 12 month quit attempts differentiate those who observe pictorial warnings and respond to them with new quit attempts and those who do not. Data and Method Ethics statement The Global Ault Tobacco Survey was conducted in 2009-10. The Ministry of Health and Family Welfare (MoHFW), Government of India, designated the International Institute for Population Sciences (IIPS), Mumbai, as the nodal agency for conducting GATS in India. Accordingly, prior to launching of the survey, the human subject protection mechanism was presented before the institutional ethical review committee of the IIPS and same was duly approved by the committee. A formal written consent was obtained and ethical issues were taken care of before interviewing the respondent in the survey. Moreover, this paperis based on anonymous data set placed in the public domainwith no identifiable information on the survey participants. Survey data are available upon the request on the official website of the institute at http://www.iipsindia.org. Data The present study uses the Global Adult Tobacco Survey India (GATS India) data. GATS is the global standard for systematically monitoring adult tobacco use (smoking and smokeless) and tracking key tobacco control indicators. Global Adult Tobacco Survey India was carried out in all 29 states of the country and 2 Union Territories of Chandigarh and Puducherry, covering about 99.9 percent of the total population of India. The major objectives of the survey were to obtain estimates of prevalence of tobacco use (smoking and smokeless tobacco); exposure to second-hand smoke; cessation; the economics of tobacco; exposure to media messages on tobacco use; and knowledge, attitudes and perceptions towards tobacco use.gats India was conducted in 2009 2010 as a household survey of persons age 15 and above. The survey was designed to produce internationally comparable data on tobacco use and other tobacco control indicators using a standardized questionnaire, sample design, data collection and management procedures. A total of 69,296 interviews were completed among which 33,767 and 35,529 were of males and females respectively. Out of all completed interviews, 41,825 interviews were conducted in rural areas and 27,471 interviews in urban areas. The overall response rate was 92 percent which ranged from the highest of 99 percent in Tamil Nadu to the lowest of 80 in Arunachal Pradesh. The study has included the dependent variables noticing pictorial health warning on cigarette, bidi and smokeless tobacco products in the last 30 days preceding the survey, thought of quitting after noticing the pictorial health warning and quitting efficacy define in terms of quit attempts made in last 12 months. These variables are derived from the direct questions canvassed to the subjects as part of survey tools. These response variables have been analysed by using bivaiate as well as multivariate techniques with the set of predictors like age, sex, current place of residence, educational attainment, main occupation in the last 12 months, geographical regions of the county and perceived health risk of smoking as well

as use of smokeless tobacco, measured in terms of occurrence of lung cancer, heart attack and stroke due to tobacco use. Results The findings of the study are organised in four sections. The first section deals with the demographics of noticing of graphic images.the second section presents the effect of noticing pictorial health warning on the thought of quitting (or intention to quit). The third section addresses correlates of noticing pictorial health warnings in relation to the integrated theory of fear responses and self-efficacy to act. To do so, it highlights the association between fear of health consequences and quit self efficacy as indicated by past 12 month quit attempts. The last section discusses the results on the theoretical premises of psychological and behavioural models to explain the factors operating towards desired action. Who Notices Pictorial Health Warnings? Overall, cigarette smokers were most likely to notice pictorial warnings (71%) as compared to 63% of bidi and smokeless tobacco users. Interestingly, a gender wise analysis shows that when it comes to noticing the health warnings, men are better than women.among cigarette users, only 17% of women as compared to 75% men reported to have noticed the warning picture on the packaging, whereas among bidi users it was 38% females as compared to 65% males. Further, the adjusted effect for the same shows that women cigarette users are 0.33 (P<0.01) times less likely to notice warning labels as compared to their men counter parts. Among those who reported using bidis, women are 0.5 (P<0.01) times less likely to notice health warnings. Education has a profound effect on noticing health warning on tobacco products. Cigarette and bidi smokers who have secondary or higher education are 6.63 (P<0.01) times and 2.85 (P<0.01) times more likely to notice these health warnings as compared to those who are illiterate. Further, the more the education, the smokers as well as smokeless tobacco users are more likely to notice the warnings. On the other hand, increasing age shows a negative impact on noticing the warning among cigarette as well as bidi smokers. Among respondents in the age group 45-64 and 60 and above, cigarette smokers are 0.70 (P<0.01) and 0.52 (P<0.01) times less likely and bidi smokers are 0.84 (P<0.01) and 0.65 (P<0.01) times less likely to notice the health warnings. A strong regional variation in noticing the warning is also observed. All those cigarette users belonging to the central, eastern and western regions are less likely to notice the warning labels as against those belonging to the northern region. The proportion of bidi smokers noticing the warning labels is the highest in the northern region. This variation is further established by the results from the logistic regression analysis. It is important to note that the eastern region is the least performing in terms of noticing the pictorial health warning. This is essentially true in the case of bidi smokers as they are 0.12 (P<0.01) times less likely to notice any health warning as compared to those from the northern region. A similar analysis for users of smokeless tobacco reveals that the trend of noticing the health warning on the packets of the tobacco products in this group is similar to that of cigarette and

