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Original Article
1 (
2
); 41-52
doi:
10.25259/ICAJ_1_2022

Knowledge, Attitude and Perceptions on Pictorial Warnings on Tobacco Packaging in Relation to Age, Gender and Socio-economic Status among Patients Visiting a Dental Hospital in Mysuru City

,
1Department of Public Health Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India.

*Corresponding author: Byalakere Rudraiah Chandrashekar, Department of Public Health Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India. drchandrubr@yahoo.com

Received: , Accepted: ,
© 2022 Published by Scientific Scholar on behalf of Indian Cancer Awareness Journal
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Mary A, Chandrashekar BR. Knowledge, attitude and perceptions on pictorial warnings on tobacco packaging in relation to age, gender and socio-economic status among patients visiting a dental hospital in Mysuru city. Indian Cancer Awareness J 2022;1:41-52.

Abstract

Objectives:

The objectives of the study were to assess knowledge, attitude and perceptions on pictorial warnings on tobacco packaging in relation to age, gender and socio-economic status (SES) among patients visiting a dental hospital in Mysuru city.

Materials and Methods:

This cross-sectional study was conducted among patients visiting a dental college and hospital in Mysuru. Initial questionnaire development was done using synthesis of inputs from subject experts and literature review. This questionnaire was then validated by three subject experts. Cognitive interview using concurrent verbal probing technique was undertaken on three prospective participants to elicit response process validity. Known group validity was assessed by distributing the questionnaire among three public health dentists and three 3rd year BDS students. Questionnaire was then subjected to reliability assessment on five participants using test retest method. Final questionnaire having 30 items was used on 400 participants aged more than 18 years visiting dental college hospital. Census enumeration of all eligible adult participants was done till the required sample size was reached.

Results:

Mean knowledge score on warning signs on tobacco packaging was significantly higher among those aged <40 years (7.47 ± 2.47) compared to those aged 40 years and above (6.59 ± 2.47). It was also significantly higher among those from the upper classes (7.55 ± 2.41) compared to those from the lower classes (6.52 ± 2.52) with no significant difference in relation to gender and smoking status.

Conclusion:

Knowledge on pictorial health warning labels was higher among younger individuals and those from the upper socio-economic classes with no significant difference in the attitude and perception in relation to age, gender, SES and smoking status.

Keywords

Pictorial health warnings
Tobacco packaging
Knowledge
Attitude
Perceptions

INTRODUCTION

Tobacco refers to a product prepared using the leaves of tobacco plants. Tobacco plants belong to the genus ‘Nicotiana’ and family ‘Solanaceae.’[1] Tobacco is the only product that is legally permitted to be sold that kills most of its users when the product is consumed according to the manufacturer’s instructions. According to estimates of the World Health Organisation (WHO), worldwide, 6 million deaths occur annually which can be attributed to tobacco use either in the form of smoked tobacco or smokeless tobacco. Within this annual tobacco related mortality, it is estimated that around 600,000 deaths every year is because of exposure to second hand smoke. Tobacco use has far reaching adverse consequences on health, social status, economic status and environment.[2] Despite adverse consequences; tobacco use is very common around the globe. This can be due to low prices, aggressive and extensive marketing, low awareness about its dangers among general public and lack of consistent public policies against its use.[2] World Health Assembly unanimously espoused the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2003 which is in force since 2005. The intension was to safeguard present and future generations from the devastating consequences of tobacco use and second hand exposure on health, social, environmental and economic conditions. The WHO FCTC was ratified by 180 countries as on March 2015. It covers about 90% of the population in the world.[2] It becomes legally binding to the parties to the convention that they develop and implement evidence based policies to regulate marketing activities of tobacco industry, sales, demand for tobacco while providing agricultural alternatives for those involved in tobacco cultivation.[2] The WHO introduced ‘MPOWER’ strategy in 2008 which include six evidence based measures to reduce the demand for tobacco. ‘MPOWER’ is an abbreviation where ‘M’ refers to ‘Monitoring tobacco use and prevention policies,’ ‘P’ refers to: ‘Protecting people from tobacco smoke,’ ‘O’ refers to: ‘Offering help to quit tobacco use,’ ‘W’ refers to: ‘Warning about the dangers of tobacco,’ ‘E’ refers to: ‘Enforcing bans on tobacco advertising, promotion and sponsorship,’ and ‘R’ refers to: ‘Raising taxes on tobacco.’[2]

