A study on adolescents to assess the impact of ...

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ORIGINAL ARTICLE A study on adolescents to assess the impact of pictorial and textual warnings on panels of smoked and smokeless tobacco products in Western Maharashtra, India Anand Thakur, K. M. Shivakumar, Snehal Patil, K. V. Suresh1, Vidya Kadashetti2 Departments of Public Health Dentistry, 1Oral Medicine and Radiology and 2Oral Pathology, Microbiology and Forensic Odontology, School of Dental Sciences, Krishna Institute of Medical Sciences University, Karad, Maharashtra, India Address for correspondence: Dr. K. M. Shivakumar, Department of Public Health Dentistry, School of Dental Sciences, Krishna Institute of Medical Sciences University, Karad ‑ 415 110, Maharashtra, India. E‑mail: [email protected]

ABSTRACT: Introduction: Various pictorial and textual warnings are depicted with a hope that they will deter the individuals from using

tobacco and inform them regarding the risks of tobacco. Yet there is lack of information regarding the comprehension of these signs by the adolescents. Aims: The aim was to explore the perception of the adolescents regarding the pictorial and textual warnings on tobacco packs. Materials and Methods: A cross‑sectional study was conducted among 500 adolescents of Satara district using simple random sampling technique. A specially designed questionnaire was administered to assess understanding, credibility and persuasiveness of the pictorial and textual warnings on panel of smoked and chewable tobacco. A model containing the pictorial and textual warnings on panel of smoked and smokeless tobacco products were shown to the study subjects. Chi‑square test was used for intergroup comparisons based on gender and age of the participants. The statistical analysis of data were done using SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). Results: Nearly one‑third of the study participants had often noticed warnings on tobacco packs in the last month, had sometimes read or looked closely at the warnings on tobacco packs in the last month and had rarely talked with anyone about these warnings. About more than two‑third of the study participants had found the warning related pictures as not easy to understand, not believable and that these images did not deter them from the likely use of tobacco, and it did not stop them from using tobacco. Conclusion: We can infer that the textual and pictorial warnings failed to have desired deterrent impact on the adolescent who tend to initiate or continue the tobacco use despite the warning.

Key words:

Adolescents, perception, pictorial warnings, tobacco

INTRODUCTION Tobacco in smoke and smokeless form is a leading cause of preventable morbidity and mortality worldwide. With over 8 million deaths projected to be attributable to smoking by the year 2020, smoking has been described as a major public health scourge of modern times.[1] Access this article online Quick Response Code:

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DOI: 10.4103/2319-5932.165243

Government of India has been taking initiative with regards to the ban of sale of tobacco products, placing pictorial warnings on the tobacco packets, advertising related to the vices of tobacco use and also has been contemplating about raising the taxes on tobacco products. These combined efforts have been instrumental in raising awareness among the masses regarding the ill effects of tobacco consumption and This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: [email protected] How to cite this article: Thakur A, Shivakumar KM, Patil S, Suresh KV, Kadashetti V. A study on adolescents to assess the impact of pictorial and textual warnings on panels of smoked and smokeless tobacco products in Western Maharashtra, India. J Indian Assoc Public Health Dent 2015;13:250-3.

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have been discouraging people from adopting this habit.[2] The World Health Organization explains that consumers have “fundamental right to accurate information” about the risks of smoking, with warnings on tobacco packaging as a simple means of communicating these risks.[1] More than 60 countries now require pictorial health warnings on packs and in five countries they cover 75% or more of the principal surfaces (Canada, Brunei, Uruguay, Sri Lanka, Australia). In India too, a mandate on the display of such warnings has been implemented. Three different pictorial and many textual warnings on rotation basis are used. These warnings usually state “smoking is injurious to health” and “chewing tobacco causes oral cancer” in local languages to make it more effective.[3] According to the United Nations (UNICEF 2011), adolescent are the people in the age group of 11–19 years.[4] As we know it is the age of experimentation which often is instrumental in the initiation of tobacco related habits. The individuals in this age group are very much inquisitive and want to try different things so the chances of being a tobacco addict are very high among them. According to the global youth and adult tobacco survey it has been found that initiation of tobacco habits starts at an average age 17.9 years in males and 21.0 years in females.[5] Government of India as a part of its campaign against tobacco use has mandated the presence of pictorial warning on the packs of tobacco: Smoked and smokeless. These warnings are depicted with a hope that they will deter the individuals from using tobacco and inform them regarding the risks of tobacco. Yet there is lack of information regarding the comprehension of these signs by the adolescents. Such information will give an insight into the thinking process of the adolescents regarding these warnings. This is the first study of its kind in Western Maharashtra exploring the other side of the scenario of tobacco free initiative. In our study, Satara district was chosen as the study area as Maharashtra is one of the leading states in tobacco consumption and it has been observed on a national and state level survey that age of initiation of tobacco habits is quite young in these state inhabitants. Hence, this study was conducted with the aim to assess the understanding, credibility and persuasiveness of the adolescents regarding the pictorial and textual warnings on reverse panel of smoked and chewable tobacco packages.