bidi smokers. The spatial pattern in proportion of adults noticing pictorial health warning on the packets of tobacco products are presented in Figure 1. A substantial proportion of smokers in the states of Northern, Westerns and Southern regions reported noticing pictorial health warning in the last 30 days preceding the survey. However, the pattern gets changed in case of users of SLTs, where substantial proportion of adults from central and western regions reported noticing pictorial health warning by smokeless tobacco users. As seen among the smokers, age, gender, place of residence, education and region have a profound effect on noticing the health warnings. In addition to these variables, current occupation makes a marked difference in noticing behaviour. Those users who are retired and unemployed, homemakers or students are less likely to notice the health warning on smokeless tobacco products. Overall, it has been observed that age, sex, place of residence, education and region show a marked effect on noticing the health warnings by smokers and users of smokeless tobacco. Figure 1: Percentage of smokers and users of smokeless have seen warning label on tobacco products.

Table 1. Tobacco Users who noticed Warning Label on Tobacco Products by their Tobacco use Status in thirty days preceding the Survey by Background Characteristics, India, 2009-10 Smokeless tobacco Cigarette smoker Bidi smokers who users who saw warning who saw warning label saw warning label label on smokeless on cigarette on bidi tobacco Odds Odds Odds Ratio Ratio Ratio Overall 70.8 62.3 62.9 Age Group 15-24(reference) 79.0 1.00 71.1 1.00 76.6 1.00 25-44 73.5 0.84 65.1 0.96 67.3 0.79** 45-64 66.7 0.70** 61.7 0.84** 53.4 0.60** 65+ 43.7 0.52** 46.9 0.65** 38.6 0.40** Sex Male (reference) 74.9 1.00 64.9 1.00 73.4 1.00 Female 16.7 0.33** 38.0 0.54** 42.6 0.59** Residence Rural (reference) 64.2 1.00 59.9 1.00 60.9 1.00 Urban 82.6 1.70** 74.0 1.61** 70.8 1.37** Education No formal schooling (reference) 41.0 1.00 52.2 1.00 49.0 1.00 Less than primary 67.4 2.07** 63.5 1.50** 64.4 1.46** Primary but less than 78.7 3.26** 72.8 2.25** 72.7 1.98** secondary Secondary and above 87.1 6.63** 76.7 2.85** 79.3 2.66** Occupation Government and nongovernment employee (reference) 75.4 1.00 65.5 1.00 71.1 1.00 Self-employed 71.0 0.91 64.9 1.06 69.0 0.90 Student 79.4 0.80 81.6 1.40 75.0 0.66** Homemaker 39.2 0.87 48.5 0.84 40.8 0.59** Retired and unemployed 66.0 0.77* 46.4 0.74** 54.5 0.66** Region North (reference) 79.4 1.00 78.4 66.1 1.00 Central 61.4 0.52** 72.6 0.73** 75.5 1.54** East 66.5 0.31** 38.8 0.12** 52.8 0.57** North-East 72.6 0.83 47.6 0.28** 45.1 0.51** West 78.9 0.61** 62.0 0.33** 71.6 1.06 South 76.3 1.09 65.2 0.45** 45.7 0.48**