Tobacco is consumed in several smoked and smokeless forms besides exposing non users also to the dangers of exposure to second hand smoke. India is the second largest consumer of tobacco and third largest tobacco producer. According to the National Family Health Survey-3 conducted in 2005–2006, one-third (33.3%) of the men and 1.6% of women aged 15–49 years smoked while smokeless tobacco use was found among more than one-third (38.1%) of the men and one-tenth (9.9%) of the women.[3,4] Ministry of Health and Family Welfare Government of India had enacted ‘The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003’ (COTPA) in 2004 even before it became party to the WHO FCTC. COTPA is a comprehensive legislation to control production, supply, distribution and sales of tobacco products in India.[5] Government of India also launched National Tobacco Control Programme (NTCP) in 2007–08 during the 11th 5-Year-Plan. NTCP was aimed at creating awareness on harmful effects of tobacco, reducing production and supply of tobacco products, ensuring effective implementation of the provisions under COTPA, helping people to quit tobacco use, while facilitating implementation of MPOWER strategies for prevention and control of tobacco.[6]

Two Global Adult Tobacco Surveys (GATS) have been conducted in India. It was found that the tobacco consumption has reduced by around 6% points in GATS 2 (2016–17) compared to GATS 1 (2009–10). Tobacco use among adult participants aged 15 years or more in India in 2009–10 was 34.6% which reduced to 28.6% in 2016–17. This clearly indicates that the strategies adopted by Government of India has helped in reducing tobacco use to certain extent.[7]

Tobacco is an integral component of culture and tradition in many South-East Asian countries including India. Tobacco is used for various purposes in local communities with different societal mores and relations attached to its use. In Myanmar, tobacco use is culturally and socially accepted and is an element of social norm. Tobacco products are offered to guests during social congregations and religious festivities. Children offer raw tobacco to the elderly as a present when elderly visit their homes. This is a culturally ingrained practice in some communities in Kerala, India. The use of tobacco in celebrations including marriage is very common in most regions of India. Taibur (Tobacco water) is served to guests or visitors at parties in rural areas of Mizoram, India. Sharing a hookah is considered a symbol of companionship and solidarity among North Indian men. Tobacco chewing is socially acceptable and highly prevalent than smoking among rural women in Nepal. Contrary to this, some countries have certain beliefs and practices about tobacco that reduce its use. There is a belief among people in Myanmar that tobacco smoke is harmful to foetus. In view of this belief, men keep away from smoking and some choose smokeless tobacco when their wives become pregnant. Tobacco use is not permitted in Sikkism as it was banned by a Sikh Guru in the 17th century. As a result, the prevalence of tobacco use is low in Punjab compared to other regions. In Bhutan, tobacco use is considered as a sin. Tobacco consumption in Bhutan is very low. It’s evident that tobacco use is intimately laced into social and cultural fabrics of many South-East Asian countries including India.[8]

Pictorial warnings on tobacco packaging are expected to motivate a tobacco user to quit the habit. Insertion of warning labels on tobacco packaging was first notified in 2006 in India and enforced from 31 May 2009 under Section 7 of The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production and Supply and Distribution) Act, 2003. Studies have shown that warning labels on tobacco products help in communicating the adverse consequences of tobacco use even for an illiterate person. These warning labels are expected to bring about behavioural changes which help in quitting and/or at least in reducing tobacco consumption to certain extent.[9-12]

Literature evaluating the effectiveness of pictorial warning signs on tobacco products among Mysore population was scanty. Hence, the present study was undertaken to assess knowledge, attitude and perceptions (KAP) on pictorial warnings on tobacco packaging in relation to age, gender and SES among patients visiting a dental hospital in Mysuru city.

MATERIALS AND METHODS

This cross-sectional study was conducted among patients visiting the OPD of JSS dental college and hospital, Mysuru over a period of 4 months from December 2019 to March 2020. Permission to conduct the study was obtained from head of the institution. Ethical clearance for the study was obtained from Institutional Ethics Committee vide JSSDCH IEC Research protocol number 84/2019 dated 25 October 2019. Investigator distributed the participant information sheet in the OPD registration counter in local language and requested informed consent from the participants willing to complete the questionnaire. Participant information sheet and consent forms were given either in English or local language based on participant preference. Participants willing to enrol into the study offered the informed consent and completed the questionnaire.

