How Compliant are Tobacco Vendors to India’s Tobacco Control Legislation on Ban of Advertisments at Point of Sale? A Three Jurisdictions Review

Background: Section 5 of India’s tobacco control legislation “Cigarettes and Other Tobacco Products Act(COTPA), 2003”comprehensively prohibits all kinds of tobacco advertisement, promotion and sponsorship(TAPS), but permits advertisments at the point-of-sale (POS) under certain conditions. This provision hasbeen exploited by the tobacco companies to promote their products. Objective: To measure compliance withthe provisions of Section 5 of Indian tobacco control legislation (COTPA, 2003) at point of sale. Materials andMethods: A cross-sectional survey using an observation checklist was conducted in 1860 POS across threejurisdictions (Chennai city, District Vadodara and District Mohali) in India. Results: The most common modeof advertisement of tobacco products was product showcasing (51.1%), followed by dangles (49.6%), stickers(33.8%) and boards (27.1%). More than one fourth of POS were found violating legal provisions for displayingadvertisement boards in one or other forms (oversized, extended to full body lenth of POS, displayed brandname/packshot and promotional messages). Advertisement boards (16.3%) without health warnings were also foundand wherever found, more than 90% health warning were not as per the specification in respect to size, font andbackground color. Conclusions: Point of sale advertising is aggressively used by the tobacco industry to promotetheir products. There is an urgent need of effective implementation of a comprehensive ban on tobacco productadvertisement, promotion and sponsorship at point of sale.     

Pan masala advertisements are surrogate for tobacco products

BACKGROUND: Pan masala is a comparatively recent habit in India and is marketed with and without tobacco. Advertisements of tobacco products have been banned in India since 1st May 2004. The advertisements of plain pan masala, which continue in Indian media, have been suspected to be surrogate for tobacco products bearing the same name. The study was carried out to assess whether these advertisements were for the intended product, or for tobacco products with same brand name. MATERIALS AND METHODS: The programme of a popular television Hindi news channel was watched for a 24-h period. Programmes on the same channel and its English counterpart were watched on different days to assess whether the advertisements were repeated. The total duration of telecast of a popular brand of plain pan masala (Pan Parag) was multiplied by the rate charged by the channel to provide the cost of advertisement of this product. The total sale value of the company was multiplied by the proportion of usage of plain pan masala out of gutka plus pan masala habit as observed from a different study, to provide the annual sale value of plain pan masala product under reference. RESULTS: The annual sale value of plain Pan Parag was estimated to be Rs. 67.1 million. The annual cost of the advertisement of the same product on two television channels was estimated at Rs. 244.6 million. CONCLUSION: The advertisements of plain pan masala seen on Indian television are a surrogate for the tobacco products bearing the same name.     

Does Awareness on Tobacco Control Legislations Pertaining to Tobacco Sellers Lead to Compliance? – A Study from Chennai,India

Background: Tobacco Sellers (TS) are key stake holders in tobacco control and their compliance with the legislation is crucial to achieve the intended outcome. The current study was conducted to assess the awareness of the Cigarette and Other Tobacco Products Act (COTPA) among TS and their response. Methodology: TS (N=527) were randomly chosen from ten zones of Chennai city. A structured self-administered questionnaire was used to assess awareness and compliance regarding sections 4, 5 and 6. Results: Awareness of COTPA sections-4, 5, 6a, 6b among the TS was 42.0%, 31.0%, 69.3% and 57.2%, respectively, and 65.4% were of the opinion that the tobacco menace can be controlled through legislation. One fourth of the sellers reported that they were contemplating stopping selling tobacco and 13.4% had been requested by various people to stop doing so. The overall profit from tobacco sales was less than 10% for 58.1% of the sellers. There was no change in the sale trends of tobacco products and the smoking form of tobacco was reported to be highly sold (56.2%). Only 54.6% had displayed signboards mentioning the prohibition of smoking in public places as directed under section 4, and 90% of the sellers continued to supply accessories to smoker. In contravention of section-5, 85.6% continued to advertise tobacco in some form and total non-compliance with section-6a and 6b was observed. Conclusion: Awareness on tobacco control legislations among TS was found to be moderate. Furthermore, compliance with the COTPA was minimal.     