Pictorial Health Warning leading to the Thought of Quitting Tobacco users who noticed the warning label on tobacco products were asked whether they thought of quitting tobacco use by their tobacco use status during the thirty days preceding the survey. A three level analysis has been carried out to understand the behavior separately for cigarette smokers, bidi smokers and users of smokeless tobacco. Findings reveal that although the proportion of cigarette smokers who noticed the warning sign was 71 per cent, while the proportion who thought of quitting was as low as 50 per cent. Age seemed to have a negative impact on the thought of quitting. Table 2 reveals that, as the age increased, the proportion of cigarette smokers who thought of quitting tobacco use reduced. The adjusted effect for the same reveals that those who are in the age group 45-64 and 65 and above are 0.7 (P<0.01) and 0.63(P<0.05) times less likely to have thought of quitting cigarette use after noticing the warning label. Regional variation also shows a profound effect here. More than 60 per cent of the men in the western and central regions reported that they had thought of quitting, whereas this proportion was less than 50 per cent in the other regions (Figure 2). Adjusted effect of region on the thought of quitting among cigarette smokers also reveals that the odds were high in the western (1.92, P<0.01) and central regions (1.44, P<0.05) whereas, it was lowest in the north-eastern region (0.71, P<0.01). Among bidi smokers, almost 75 per cent of the respondents reported noticing the health warning on the package but less than 50 per cent of them thought of quitting tobacco use. In this group, education has a significant effect, as those who have primary education but less than secondary education, and secondary education and above are 1.21 (P<0.05) and 1.39 (P<0.01) times more likely to have thought of quitting tobacco use after noticing the warning sign. A strong regional variation is seen in the thought to quit among bidi smokers. The odds of thinking of quitting after noticing the health warning was the highest in the western region (1.70, P<0.01) followed by the central region (1.22, P<0.05) whereas, it was lowest in the north-eastern region (0.68, P<0.01). The analysis, when done for users of smokeless tobacco, reveals that only half of the users who had noticed warning labels thought of quitting the use of tobacco. Age is an important predictor of the thought of quitting and it affects the behavior negatively. Nearly three-fifths of the users belonging to the age group 15-24 thought of quitting, whereas, this proportion reduces to two-thirds for the age group 65 and above.smokeless tobacco users in the age group 65 and above are 0.53 (P<0.01) times less likely to have thought of quitting as compared to those in the 15-24 age group. The odds are 0.74 (P<0.01) among those in the age group 25-44, and 0.65 (P<0.01) among those in the age group 45-64. Increasing education, on the other hand shows a positive impact. As the level of education increases, the odds of thinking of quitting after noticing the warning also increase. Those users who are educated up to the secondary level and above are 1.72 (P<0.01) times more likely to have thought of quitting as compared to those who are illiterate. Occupation seems to have an impact on users of smokeless tobacco, as those who are retired and unemployed or are self-employed are 1.38 (P<0.01) and 1.15 (P<0.01) times more likely to have thought of quitting tobacco. The regional variation for smokeless tobacco users