Development and validation of the questionnaire

The questionnaire development was done using synthesis of inputs from subject experts and literature review. A questionnaire used in the previous study[10] was identified and permission to use this questionnaire after requisite additional validation process in our study was obtained from the authors concerned. The initial questionnaire having 35 items was shared among three subject experts with a template to submit their scoring for each item in the questionnaire for its relevance on a scale of 1–5 (1 = Not all relevant, 2 = Not Relevant, 3 = Relevant, 4 – Quite relevant and 5 – Very much relevant). The subject experts were also requested to submit their comments on clarity of wordings used in each item and suggest revisions in the wordings (if essential). Based on inputs from subject experts, five items were deleted due to redundancy.[13,14] The item level and scale level content validity index for the final questionnaire having 30 items was 1.[15] The final questionnaire having 30 items was then subjected to reliability assessment on five participants using test retest method. The questionnaire was given in the morning session for these participants and the filled questionnaires were collected. The same questionnaire was distributed again to these participants in the afternoon session after explaining the need for collecting the information again. The consistency in the scores between first and second examination was determined using Kappa coefficient. It was found to be 0.84. The questionnaire was then subjected to cognitive interview on three prospective participants visiting the department to elicit response process validity. Concurrent verbal probing technique was used to elicit respondent’s interpretation of each item during cognitive interview process.[13] Investigator interviewed the respondents with regard to their interpretation of each item in the questionnaire at the time when respondents were choosing their answers for each item. If the interpretation by respondent was as intended by the investigator, a score of 1 was assigned and a score of 0 was given when the interpretation was different from the intended interpretation. The respondents were requested to rephrase the item in their own words after explaining the intended meaning. Revised item using the wording suggested by the prospective participants only was considered for the study. Known group validity was assessed by distributing the questionnaire among three public health dentists and three 3rd year BDS students. The mean knowledge score from public health dentists was significantly higher (11 ± 1) compared to that obtained from students (5.7 ± 0.58) demonstrating known group validity evidence for the tool. Final questionnaire in English and Kannada is attached as [Annexure 1].

Sample size estimation and sampling technique

The sample size was estimated based on single proportion using nMaster software. The sample size was computed to be 384 at an assumed proportion of 0.8 with relative precision of 5% at 95% confidence level. However, the sample size was rounded off to 400 anticipating 5% non-response. Census enumeration of all eligible adult participants aged more than 18 years visiting dental college hospital who were willing to participate in the study during the data collection period were considered for the study. Data collection was done till the required sample size was reached. Final questionnaire was distributed among the study participants with a request to complete the questionnaires.

Data analysis

Data were entered onto a personal computer and statistical analysis was done using SPSS version 24.0 (IBM, Chicago, Illinois, USA). A score of 1 was given for each correct response from item number 9–20 while an incorrect response was given a score of 0. The scores for all the 11 items were totalled and mean knowledge score was compared between different sub groups using independent sample t-test. Pearson’s Chi-square test was used for comparing the frequency distribution between different sub groups. Statistical analysis was fixed at 0.05.

RESULTS

A total of 400 participants completed the questionnaire. Among them, 238 participants were aged <40 years and 162 were aged 40 years and above. 269 participants were males and 131 were females. Although, SES was assessed using modified Kuppuswamy scale, considering the smaller sample size in some SES groups, we categorised the participants into two SES groups. 230 participants were from upper and upper middle classes and 170 participants were from lower middle, upper lower and lower classes. There was no statistically significant difference in the distribution of participants in relation to age, gender and SES (P > 0.05, [Table 1]). Among, 400 participants, 94 (23.5%) were current smokers with no statistically significant difference in the distribution of current smokers in relation to age and SES. However, a significantly higher percentage of males (33.8%) were current smokers compared to female current smokers (2.3%) (P < 0.001, [Table 2]). The most common reasons for initiating smoking among current smokers in the descending order were stress (36.2%), style statement (23.4%), combination (13.8%) and Peer influence (11.7%), fascinated by watching movies (106%) and others (4.3%) with no significant difference in relation to age and SES [Table 3]. Each correct response for item numbers 9–20 which were knowledge based questions was assigned a score of 1 and an incorrect response was scored 0. The mean knowledge score was 7.11 ± 2.50 among the participants. Mean knowledge score on warning signs on tobacco packaging was significantly higher among those aged <40 years (7.47 ± 2.47) compared to those aged 40 years and above (6.59 ± 2.47) (P = 0.001) and those from upper classes (7.55 ± 2.41) compared to those from lower classes (6.52 ± 2.52) (P < 0.001). There was no significant difference in the mean knowledge score in relation to gender (P = 0.513) and smoking status (P = 0.140) [Table 4]. Most participants expressed positive attitude about the pictorial warnings on tobacco products with no significant difference in relation to age, sender and SES (P > 0.05, [Table 5]). There was no significant difference in the perception of participants on the impact of pictorial warning on tobacco packaging in relation to age, gender and SES among current tobacco users with most participants expressing that the pictorial warnings had an impact in motivating a tobacco user to quit and non-user to continue being a non-user (P > 0.05, [Table 6]).