Compliance Assessment of Tobacco Products to Cigarettes and Other Tobacco Products Act in India with Reference to Third Amendment Rules, 2020

Objective: Tobacco use is associated with mortality in low- and middle-income countries including India with dual burden of smoking and smokeless tobacco (SLT). Aligning with the FCTC, India has made substantial amendments in strengthening graphic warning under Cigarettes and Other Tobacco Products Act (COTPA) for sections 7,8 9 and “Specified warning”. Compliance assessment studies are necessary to understand current status of implementation for packaging laws. This study aimed to assess the compliance of COTPA sections 7,8 9 and Cigarettes and other Tobacco Products (Packaging and Labelling) Third Amendment Rules, 2020 in Delhi. Methods: Cross-sectional study was conducted in two districts of Delhi selected by simple random sampling. Fifteen points of sales were selected from each district through purposive sampling and 57 smoking and smokeless tobacco products were collected with Indian and foreign origin. An observation checklist for product analysis was prepared and pack analysis done based on COTPA sections 7,8 and 9 along with Third Amendment,2020 which included pictures and warnings to be circulated in 2021. Result: Total 57 samples has smoking (49.1%), smokeless (50.9%) with no SLT product of foreign origin. SLT and foreign products had low compliance of Section 7 and third amendment 2020 rules which includes manufacturing date and origin. Indian smoking products were highly compliant to section 8 and 9 whereas foreign and SLT products showed low compliance to section 8. COTPA Third Amendment Rules (2020) compliance was seen in Indian products with regards to SW (68.4%), PW (61.4%) and quit line (78.9%) with no compliance at all for foreign products. Conclusion: Foreign brands and SLT products had low compliance with sections 7 and 8 of COTPA and its amendments (2020). Compliance with illicit trade and SW needs regulation and strict implementation of law for SLT products.     

Is Exposure to Tobacco Advertising,Promotion and Sponsorship Associated with Initiation of Tobacco Use among Current Tobacco Users in Youth in India?

Background: The rise in consumption of tobacco products among youth is a public health concern in India.Several studies have shown that advertisements promoting tobacco products influence decisions and behaviourof youth towards smoking. Objective: To ascertain which method of Tobacco Advertising, Promotion andSponsorship (TAPS) was more influential for initiating tobacco use in youth in India. Materials and Methods:The secondary data of youth (15-24 years) from nationally representative Global Adult Tobacco Survey (GATS)conducted in 2009-2010 was analyzed. Odds ratio and p-value were used to know the association between TAPSand initiation of use of tobacco products among youth. Logistic regression was used to determine the mostsignificant means of TAPS altering the youth’s behaviour towards tobacco products. Results: Out of 13,383 youths,1,982 (14.7%) used smokeless forms of tobacco and 860 (6.38%) used smoke forms. Logistic regression revealsthat promotional activities mainly through cinemas (p<0.05) and providing free samples of tobacco products (p< = .001) were most influential means of initiating consumption of tobacco products among youth. Conclusions:The smoking in youth is associated with watching advertisements particularly in cinema and promotionalactivities like distribution of free samples, coupons and sales on the price of tobacco products. Stronger legislativemeasures should be enforced to curb promotional advertisements in cinemas and distribution of free samples.     

Effectiveness of a Mass Media Campaign on Oral Carcinogens and Their Effects on the Oral Cavity