MATERIALS AND METHODS A cross‑sectional study was conducted among adolescents group of Satara district from May to June 2014. The study population was the adolescents belonging to the age group of 11–19 years attending the educational institutions of Satara district in Western Maharashtra. 251

It is inhabited by 74,335 people with an average literacy rate of 76%, which is higher than the national average.[6] An Ethical Clearance was obtained from the Institutional Ethics Committee to initiate the study. Informed consent was obtained from all the study participants. All necessary permissions were obtained from the concerned authorities. A pilot study was conducted among 30 adolescents to assess the feasibility of the study. As per the results of the pilot study, the sample size was determined 500 study subjects with the probability of 90% and error of 5%. The questionnaire used for this study was translated to Marathi which is the local language and back translated to English by a bilingual expert and the face and content validity was assessed. The reliability of the questionnaire was assessed in pilot study by measuring Cronbach’s alpha and inter‑item correlations. The internal consistency reliability coefficient (Cronbach’s alpha) for the questionnaire was 0.71. The item‑scale correlations of all the items of questionnaire ranged from 0.52 to 0.60, in which none was less than the minimum acceptable level of 0.4. A list of institutions was obtained and from them the schools and colleges were selected by using simple Random sampling techniques. Of the 120 institutions listed, 18 institutions’ were selected for the study and among them 27 students were selected by simple random sampling technique. Inclusion criteria were people who were willing to participate, who were present on the day of examination. A specially designed questionnaire was administered to assess understanding, credibility and persuasiveness of the pictorial and textual warnings on the reverse panel of smoked and smokeless tobacco. The questionnaire consisted of 6 questions 4 dealing with the comprehension of the warnings and other two dealt with the perceived seriousness of the warnings. The responses were “never,” “sometimes,” “rarely,” “very often” and last two questions responses were dichotomized as “yes” or “no.” The questionnaire assessed the salience (noticing, looking closely at warnings), depth of processing (thinking about warnings, discussing them with others), comprehension and credibility (warning comprehensibility, believability, and truthfulness), unaided recall, persuasiveness (warnings as a deterrent to smoking), avoidance techniques (e.g., hiding packs), and a behavioral indicator (forgoing cigarettes due to warnings) of the participants.[7] A model containing the pictorial and textual warnings on panel of smoked and smokeless tobacco products were shown to the study subjects. This model was displayed in the rooms where the participants were supposed to see them and then complete the questionnaire. The recorded data were transferred to the computer in Microsoft Excel worksheet and was subjected to

Journal of Indian Association of Public Health Dentistry Vol. 13, Issue 3, | July-September 2015


statistical analysis by using SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). Chi‑square test was used for intergroup comparisons based on gender and age of the participants. P value was set at 0.05) found these “pictures were not easy to understand,” 421 (84.2%, P > 0.05) found these “images were not believable,” 403 (80.6%, P 0.05

106 (21.2)

155 (31)

113 (22.6)

77 (15.4)

49 (9.8)

>0.05

Journal of Indian Association of Public Health Dentistry Vol. 13, Issue 3, | July-September 2015

P

Never

252


Conflicts of interest

Table 3: Distribution of participants based on the response of the questions Questions

Responses (n (%)) Yes

How did you feel these pictures and written warnings are Easy to understand Believable Truthful in respect to the health risks associated with tobacco use Do these warning signs Makes you less likely to use tobacco Stop you from using tobacco

There are no conflicts of interest. P

No

85 (17) 79 (15.8) 97 (19.4)

415 (83) 421 (84.2) 403 (80.6)

>0.05 >0.05