Table 1: Age and gender distribution of study participants in different SES categories.
SES Less than 40 years 40 years and above Age groups combined
Gender Males n (%) Females n (%) Total Males n (%) Females n (%) Total Males n (%) Females n (%) Total
Upper and upper middle class 99 (67.3) 48 (32.7) 147 (100) 61 (73.5) 22 (26.5) 83 (100) 160 (69.6) 70 (30.4) 230 (100)
Lower middle, upper lower and lower class 56 (61.5) 35 (38.5) 91 (100) 53 (67.1) 26 (32.9) 79 (100) 109 (64.1) 61 (35.9) 170 (100)
Total 155 (65.1) 83 (34.9) 238 (100) 114 (70.4) 48 (29.6) 162 (100) 269 (67.2) 131 (32.8) 400 (100)
Statistical inference χ2=0.835
df=1
P=0.361		 χ2=0.835
df=1
P=0.361		 χ2=1.317
df=1
P=0.251

SES: Socio-economic status

Table 2: Distribution of current tobacco users in relation to age, gender and SES.
Variable Current and past tobacco users Yes n (%) Non tobacco users No n (%) Total n (%) Statistical inference
Age
Less than 40 years 57 (23.9) 181 (76.1) 238 (100) χ2=0.066
df=1
P=0.797
40 years and above 37 (22.8) 125 (77.2) 162 (100)
Total 94 (23.5) 306 (76.5) 400 (100)
Gender
Males 91 (33.8) 178 (66.2) 269 (100) χ2=48.745
df=1
P<0001
Females 3 (2.3) 128 (97.7) 131 (100)
Total 94 (23.5) 306 (76.5) 400 (100)
SES
Upper and upper middle class 55 (23.9) 175 (76.1) 230 (100) χ2= 0.051
df=1
P=0.821
Lower middle, upper lower and lower class 39 (22.9) 131 (77.1) 170 (100)
Total 94 (23.5) 306 (76.5) 400 (100)

SES: Socio-economic status

Table 3: Reasons for initiating tobacco habits among current tobacco users in relation to age, gender and SES.
Variable Fascinated by watching movies n (%) Stress n (%) Style statement n (%) Peer’s Influence n (%) Combination n (%) Others n (%) Total n (%) Statistical inference
Age
Less than 40 years 6 (10.5) 23 (40.4) 14 (24.6) 5 (8.8) 8 (14.0) 1 (1.8) 57 (100) χ2=3.980
40 years and above 4 (10.8) 11 (29.7) 8 (21.6) 6 (16.2) 5 (13.5) 3 (8.1) 37 (100) df=5
Total 10 (10.6) 34 (36.2) 22 (23.4) 11 (11.7) 13 (13.8) 4 (4.3) 94 (100) P=0.552
Gender
Males 10 (11.0) 33 (36.3) 22 (24.2) 11 (12.1) 13 (14.3) 2 (2.2) 91 (100) χ2=30.219
Females 0 (0.00) 1 (33.3) 0 (0.00) 0 (0.00) 0 (0.00) 2 (66.7) 3 (100) df=5
Total 10 (10.6) 34 (36.2) 22 (23.4) 11 (11.7) 13 (13.8) 4 (4.3) 94 (100) P<0.001
SES
Upper and upper 9 (16.4) 16 (29.1) 15 (27.3) 6 (10.9) 6 (10.9) 3 (5.5) 55 (100) χ2=8.106
middle class df=5
Lower middle, upper 1 (2.6) 18 (46.2) 7 (17.9) 5 (12.8) 7 (17.9) 1 (2.6) 39 (100) P=0.150
lower and lower class
Total 10 (10.6) 34 (36.2) 22 (23.4) 11 (11.7) 13 (13.8) 4 (4.3) 94 (100)

SES: Socio-economic status

Table 4: Comparison of mean knowledge score in relation to age, gender, SES and tobacco status.
Variable Sub groups Mean ± SD 95% CI Statistical inference
Age Less than 40 years
n=238		 7.47 ± 2.47 0.39–1.37 t=3.50
df=398
P=0.001
40 years and above
n=162		 6.59 ± 2.47
Gender Males
n=269		 7.17 ± 2.33 −0.35–0.70 t=0.655
df=398
P=0.513
Females
n=131		 6.99 ± 2.82
SES Upper and Upper middle Class
n=230		 7.55 ± 2.41 −1.52 ± – 0.54 t=−4.150
df=398 P<0.001
Lower Middle, upper lower and lower class
n=170		 6.52 ± 2.52
Tobacco status Current users
n=94		 6.78 ± 2.52 −1.02–0.14 t=−1.478
df=398
P=0.140
Non users
n=304		 7.21 ± 2.49
Total Overall 7.11 ± 2.50 2.11–12.11