Objective: To develop a mass media campaign on oral carcinogens and their effects on the oral cavity in orderto increase awareness among the general population. Methods: Documentary and public service announcementshighlighting the effects of tobacco and its products were designed and developed based on principles of behavior change. Aquestionnaire, designed to determine the knowledge, attitude and practice of people regarding oral carcinogens, was usedto conduct a baseline survey at various sites in eastern Nepal. Local television channels and radio stations broadcastedthe documentary and public service announcements. An evaluation survey was then performed to assess the effectivenessof the campaign. Results: Baseline and evaluation surveys covered 1,972 and 2,140 individuals, respectively. A thirdof the baseline population consumed quid, 22% chewing tobacco, 16% gutka (commercial preparation of arecanut,tobacco, lime and chemicals) and 25% cigarettes. Tobacco consumption differed significantly between 3 ecologic regionswith greater use in the Terai region. The knowledge prevalence regarding the oral carcinogens quid (70%), chewingtobacco (82%), gutka (58%) and cigarettes (93%) significantly increased in the evaluation population. Females weremore aware about the various tobacco products and their effects on health. More people knew about the harmful effectsof tobacco on their health and oral cavity, and had their mouth examined and the frequency of consumption of theseproducts reduced significantly after the campaign. Attitudes towards production, sale and advertisements of tobaccoalso improved significantly. Conclusions: The mass media campaign was an effective tool for increasing awarenessamong the population.     

Tobacco Promotion and Availability in School Neighborhoods in India: a Cross-sectional Study of their Impact on Adolescent Tobacco Use

Background: Adolescent tobacco use is a major public health problem. However, there is little informationabout the impact of tobacco advertising and availability near schools on adolescent tobacco use in India.Methods: The various tobacco products and brands available in outlets within 100 meters of two high schoolsin an Indian town were identified. A stratified random sample of 172 participants from these two schoolscompleted a questionnaire on tobacco use and socioeconomic status. Results: Eighteen outlets selling tobaccoproducts were identified. In the two schools the current use of smoked and smokeless tobacco was 9.1% and17.4% respectively. School location and low socio-economic status of adolescents were associated with tobaccoawareness of advertisements (p=0.001) and the receipt of a free sample (p= 0.032). Advertisements on billboards,posters and the receipt of a free tobacco sample were significant factors (p=0.031, p=0.016, p=0.017 respectively)in current tobacco use. Conclusion: In this study a significant proportion of adolescents used tobacco. Tobacco–promotion activities (advertising, the receipt of a free sample), school location and economic status were foundto be associated with adolescent tobacco initiation. The local environment should be included in the preventionof adolescent tobacco initiation.     

Tobacco Control Law Enforcement and Compliance in Odisha,India - Implications for Tobacco Control Policy and Practice

Introduction: Tobacco use is a leading cause of deaths and disabilities in India, killing about 1.2 lakh peoplein 2010. About 29% of adults use tobacco on a daily basis and an additional 5% use it occasionally. In Odisha,non-smoking forms are more prevalent than smoking forms. The habit has very high opportunity cost as it reducesthe capacity to seek better nutrition, medical care and education. In line with the WHO Framework Conventionon Tobacco Control (FCTC), the Cigarettes and Other Tobacco Products Act (COTPA) is a powerful Indiannational law on tobacco control. The Government of Odisha has shown its commitment towards enforcementand compliance of COTPA provisions. In order to gauge the perceptions and practices related to tobacco controlefforts and level of enforcement of COTPA in the State, this cross-sectional study was carried out in seven selecteddistricts. Materials and methods:A semi-structured interview schedule was developed, translated into Odiya andfield-tested for data collection. It mainly contained questions related to knowledge on provisions of section 4-7 ofCOTPA 2003, perception about smoking, chewing tobacco and practices with respect to compliance of selectedprovisions of the Act. 1414 samples were interviewed. Results: The highest percentage of respondents was fromthe government departments. 70% of the illiterates consumed tobacco as compared to 34% post graduates.52.1% of the respondents were aware of Indian tobacco control laws, while 80.8% had knowledge about theprovision of the law prohibiting smoking in public places. However, 36.6% of the respondents reported that theyhad ‘very often’ seen tobacco products being sold ‘to a minor’, while 31.2% had seen tobacco products beingsold ‘by a minor’. In addition, 24.8% had ‘very often’ seen tobacco products being sold within a radius of 100yards of educational institutions.     