follows the same trend as in the case of cigarette and bidi smokers. The proportion of users of smokeless tobacco who thought of quitting was highest in the western region followed by the central region and lowest in the north-eastern region. The adjusted effect also shows the same trend. The odds of thinking of quitting after noticing the health warning was highest in the western region (2.77, P<0.01) followed by the central region (1.46, P<0.01) and was lowest in the north-eastern region (0.74, P<0.01). Table 2. Tobacco Users who noticed the Warning Label on Tobacco Products and thought of quitting Tobacco use in the thirty days preceding the Survey by Background Characteristics, India, 2009-10 Cigarette smoker who saw warning label on cigarette and thought about quitting Bidi smoker who saw warning label on bidi and thought about quitting Smokeless tobacco user who saw warning label on smokeless tobacco and thought about quitting Odds ratio Odds ratio Odds ratio Overall 53.7 48.9 53.9 Age Group 15-24(reference) 67.9 1.00 45.1 1.00 63.0 1.00 25-44 50.5 0.86 49.4 0.96 52.5 0.74** 45-64 50.2 0.70** 50.7 0.94 50.2 0.65** 65+ 45.7 0.63* 41.2 0.67 44.4 0.53** Sex Male (reference) 53.7 1.00 49.0 1.00 56.4 1.00 Female 56.9 1.03 47.6 0.86 45.6 0.98 Residence Rural (reference) 52.2 1.00 47.8 1.00 52.8 1.00 Urban 55.9 0.97 53.4 1.03 57.6 0.98 Education No formal schooling (reference) 53.6 1.00 45.3 1.00 45.8 1.00 Less than primary 50.4 0.90 51.9 1.10 54.4 1.15* Primary but less than secondary 54.0 0.96 50.4 1.21* 58.1 1.34** Secondary and above 54.9 1.11 54.0 1.39** 59.5 1.72** Occupation Government and nongovernment employee 53.9 1.00 47.3 1.00 51.0 1.00 (reference) Self-employed 52.3 0.95 49.9 1.02 57.8 1.15** Student 60.5 0.73 49.9 1.12 49.2 0.86 Homemaker 55.7 1.13 60.3 1.12 48.1 1.16 Retired and unemployed 56.2 1.06 39.0 0.82 58.5 1.38** Region North (reference) 48.4 1.00 46.4 1.00 48.1 1.00 Central 62.2 1.44* 49.1 1.22* 53.4 1.46** East 51.9 0.90 44.0 0.88 50.4 1.15 North-East 52.1 0.71** 37.0 0.68** 42.0 0.74** West 63.9 1.92** 61.7 1.70** 68.1 2.77**

South 49.5 1.04 48.5 1.10 45.4 1.15 *p<0.05 and **p<0.01 Percentage of smokers who Percentage of SLT users thought of quitting Figure: after 2 Impact of Pictorial Health who Warning thought of quitting noticing health warnings after noticing health warnings Figure 2: Percentage of smokers and users of smokeless who thought of quitting after seeing warning label on tobacco products. Table 3 presents the odds ratio for tobacco users who had made attempts to quit during the twelve months preceding the survey by background characteristics. Interestingly, the gender differential seen in the above two tables do not hold here. Female smokers showed a negative attitude as they were less likely to notice the warning signs and think about quitting but were more likely to make attempts to quit on seeing the warning labels. As compared to men, women are 1.38 (P<0.05) times more likely to make attempts to quit. On the contrary, urban smokers are more likely to notice the health warning but are less likely to make attempts to quit. The odds of urban smokers making attempts to quit are 0.87(P<0.01) compared to their rural counterparts. Education seems to have a positive effect on attempts to quit. Those smokers with primary but less than secondary education, and secondary education and above are 1.20 (P<0.01) and 1.19 (P<0.05) times more likely to make attempts to quit compared to illiterate smokers. Region plays an important role as it significantly affects the odds of quitting smoking in all the regions. The odds of quitting smoking are very high among

smokers from the southern region (2.82, p<0.01) followed by the central region (2.32, p<0.01). The thought of quitting because of the warning label on tobacco products has emerged as an important predictor of making attempts to quit in the case of smokers. Table 3 shows that those smokers who had thought of quitting smoking because of warning labels are 3.07 (P<0.01) times more likely to make attempts to quit. Table 3. Odds Ratio for Smokers, Smokeless Tobacco Users who made attempts in the twelve months preceding the Survey by Background Characteristics, GATS India, 2009-10 Smokers who made Smokeless tobacco users attempts to quit in the who made attempts to quit past 12 months in the past 12 months Age Group 15-24(reference) 1.00 1.00 25-44 0.83* 0.89 45-64 0.90 0.87* 65+ 0.93 0.79* Sex Male (reference) 1.00 1.00 Female 1.38** 1.05 Residence Rural (reference) 1.00 1.00 Urban 0.87** 1.01 Education No formal schooling (reference) 1.00 1.00 Less than primary 1.10 1.08 Primary but less than secondary 1.20** 1.25** Secondary and above 1.19* 1.37** Occupation Government and non-government employee (reference) 1.00 1.00 Self-employed 0.88* 1.00 Student 0.86 0.79 Homemaker 1.10 1.09 Retired and unemployed 0.95 1.18* Region North (reference) 1.00 1.00 Central 2.32** 2.16** East a 1.22* 1.18 North-East 1.21** 1.15 West 1.49** 1.61** South 2.82** 3.07** Thought about quitting because of warning label on tobacco products No(reference) 1.00 1.00 Yes 3.07** 3.51** *p<0.05 and **p<0.01.