SES: Socio-economic status

Table 5: Attitude about the pictorial warnings on tobacco products in relation to age, gender and SES.
Variables Agree Uncertain Disagree Total Statistical inference
Item No 21 Do you agree that Pictorial warning labels should be present on the tobacco packs?
Age
Less than 40 years 210 (88.2) 22 (9.20 6 (2.5) 238 (100) χ2=0.001
df=2 p=0.999
40 years and above 143 (88.3) 15 (9.3) 4 (2.5) 162 (100)
Total 353 (88.2) 37 (9.2) 10 (2.5) 400 (100)
Gender
Males 232 (86.2) 29 (10.8) 8 (3.0) 269 (100) χ2=3.193
df=2
P=0.203
Females 121 (92.4) 8 (6.1) 2 (1.5) 131 (100)
Total 353 (88.2) 37 (9.2) 10 (2.5) 400 (100)
SES
Upper 200 (87.0) 24 (10.4) 6 (2.6) 230 (100) χ2=0.928
df=2
P=0.629
Lower 152 (89.4) 13 (7.6) 5 (2.9) 170 (100)
Total 352 (88.0) 37 (9.2) 11 (2.8) 400 (100)
Item No 22 Do you agree that Pictorial warnings labels on tobacco products create awareness about hazards on general health?
Age
Less than 40 years 191 (80.3) 35 (14.7) 12 (5.0) 238 (100) χ2=1.065
df=2
P=0.587
40 years and above 135 (83.3) 22 (13.6) 5 (3.1) 162 (100)
Total 326 (81.5) 57 (14.2) 17 (4.2) 400 (100)
Gender
Males 213 (79.2) 40 (14.9) 16 (5.9) 269 (100) χ2=6.335
df=2
P=0.042
Females 113 (86.3) 17 (13.0) 1 (0.8) 131 (100)
Total 326 (81.5) 57 (14.2) 17 (4.2) 400 (100)
SES
Upper 188 (81.7) 32 (13.9) 10 (4.3) 230 (100) χ2=0.059
df=2
P=0.971
Lower 138 (81.2) 25 (14.7) 7 (4.1) 170 (100)
Total 326 (81.5) 57 (14.2) 17 (4.2) 400 (100)
Item No 23 Do you agree that Pictorial warnings labels on tobacco products create awareness about hazards on oral health?
Age
Less than 40 years 181 (76.1) 40 (16.8) 17 (7.1) 238 (100) χ2=3.114
df=2
P=0.211
40 years and above 127 (78.4) 30 (18.5) 5 (3.1) 162 (100)
Total 308 (77.0) 70 (17.5) 22 (5.5) 400 (100)
Gender
Males 201 (74.7) 52 (19.3) 16 (5.9) 269 (100) χ2=2.427
df=2
P=0.297
Females 107 (81.7) 18 (13.7) 6 (4.6) 131 (100)
Total 308 (77.0) 70 (17.5) 22 (5.5) 400 (100)
SES
Upper 181 (78.7) 38 (16.5) 11 (4.8) 230 (100) χ2=1.004
df=2
P=0.605
Lower 127 (74.7) 32 (18.8) 11 (6.5) 170 (100)
Total 308 (77.0) 70 (17.5) 22 (5.5) 400 (100)
Item No 24 Do you agree that Pictorial warning labels on the tobacco products encourage one to quit the habit of tobacco usage?
Age
Less than 40 years 169 (71.0) 49 (20.6) 20 (8.4) 238 (100) χ2=4.009
df=2
P=0.135
40 years and above 116 (71.6) 40 (24.7) 6 (3.7) 162 (100)
Total 285 (71.2) 89 (22.2) 26 (6.5) 400 (100)
Gender
Males 185 (68.8) 65 (24.2) 19 (7.1) 269 (100) χ2=2.460
df=2
P=0.292
Females 100 (76.3) 24 (18.3) 7 (5.3) 131 (100)
Total 285 (71.2) 89 (22.2) 26 (6.5) 400 (100)
SES
Upper 165 (71.7) 47 (20.4) 18 (7.8) 230 (100) χ2=1.771
df=2
P=0.412
Lower 119 (70.0) 42 (24.7) 9 (5.3) 170 (100)
Total 284 (71.0) 89 (22.2) 27 (6.8) 400 (100)
Item No 25 After seeing Pictorial warning labels on tobacco packs, a non-tobacco user prefers to stay as nonuser.
Age
Less than 40 years 164 (68.9) 52 (21.8) 22 (9.2) 238 (100) χ2=1.906
df=2
P=0.386
40 years and above 118 (72.8) 35 (21.6) 9 (5.6) 162 (100)
Total 282 (70.5) 87 (21.8) 31 (7.8) 400 (100)
Gender
Males 183 (68.0) 63 (23.4) 23 (8.6) 269 (100) χ2=2.443
df=2
P=0.295
Females 99 (75.6) 24 (18.3) 8 (6.1) 131 (100)
Total 282 (70.5) 87 (21.8) 31 (7.8) 400 (100)
SES
Upper 170 (73.9) 46 (20.0) 14 (6.1) 230 (100) χ2=3.587
df=2
P=0.166
Lower 112 (65.9) 41 (24.1) 17 (10.0) 170 (100)
Total 282 (70.5) 87 (21.8) 31 (7.8) 400 (100)
Item No 26 Do you agree that Pictorial warning is more impactful than statutory warning alone on the tobacco packets?
Age
Less than 40 years 176 (73.9) 42 (17.6) 20 (8.4) 238 (100) χ2=2.570
df=2
P=0.277
40 years and above 126 (77.8) 29 (17.9) 7 (4.3) 162 (100)
Total 302 (75.5) 71 (17.8) 27 (6.8) 400 (100)
Gender
Males 201 (74.7) 48 (17.8) 20 (7.4) 269 (100) χ2=0.641
df=2
P=0.726
Females 101 (77.1) 23 (17.6) 7 (5.3) 131 (100)
Total 302 (75.5) 71 (17.8) 27 (6.8) 400 (100)
SES
Upper 170 (73.9) 46 (20.0) 14 (6.1) 230 (100) χ2=0.631
df=2
P=0.729
Lower 112 (65.9) 41 (24.1) 13 (7.6) 170 (100)
Total 282 (70.5) 87 (21.8) 27 (6.8) 400 (100)
Item No 27 Do you agree that Pictorial warning in present form is more impactful than the previous forms used?
Age
Less than 40 years 181 (76.1) 39 (16.4) 18 (7.6) 238 (100) χ2=5.413
df=2
P=0.067
40 years and above 125 (77.2) 33 (20.4) 4 (2.5) 162 (100)
Total 306 (76.5) 72 (18.0) 22 (5.5) 400 (100)
Gender
Males 206 (76.6) 50 (18.6) 13 (4.8) 269 (100) χ2=0.823
df=2
P=0.663
Females 100 (76.3) 22 (16.8) 9 (6.9) 131 (100)
Total 306 (76.5) 72 (18.0) 22 (5.5) 400 (100)
SES
Upper 178 (77.4) 42 (18.3) 10 (4.3) 230 (100) χ2=1.383
df=2
P=0.501
Lower 128 (75.3) 30 (17.6) 12 (7.1) 170 (100)
Total 306 (76.5) 72 (18.0) 22 (5.5) 400 (100)
Item No 28 Do you agree a tobacco user avoids looking at Pictorial warning labels on tobacco products?
Age
Less than 40 years 146 (61.3) 47 (19.7) 45 (18.9) 238 (100) χ2=0.033
df=2
P=0.984
40 years and above 98 (60.5) 33 (20.4) 31 (19.1) 162 (100)
Total 244 (61.0) 80 (20.0) 76 (19.0) 400 (100)
Gender
Males 160 (59.5) 62 (23.0) 47 (17.5) 269 (100) χ2=5.137
df=2
P=0.077
Females 84 (64.1) 18 (13.7) 29 (22.1) 131 (100)
Total 244 (61.0) 80 (20.0) 76 (19.0) 400 (100)
SES
Upper 139 (60.4) 45 (19.6) 46 (20.0) 230 (100) χ2=0.218
df=2
P=0.897
Lower 104 (61.2) 35 (20.6) 31 (18.2) 170 (100)
Total 243 (60.8) 80 (20.0) 77 (19.2) 400 (100)