Compliance with Tobacco Promotion and Sale Laws in School Neighbourhoods in India

Objective: Regulation of sale of tobacco has given sufficient attention in India and little information exists about the impact of bans near schools. Our study aim was to check the levels of tobacco promotion, advertising and sales in school neighborhoods’ of Central Delhi. Methods: Using multistage random sampling 15 schools were selected in Central Delhi. Areas 100 meters around each were mapped using a map tool and screened using a self designed questionnaire consisting of 26 questions, both closed and open ended, to determine the details of outlets, sales of tobacco and tobacco products, advertising, promotions, school roles, and children seeking tobacco. The data were subjected to statistical analysis. Results: The response rate was 65%. Outlet licenses were present in only 6 (3.47%). The point sale of tobacco was most frequently in tea stalls and a total of 173 (41.2%) outlets had some form of tobacco sale. The brands of smokeless tobacco sold more were shikar (50%) and classic citrus (30%). Advertisement or promotion of sales was mainly in the form of signs and displays (53%). Major schools did not have any no tobacco boards displayed. Conclusion: Sale of tobacco continues in central Delhi with a lack of compliance with the rules of COPTA. The implications of this non compliance in the Capital region is of major significance for the rest of the country.     

Legislation Related to E-Cigarettes in The Gulf Cooperation Council Countries

Even though 90% of the world’s population is covered by the World Health Organization’s Framework Convention on Tobacco Control, it is estimated that only one-fifth (21%) and half (49%) of the countries that ratified this convention will achieve the target of reducing tobacco use by 30 % among men and women respectively in 2025. Over the past decade, there has been an increasing trend in the use of electronic cigarettes or e-cigarettes for recreational use as well as smoking cessation. In concurrence with the increasing use of e-cigarettes among smokers of different age groups, nations have developed relevant national regulations on its sale, advertisement, packaging, product regulation, taxation, and surveillance. The countries of the Gulf Cooperation Council (GCC) region have also witnessed several legislations, at varying extent, related to the use of electronic cigarettes. However, the evidence on the use of electronic nicotine delivery systems remains scarce in the GCC region. Thus, further research on this emerging public health issue is warranted to generate the evidence necessary for the formulation of comprehensive tobacco control laws and effective prevention strategies.     

Strategic marketing in the UK tobacco industry

Tobacco-industry marketing has played a central part in the global spread of tobacco use and addiction. Although the absolute size of the tobacco market has dwindled, the industry is still immensely successful, largely due to sophisticated and manipulative marketing strategies. The UK tobacco industry identifies target groups and builds enduring relationships based on careful brand management. Potential customers are exposed to brands which are likely to appeal to them most. Tobacco companies tailor their products to target markets by altering the content of tar and nicotine, and by adding flavourings to produce a distinctive taste. Marketing strategies ensure that the products are promoted heavily at the point of sale, and directed advertising and sponsorship agreements are used to increase the visibility of the brand and strengthen its image. Tobacco companies also target non-consumer organisations such as retailers and policy makers with the aim of creating the best possible business environment for tobacco sales. We review published evidence, internal-advertising-agency documents, and observational data about tobacco promotion, and discuss the use of targeted marketing strategies in the UK.     

Women and Tobacco Use: Discrepancy in the Knowledge,Belief and Behavior towards Tobacco Consumption among Urban and Rural Women in Chhattisgarh,Central India

Background: Tobacco consumption has become pandemic, and is estimated to have killed 100 million peoplein the 20th century worldwide. Some 700,000 out of 5.4 million deaths due to tobacco use were from India. Theera of global modernization has led to an increase in the involvement of women in tobacco consumption in thelow income and middle-income countries. Tobacco consumption by females is known to have grave consequences.Objectives: To assess: (1) the tobacco use among urban and rural women; (2) the discrepancy in the knowledge,belief and behavior towards tobacco consumption among urban and rural women in Durg-Bhilai Metropolitan,Chhattisgarh, Central India. Materials and Methods: The study population consisted of 2,000 18-25 year oldyoung women from Durg-Bhilai Metropolitan, Chhattisgarh, Central India, from both urban and rural areas.Data were collected using a pretested, anonymous, extensive face to face interview by a female investigator toassess the tobacco use among women and the discrepancy in the knowledge, belief and behavior towards tobaccoconsumption among urban and rural individuals. Results: The prevalence of tobacco use was found to be 47.2%.Tobacco consumption among rural women was 54.4% and in urban women was 40%. The majority of the womenfrom urban areas (62.8%) were smokers whilst rural women (77.4%) showed preponderance toward smokelesstobacco use. Urban women had a better knowledge and attitude towards harms from tobacco and its use thanthe rural women. Women in rural areas had higher odds (1.335) of developing tobacco habit than the urbanwomen. Conclusions: Increased tobacco use by women poses very severe hazards to their health, maternal andchild health, and their family health and economic well-being. Due to the remarkably complex Indian pictureof female tobacco use, an immediate and compulsory implementation of tobacco control policies laid down byt he WHO FCTC is the need of the hour.     