In the case of users of smokeless tobacco, age plays an important role in shaping quitting behavior. The odds of making an attempt to quit seem to decrease with increasing age. The users of smokeless tobacco belonging to the age groups 65 and above and 45-64 are 0.79 (P<0.01) and 0.87 (P<0.01) times less likely to make attempts to quit. Education has a significant effect on attempts to quit. As the level of education increases, the odds of making attempts to quit seem to increase. Users of smokeless tobacco with primary level education but less than secondarylevel, and secondary level of education and above are 1.25 (P<0.01) and 1.37 (P<0.01) times more likely to make attempts to quit as compared to their illiterate counterparts. A regional analysis reveals that users of smokeless tobacco from the southern, central and western regions are 3.07 (P<0.01), 2.16 (P<0.01) and 1.61 (P<0.01) times more likely to make attempts to quit. The thought of quitting after noticing the health warning on the packaging has contributed significantly in making both smokers and users of smokeless attempt to quit tobacco. Those users of smokeless tobacco who had thought of quitting are 3.51 times more likely to make attempts to quit compared to those who did not think of quitting. Table 4 tests the theoretical interaction of fear of consequences of tobacco use, combined with quitting efficacy on noticing pictorial health warning in the 30 days preceding the survey and though of quitting afternoticing pictorial health warnings on the packets of smoking as well as smokeless tobacco products. It is evident from the results that those having perception about adverse effects of tobacco smoking as well as use of smokeless tobacco are significantly more likely to notice pictorial health warnings on the packages of these products ( 75% and 50% as against 45% and 28%) in comparison to those who do not perceive the health risks of tobacco use. Further, noticing of pictorial health warnings have also resulted into, a significantly higher prevalence of thought of quitting smoking and use of smokeless tobacco, among those who perceive the health risks of tobacco use in comparison to those who do not perceive. By and large a similar association has also been emerged between quitting efficacy and noticing pictorial health warning in the last 30 days and also the intention to quit. Thus, findings of Table 4 demonstrate that those who expressed fear about the health consequences of tobacco use, and had tried to quit in the past 12 months, were more likely to both notice pictorial warnings, and consider quitting the use of tobacco.

Table 4: Percent of tobacco users reporting perceived health risk of tobacco use, and prior 12 month quit attempts in relation to whether they saw the pictorial warnings and thought of quitting after seeing the warnings. in the last 30 days preceding the survey, India, 2009-10 Perceived Health risk of smoking Did not see Pictorial Health Warning in the last 30 days Seen Pictorial Health Warning in the last 30 days No perceived health risk 55.0 45.0 42.8 Perceived Health risk 25.0 75.0 60.1 Total 28.8 71.2 Thought of quitting after noticing Pictorial Health Warning in the last 30 days Chisquare value 598.2 (p<0.01) Perceived Health risk of using smokeless tobacco No perceived health risk 72.0 28.0 37.8 Perceived Health risk 49.6 50.4 55.5 Total 52.1 47.1 Quit attempts of smoking in the last 12 months No attempts 30.6 69.4 48.4 Made quit attempts 25.4 74.6 74.5 Total 28.7 71.3 Quit attempts of using smokeless tobacco in the last 12 months No attempts 41.2 58.8 40.5 Made quit attempts 30.0 70.0 75.6 Total 37.3 62.7 1189.2 (p<0.01) 8.7 (p<0.01) 177.6 (p<0.01) Discussion The current manifestation of epidemiological transition in India lies in the shift from communicable diseases to non-communicable and lifestyle based diseases accounting for the major disease burden. Recent estimates portray that deaths due to non communicable diseases constitute about 42 percent of all the deaths in India compared to 38 percent of deaths due to communicable diseases, maternal and perinatal deaths (Upadhyay, 2012). Tobacco smoking and use of smokeless tobacco have been widespread for many decades among men in India, and have been responsible for most adult deaths involving cardiovascular disease, hypertension, and stroke, different forms of cancer, tuberculosis, and other respiratory diseases. Around 15-18 percent of the total deaths in India are preventable in nature as a high proportion of these deaths are due to tobacco related morbidity linked to lifestyle based diseases. India has taken the initiative to control tobacco use by adopting the MPOWER strategy and implementing the COTPA Act in 2003, which shape India s tobacco control regulatory actions and implementation. Mandatory health warnings on cigarette packages and other packaged tobaccos can be an effective way to inform smokers about the harmful effects of tobacco use and motivate them to quit smoking (Popova, 2014). Pictorial health warnings are expected to enhance people's awareness of the dangers of tobacco use and motivate them to quit tobacco (Arora, Tiwari, Nazar, Gupta & Srivastava, 2012). Overall, the findings from this study are consistent with