SES: Socio-economic status

Table 6: Perception on the impact of pictorial warning on tobacco packaging in relation to age, gender and SES among current tobacco users.
Item No Variable Always n (%) Sometimes n (%) Never n (%) Total n (%) Statistical Inference
Item 29 Have you thought of quitting it because of the Pictorial warning label and image on the tobacco package?
Age
Less than 40 years 14 (24.6) 37 (64.9) 6 (10.5) 57 (100) χ2=1.327
40 years and above 6 (16.2) 25 (67.6) 6 (16.2) 37 (100) df=2
Total 20 (21.3) 62 (66.0) 12 (12.8) 94 (100) P=0.515
Gender
Males 20 (22.0) 60 (65.9) 11 (12.1) 91 (100) χ2=1.686
Females 0 (0.00) 2 (66.7) 1 (33.3) 3 (100) df=2
Total 20 (21.3) 62 (66.0) 12 (12.8) 94 (100) P=0.430
SES
Upper 9 (16.4) 37 (67.3) 9 (16.4) 55 (100) χ2=2.883
Lower 11 (28.2) 25 (64.1) 3 (7.7) 39 (100) df=2
Total 20 (21.3) 62 (66.0) 12 (12.8) 94 (100) P=0.237
Item No 30 Have you made an attempt to quit, because of the Pictorial warning label on the tobacco package?
Age
Less than 40 years 15 (26.3) 33 (57.9) 9 (15.8) 57 (100) χ2=0.870
40 years and above 11 (29.7) 18 (48.6) 8 (21.6) 37 (100) df=2
Total 26 (27.7) 51 (54.3) 17 (18.1) 94 (100) P=0.647
Gender
Males 26 (28.6) 50 (54.9) 15 (16.5) 91 (100) χ2=5.151
Females 0 (0.00) 1 (33.3) 2 (66.7) 3 (100) df=2
Total 26 (27.7) 51 (54.3) 17 (18.1) 94 (100) P=0.076
SES
Upper 13 (23.6) 32 (58.2) 10 (18.2) 55 (100) χ2=1.153
Lower 13 (33.3) 19 (48.7) 7 (17.9) 39 (100) df=2
Total 26 (27.7) 51 (54.3) 17 (18.1) 94 (100) P=0.562
Total 86 (37.9) 112 (49.3) 29 (12.8) 227 (100)