Tobacco use among school children in Chennai city, India

AIMS: The present study was done to build a database on prevalence of tobacco use among students of grade 8 to 10 in Chennai city, for the purpose of advocacy of tobacco control and planning tobacco control interventions and evaluation. MATERIALS AND METHODS: A two-stage stratified probability sample of students in grades 8-10 corresponding to 13 to 15 years of age were selected from private/government aided private schools and purely government aided corporation schools. Data was collected by a pretested, closed-ended self-administered questionnaire. RESULTS: A total of 1255 students participated in this survey. Among them 64.4 boys and 35.6% were girls. Ever tobacco use was reported by 37.6% of the students (41.6 males and 30.2% females). Current users of tobacco (any products) were reported by 41.1% of the students. Prevalence was more among boy students (46.3%) when compared to that of girl students (31.6%). There existed no significant difference between current users of tobacco based on the zones of the school. Tobacco users prevalence was found more in corporation schools when compared to that of private schools. Parental and friends tobacco use was reported more often by tobacco users compared to never users. Purchasing tobacco products in a store was reported by 82.5% and almost no one was refused because of age. Almost everyone reported watching a lot of cigarette advertisements on TV, whereas about half reported watching advertisements on other medias like outdoor hoardings (45.7%), newspapers (65.3%) and social events (67.4%). CONCLUSION: This study demonstrates that among the 13 to 15-year old school going children (corresponding to grades 8 to 10) in Chennai city, the current tobacco use is high.     

Tobacco control activities in Japan

In Japan, effective tobacco control programs have not been conducted, although there have been as many epidemiological evidences regarding health risks of tobacco smoking and passive smoking as in western European countries and the United States. This seems due to the attitude of the Japanese Government which is behind the times in promoting public health while the tobacco industry has turned a profit. The onus is on medical doctors who know the health risks of tobacco well enough to make a breakthrough in these difficulties. Medical associations and societies should take actions in shaping public opinion and lobbying for legislation of comprehensive tobacco control policy in correspondence with the WHO Framework Convention on Tobacco Control (FCTC) which the Japanese Government signed on 10 March, 2004.     

Smoking prevalence and beliefs on smoking cessation among members of the Japanese Cancer Association in 2006 and 2010

Smoking is a significant contributing factor to disease-related deaths worldwide. Members of the Japanese Cancer Association (JCA) can play a leading role in helping people to live tobacco-free through social action. In 2010, this study assessed smoking prevalence among JCA members and their attitudes toward smoking, smoking cessation, and their responsibilities. Results of the 2010 survey were compared with those of a 2006 survey. Final response rates were 60.8% in the 2006 survey and 47.4% in the 2010 survey, and the current smoking rates were 9.0% and 5.3%, respectively. Regarding concern by current smokers over smoking cessation, the percentage of smokers who were ready to quit smoking within the next month increased from 4.9% to 6.3% between 2006 and 2010. Most JCA members agreed with antismoking actions such as smoking bans in all workplaces, public places, or while walking in the street, regulation restricting the sale and distribution of tobacco to children, tobacco education at school, use of tobacco tax for health, provision of information on tobacco, and smoking cessation support. Approximately 30% of responders disagreed on actions to raise the price of tobacco, regulations restricting the sale of tobacco, health warnings on tobacco packaging, bans on tobacco advertisement, and antismoking campaigns. Barriers to smoking cessation interventions identified were physician's time required to provide interventions, resistance of patients to smoking cessation advice, and lack of education on tobacco control. Not only antismoking actions but also support of smokers by health professionals through adequate education on smoking cessation treatment is needed in the future. (Cancer Sci 2012; 103: 1595-1599).     