previous research on cognitive processing and warning labels (Krugman, Fox and Fletcher, 1994 ; Fischer, Richards, & Krugman, 1989), which portray that marketing cues like warning labels have an impact on the thought to quit tobacco and smoking cigarettes (Borland,1997). The GATS study was completed in 2010, at a time when pictorial health warnings included a lung image intended to convey the idea that smoking causes lung disease, and the symbol of the scorpion intended to convey the concept that smoking causes cancer. These images were required on cigarette packages, and packaged smokeless tobacco products but were not necessarily utilized with all forms of bidi, which are often made at home or in the informal sector, and loose smokeless tobacco products. The findings from our study show that more than three-fifths of tobacco users reported that they had noticed the warning labels on the tobacco packaging. However, noticing the warning labels was highest among cigarette smokers, as compared to bidi and smokeless tobacco users. The results show that users of higher ages, lower education and urban residence are less likely to notice warning labels even in pictorial form. Increasing age shows a negative impact on noticing the warning label, thinking about quitting as well as having made an attempt to quit. The urban smokers are more likely to notice the health warning but are less likely to make attempts to quit. Education also shows a positive impact as with increasing education the noticing of warning label, thinking about quitting as well as making an attempt to quit is increasing (Arora, Tiwari, Nazar, Gupta and Srivastava, 2012). Many studies show that pictorial warnings even when noticed are not properly understood. The scorpion becomes associated with the product in a non-scientific manner and X-rays of lung are hardly understood by anybody (Oswal, Raute, Pednekar and Gupta, 2011).Regional variation shows that users from western region reported maximum noticing of warning labels and it was lowest in the eastern part of the country. Further, 12 month quit attempts are also high among smokers from the southern region followed by the central region. A profound gender difference is seen in noticing the health warning. Smaller proportion of women users of tobacco notice the pictorial health warning labels. This may be attributed to women s use of forms of smokeless tobacco, which do not include pictorial warnings as well as their lack of understanding of the meaning of the scorpion as a cancer warning (Oswal, Raute, Pednekar & Gupta, 2011). Female smokers were less likely to notice the warning signs and think about quitting but were more likely to make attempts to quit on seeing the warning labels (Arora, Tiwari, Nazar, Gupta & Srivastava, 2012). Our observations are thus consistent with previous studies conducted in Indian settings. Literature evidences that, although awareness and acceptance of the health risks of smoking may not be a sufficient condition for quitting, it is likely a necessary one for most smokers and serves an important source of motivation (Abdolahinia, Maadani & Radmand, 2010). Motivating the users of tobacco to make a behavior change remains a challenge. Health warning communication can be most effective in terms of reach and cost through pictorial warnings depicting the harmful effects of tobacco use on the packaging of tobacco products (Mathur & Shah, 2012).The assumption is that pictorial warnings can inspire quitting or reducing the consumption of tobacco even among illiterate users.