SES: Socio-economic status

DISCUSSION

Tobacco results in death among half of its users. If the present pattern of morbidity and mortality continues with no stringent efforts to reduce tobacco consumption, it is estimated that more than 8 million people around the world will experience tobacco related morbidity and mortality annually by 2030.[16] Textual and pictorial health related warnings cover 85% of the tobacco packaging. They are inserted on front and back of tobacco packaging with 25% dedicated to text and 60% dedicated to the picture.[17] These pictorial health warnings are expected to enhance motivation of people indulging in tobacco habits to make quit attempts. Warning about dangers of tobacco is one among the six evidence based approaches under MPOWER strategies recommended by the WHO to reduce the demand for tobacco. Pictorial health warnings on tobacco packaging are a cost effective way of creating awareness about tobacco even among illiterate users. The present study made an attempt to elicit knowledge, attitude and perceptions on pictorial health warnings on tobacco packaging in relation to age, gender and SES among patients visiting a dental college hospital in Mysuru city. The study had 23.5% current smokers with more prevalence among males compared to females with no significant difference in relation to age and SES. The prevalence of tobacco use among adults aged more than 15 years in Karnataka was found to be 22.8% in 2016–17 according to the results of GATS-2.[18] These results were almost similar to the results of our findings. Stress (36.2%) was quoted as the most common reason for initiating tobacco use among current tobacco users in our study with no significant difference in relation to age and SES. This was consistent with a finding from a study conducted by Patel et al. in India.[19] It is perceived by people in stress that tobacco use reduces stress. This false perception is responsible for initiating tobacco use especially among adolescents who most often will be under stress.

A review on how stress modulates negative consequences of nicotine abuse concludes that there is a need to address the issue of reducing stress among adolescents in future policies as a means of reducing adolescent nicotine abuse.[20] Risky behaviours, such as substance abuse including tobacco use, are considered as coping mechanism among adolescents who most often will be in search of an identity and also, feel vulnerable and self-conscious during this stage of intrapersonal flux.[21] Knowledge score on pictorial warning signs on tobacco packaging was significantly higher among those aged <40 years compared to those aged 40 years and above as well as among those from upper classes compared to those from the lower classes with no significant difference in relation to gender and smoking status. Better educational opportunities that the younger individuals and upper classes would have had compared to their older counterparts and people from the lower classes enhances their educational attainment. This improved educational attainment will help them to gather information from variety of sources on tobacco legislations. Our results were similar to results of study by Hall et al.[22] There was no significant difference in the attitude and perceptions on pictorial health warnings in relation to age, gender, SES and tobacco status. This finding indicates the fact that the attitude and perceptions on pictorial health warnings are similar in relation to various demographic factors. This finding was consistent with the results of a study conducted in United States[23] which found that the impact of pictorial warning label was consistent across diverse racial/ethnic and socioeconomic populations. It was found that pictorial health warnings in comparison with textual messages have greater reach. It was concluded that the incorporation of pictorial warning labels was one of the few tobacco control policies having potential to reduce communication inequalities across various socio-demographic groups while being instrumental in reducing the morbidity and mortality related to tobacco epidemic among vulnerable communities.

CONCLUSION

Knowledge on pictorial health warning labels was higher among younger individuals and those from the upper socio-economic classes with no significant difference in the attitude and perception in relation to age, gender, SES and smoking status. This indicates that pictorial health warnings are an effective way of creating awareness, positive attitude and perceptions, among population with different socio-demographic nature.

Novelty

This study assessed the KAP on pictorial warnings pertaining to tobacco packaging in relation to age, gender and SES among Indian Population.

Limitations and future proposal

This was a cross-sectional study and sampling distribution between five different SES categories was unequal with some SES categories having very less number. This compelled us to dichotomise SES categories by combining the upper two classes as one category and lower three SES classes as the other category. A study with larger sample size with almost equal distribution of participants in different socio-demographic variables is essential to validate the results of present study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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ANNEXURE 1

Department of Public Health Dentistry

JSS DENTAL COLLEGE AND HOSPITAL

Knowledge, attitude and perceptions (KAP) on pictorial warnings on tobacco packaging in relation to age, gender and socio-economic status among patients visiting a dental hospital in Mysuru city.

Guided By: Dr. Chandrashekar BR

Head of the Department

Investigator: Anne Mary

Under graduate student

QUESTIONNAIRE (Kindly TICK [✓] on appropriate option)

DEMOGRAPHIC DETAILS:

  • Name (optional):

  • Age:

  • Gender:

  • Level of education attained:

  • Occupation:

  • What is the Family Income per month?