Perspective on Cancer Control: Whither the Tobacco Endgame for Canada?

Aims: In 2014, in response to evidence that Canada’s tobacco use would lead, inexorably, to substantial morbidity and mortality for the foreseeable future, a group of experts convened to consider the development of a “Tobacco Endgame” for Canada. The “Tobacco Endgame” defines a time frame in which to eliminate structural, political, and social dynamics that sustain tobacco use, leading to improved population health. Strategies: A series of Background Papers describing possible measures that could contribute to the creation of a comprehensive endgame strategy for Canada was prepared in advance of the National Tobacco Endgame Summit hosted at Queen’s University in 2016. At the summit, agreement was reached to work together to achieve <5% tobacco use by 2035 (<5 by ’35). A report of the proceedings was shared widely. Achievements: Progress since 2016 has been mixed. The Summit report was followed by a national forum convened by Health Canada in March 2017, and in 2018, the Canadian Government adopted “<5 × ’35” tobacco use target in a renewed Canadian tobacco reduction strategy. Tobacco use has declined in the last 5 years, but at a rate slower than that which will be needed to achieve the <5 by ’35 goal. There remain > 5 million smokers in Canada, signaling that smoking-related diseases will continue to be an enormous health burden. Furthermore, the landscape of new products (e-cigarettes and cannabis) has created additional risks and opportunities. Future directions: A bold, reinvigorated tobacco control strategy is needed that significantly advances ongoing policy developments, including full implementation of the key demand-reduction policies of the WHO Framework Convention on Tobacco Control. Formidable, new disruptive policies and regulations will be needed to achieve Canada’s Endgame goal.     

Using salivary cotinine to validate self-reports of tobacco use by Indian youth living in low-income neighborhoods

Background: Self-reported tobacco use among young people can underestimate the actual prevalence of tobacco use. Biochemical validation of self-reports is particularly recommended for intervention studies where cessation outcomes are to be measured. Literature on biochemical validation of self-reports of multiple forms of tobacco use in India is sparse, particularly among young people. Methods: The study was conducted during the baseline household survey of a community-based tobacco prevention and cessation intervention trial for youth (10-19 years old) residing in slum communities in Delhi, India in 2009. Salivary cotinine measurement on 1,224 samples showed that youth were under-reporting use of chewing and smoking tobacco. Results: Self-reports had a low sensitivity (36.3%) and a positive predictive value of 72.6%. No statistically significant difference in under-reporting was found between youth in the control and intervention conditions of the trial, which will be taken into consideration in assessing intervention outcomes at a later time point. Conclusion: Biochemical validation of self-reported tobacco use should be considered during prevention and cessation studies among youth living in low-income settings in developing countries like India. Impact: The future results of biochemical validation from Project ACTIVITY (Advancing Cessation of Tobacco In Vulnerable Indian Tobacco consuming Youth) will be useful to design validation studies in resource-poor settings.     

Role of Tobacco Warning Labels in Informing Smokers about Risks of Smoking among Bus Drivers in Mangalore,India