When recognized as such, pictorial warnings have short term and immediate rather than longer term effects. Thus they are likely to influence behaviour change intentions and even quit attempts immediately after they are noticed. In a study conducted in Malaysia on 2000 smokers in the year 2008, a significant number of participants believed that they were more likely to quit or stopped from having a cigarette when about to smoke one because of the warning labels (Fathelrahman, Omar, Awang, Borland, Fong & Hammond, 2009). Similar results were also seen in the ITC project (International Tobacco Control Policy Evaluation Project) conducted in 10 different countries in 2006 (Fong, 2009; Abdolahinia, Maadani & Radmand, 2010). This paper shows similar results those who noticed pictorial warnings were more likely to intend to quit tobacco use because of them, in the next 30 days. Other studies, however, do not explore the mechanisms through which fear based messaging influences intention or behaviour. Message framing theory argues that fear based messaging is most successful when it is combined with self efficacy to engage in the behaviour. We have suggested that it may also be more effective in reaching tobacco users when they are already concerned about their health. The results of our analysis show that both male and female tobacco users who worry about tobacco s effects on their health, and who have been efficacious in trying to quit their use of tobacco in the past 12 months, are more likely to notice pictorial warnings, and to respond to them with immediate intentions to quit. In India these results are significant despite the recognition that the pictorial warnings used at the time of the GATS study may have had limited influence due to lack of understanding of the images or the lack of use of images for some tobacco products, especially unpackaged forms of SLT. Now the Indian government has been able to counter the powerful tobacco lobby with a mandate to include graphic image warnings on cigarette boxes and packaged tobacco (Anand, 2016). These images may be expected to have a more profound effect by increasing noticeability. At the same time, through clearer images related to illness and disease, they may increase tobacco users recognition of the negative health implications of tobacco use, a necessary antecedent to behavioural change. Thus, these newer and more powerful images may counter findings that the effectiveness of warning labels erodes over time as tobacco users become desensitized to their messages (Tandemar Research, 1996; Hammond et al., 2003). Our results point to the fact that pictorial images (and by extension, graphic images) on tobacco packets are best at reaching people who are already worried about their health, and have tried to reduce their tobacco use. They also indicate that women respond less well to pictorial images and that there are significant regional variations in responses. Further research and image tailoring are required to make sure that the negative framing fear based messaging on the current graphic images reach and appeal to these as well as other as yet unidentified subpopulations of tobacco users especially users of loose forms of smokeless tobacco and home made products such as bidis and paan with tobacco. The media has to play a proactive role among the most vulnerable groups, especially women to minimize the tobacco related disease burden.

Also, the effect of graphic images on prevention of tobacco initiation is not known although fear based messaging is known to work best among those who already suffer from a problem, rather than with those who have not yet experienced it. Research is required to understand the effects of the new graphic image pictorial warnings on initiation rates for both smoked and smokeless tobacco. Finally, intention to quit does not always lead to actual quit attempts or successful tobacco cessation. Additional intervention approaches are required to ensure that those who are concerned about their health, and have tried to quit and wish to quit obtain the assistance they require to do so. In sum, In view of the existing epidemiology transition and significant link between the use of tobacco and health hazards, the Government should strengthen the MPOWER strategies for tobacco control and ensure and evaluate their reach to vulnerable subpopulations. Conclusions and Recommendations: Key issues emerged from this paper reinforce that GATS data do seem to confirm the theory that fear based messaging reaches people who are already concerned about the effects of tobacco on their health, and who have had at least some limited success in trying to quit in the past, and are thus efficacious. These are the people who notice the messages and think about quitting immediately afterward. These findings, therefore, affirm that India Supreme Court recent order of May 04, 2016 for all tobacco companies to comply with the health warning rules covering 85 percent area of all cigarette packets is likely to provide a significant momentum in the tobacco control programme in the country. Further, those who use smokeless tobacco, especially women, are not well reached by pictorial health warnings, and may be poorly reached by the new graphic images especially since those images are not very directly relevant to women's concerns. Finally special efforts must be made to understand and tailor messages to those regions of the country that responded less well to the earlier pictorial warnings. Acknowledgment We would like to thank International Institute for Population Sciences, Mumbai for providing us the GATS India data. Declaration of Conflicting Interests The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper.

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