HISTORY OF TOBACCO USE

  1. Do you presently use tobacco in any form?

    1. Yes

    2. No (If Yes, go to question 4) If no,

  2. Did you use tobacco previously?

    1. Yes

    2. No (If No, please answer from question 9–30) If yes,

  3. What was the reason to quit?

    1. Medical problem

    2. Family pressure

    3. Health professionals

    4. Warnings

    5. Own willingness

    6. Others, specify____________

  4. What form of Tobacco do you use?

    1. Cigarette

    2. Bidis

    3. Cigar

    4. Hookah

    5. Chillum

    6. Gutkha

    7. Khaini

    8. Others, specify __________

  5. What was the reason to start using tobacco?

    1. Fascinated by watching movies

    2. Stress

    3. Style statement

    4. Peer’s influence

    5. Combination

    6. Others, specify __________

  6. Since how long have you been using Tobacco in any form?

    1. <1 years

    2. 1–5 years

    3. 6–10 years

    4. >10 years

  7. How often do you indulge in the habit?

    1. Daily

    2. Once in 2 days

    3. Once in a week

    4. Occasionally

  8. How many times do you consume tobacco in any form in a day?

    1. <5 times

    2. 6–10 times

    3. 11–20 times

    4. >20 times

KNOWLEDGE AND UNDERSTANDING OF PICTORIAL WARNINGS ON TOBACCO PRODUCTS

  1. Do you know about the presence of pictures on the Tobacco packets?

    1. Yes

    2. No If yes,

  2. Why do you think they are present?

    1. Company Logos

    2. Warnings

    3. Entertainment

    4. Others, specify

  3. Have you noticed presence of Pictorial warning labels on tobacco packets?

    1. Yes

    2. No

    3. Don’t know

  4. Do you understand the Pictorial warning labels on tobacco packets?

    1. Yes

    2. No

    3. Don’t know

  5. Do the Pictorial warnings signify any of the following?

    1. Lung cancer

    2. Oral cancer

    3. Combination

    4. None of the following

  6. Do you think usage of tobacco product can cause oral diseases?

    1. Yes

    2. No

    3. Don’t know

  7. Do you think pictorial warning labels represent any of the oral diseases?

    1. Yes

    2. No

    3. Don’t know

  8. Can you identify what is given in this picture?

    1. Injury

    2. Oral Cancer

    3. Ulcer

    4. Dont know

  9. Do you know about implementation of Govt. legislation on Pictorial health warnings on tobacco packets?

    1. Yes

    2. No If yes,

  10. How much percentage of tobacco packs should be covered with Pictorial and statutory warning?

    1. 15%

    2. 40%

    3. 60%

    4. 85%

  11. On which side the Pictorial warning is present on the tobacco packs?

    1. Front side

    2. Back side

    3. Both sides

    4. Don’t know

  12. Can you identify what is given in this picture?

    1. Lung cancer

    2. Burning sensation

    3. Asthma

    4. Don’t know

ATTITUDE ABOUT THE PICTORIAL WARNINGS ON TOBACCO PRODUCTS

  1. Do you agree that Pictorial warning labels should be present on the tobacco packs?

    1. Agree

    2. Uncertain

    3. Disagree

  2. Do you agree that Pictorial warnings labels on tobacco products create awareness about hazards on general health?

    1. Agree

    2. Uncertain

    3. Disagree

  3. Do you agree that Pictorial warnings labels on tobacco products create awareness about hazards on oral health?

    1. Agree

    2. Uncertain

    3. Disagree

  4. Do you agree that Pictorial warning labels on the tobacco products encourage one to quit the habit of tobacco usage?

    1. Agree

    2. Uncertain

    3. Disagree

  5. After seeing Pictorial warning labels on tobacco packs a non tobacco user, prefers to stay as nonuser.

    1. Agree

    2. Uncertain

    3. Disagree

  6. Do you agree that Pictorial warning is more impactful than statutory warning alone on the tobacco packets?

    1. Agree

    2. Uncertain

    3. Disagree

  7. Do you agree that Pictorial warning in present form is more impactful than the previous forms used?

    1. Agree

    2. Uncertain

    3. Disagree

  8. Do you agree a tobacco user avoids looking at Pictorial warning labels on tobacco products?

    1. Agree

    2. Uncertain

    3. Disagree

IMPACT OF PICTORIAL WARNING ON TOBACCO PRODUCTS PACKETS

  1. Have you thought of quitting it because of the Pictorial warning label and image on the tobacco package?

    1. Always

    2. Sometimes

    3. Never

  2. Have you made an attempt to quit, because of the Pictorial warning label on the tobacco package?

    1. Always

    2. Sometimes

    3. Never

Thank you for your time and cooperation


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