Background: Smoking tobacco is considered as a leading cause of preventable death, mostly in developingcountries like India. One of the primary goals of international tobacco control is to educate smokers about therisks associated with tobacco consumption. Tobacco warning labels (TWLs) on cigarette packages are one ofthe most common statutory means to communicate health risks of smoking to smokers, with the hope that onceeducated, they will be more likely to quit the habit. Materials and Methods: The present survey was conductedto assess the effectiveness of TWLs in communicating health risks of tobacco usage among 263 adult smokersworking as bus drivers in Karnataka State Road Transport Corporation (KSRTC), Mangalore, India. Informationwas collected on demographic details, exposure and response to health warnings on tobacco products, intentionto quit and nicotine dependency. Results: The majority (79.5%) of the respondents revealed negative intentionstowards quitting smoking. Nearly half of the participants had a ‘low’ nicotine dependency (47.5%) and 98.1%of the respondents had often noticed warning labels on tobacco packages. These health warnings made 71.5% ofthe respondents think about quitting smoking. Respondents who noticed advertisement or pictures about dangersof smoking had better knowledge, with respect to lung cancer and impotence as a consequence of tobacco. Ahigher exposure to warning labels was significantly associated with lower nicotine dependency levels of smokersamong the present study population. A significantly higher number of respondents who noticed advertisementor pictures about the dangers of smoking thought about the risks of smoking and were more inclined to thinkabout quitting smoking. As exposure increased, an increase in the knowledge and response of participants wasalso observed. Conclusions: Exposure to tobacco warning labels helps to educate smokers about health risksof tobacco smoking. It may be possible to promote oral health among bus drivers by developing strategies toeducate them about these risk factors.     

Pan Masala Plus Tobacco is Equal to Gutka Square - New Formulation of Tobacco in India after the Gutka Ban

Tobacco is a well known cause of death worldwide. With existing comprehensive laws and various othermeasures for tobacco control, the mortality and morbidity due to tobacco usage have unfortunately not beenreduced. A large number of tobacco users have altered their pattern of tobacco use after the gutka ban. Traditionalgutka is sold in the open market in a pre-mixed format. Manufacturers are supplying pan masala and tobaccoin separate pouches as there is no restriction for sale of pan masala and tobacco individually in many states.Although most of the population is aware of the health hazards of tobacco, it is necessary to develop an effectivestructured strategy. Tobacco control programs need to be strengthened by separate tobacco control measuresat various levels.     

Evaluation of the Knowledge and Perceptions with Regards to Pictorial Health Warnings on Tobacco Products among Tobacco Users Diagnosed with Head and Neck Carcinoma: a Study from the Kumaon Hills of India

Background: Tobacco products continue to be used in large quantities in India despite the mandatory inclusionof pictorial health warnings (PHWs) on all tobacco packaging. The circumstances as to how people could continuethe use of tobacco to the point of developing head and neck cancer despite enhanced awareness about the illeffects of tobacco is the main focus of this study. Materials and Methods: This study concerned patients withleast 5-years history of tobacco use, having been diagnosed with histopathologically proven malignancies of thehypopharynx, larynx, oropharynx and oral cavity presenting at the Government Medical College-Haldwani,Nainital, India. A total of 183 patients were eligible for inclusion during July 1 2013- June 30 2014. Of these,59 patients used smoked tobacco exclusively, 22 patients used smokeless tobacco exclusively, and 102 patientsused both forms of tobacco. Among users of smoked forms, 75.2% (n=121) were beedi users, and 24.8% (n=40)were cigarette users. Patients were asked direct questions as to whether they had noticed the presence of PHWsupon tobacco products. The reasons as to why PHWs were not effective in stopping the patients from tobaccouse were investigated. Results: Of the 183 patients, 146 reported being aware about the presence of PHWs, andwhen they were asked reasons as to why they continued tobacco despite being aware of ill-effects, the commonestreason chosen (by 53.4%) was that patients had not regarded themselves as using tobacco heavy enough to causecancer. Among the 36 patients who reported as being oblivious to the presence of PHWs on tobacco products,63.9% reported that the products they used never displayed any PHWs, and 36.1% reported never having paidattention to the packaging. The awareness about PHWs was higher among cigarette smokers in comparisonto beedi smokers (100% vs 76.1%, p=0.0002). Conclusions: Locally produced and marketed tobacco productssuch as beedis and oral tobacco often fail to display PHWs. The presence of PHWs without doubt enhancesawareness about the carcinogenic risks of tobacco. However, enhanced awareness alone may not be enough, andas elucidated by this study, some persons continue to use tobacco to the point of developing malignancies. Theneed of the hour is the implementation of legal and economic sanctions discouraging the use of tobacco products.