Introduction:
Framework Convention on Tobacco Control (FCTC) recognized pictorial health warnings on tobacco products as a powerful public health intervention tool to communicate health risks and to bring about a behavioral change like quitting and reduction in tobacco consumption.1 Researches in various countries demonstrated the effectiveness of pictorial warnings by recording a reduction in tobacco use through its wide reach and ability to frequently expose target audiences to a range of health warning messages.1 Recently, the Indian government under the Cigarettes and Other Tobacco Products (COTPA) Act, 2003, mandated pictorial warnings covering 40% of cigarette pack area from 31 May 2009. Research has also shown that regularly updated, large, and prominent pictorial warnings located on the top of packages are more credible, have public support, and can increase awareness and stimulate motivation to quit.2,3 Hence, to make it more effective and to provoke an enhanced emotional response the new warnings covering 85% of the principal display areas (both sides at the top edge) of tobacco packages, of which 60% consists of specified pictorial warnings and 25% consists of the text warning was introduced from May 31st 2016. So far no studies in India have explored the perceived effectiveness of this newly introduced 85% pictorial warning in bringing about a behavioral change like intention to quit. Hence it is necessary to assess the perceived effectiveness of these warning among the most vulnerable age group which is much needed in promoting the overall tobacco control measures. Obtaining information on these factors can contribute significantly to improve the tobacco cessation activities at individual as well as at the population level. Hence the present study was done in a private engineering college with the following objectives.
Objectives:
- To explore the perceptions on old and new pictorial warnings on tobacco products and ‘intention to quit’ among male students
- To find out the prevalence of ever and current tobacco product users, influencing factors and barriers in intention to quit tobacco among male college students
Material and Methods:
Study Setting:
The study was conducted in a private engineering college which is located at Madagadipet, a place in the border of Pondicherry and Villupuram District of Tamil Nadu. At the time of study, there were 1653 undergraduate students studying in the college.
Study Design:
It was an Exploratory Mixed-Method study Design where a Qualitative method [Focus Group Discussion (FGD)4 was followed by a Quantitative method (self-administered questionnaire survey)]5
Phase 1: Qualitative data collection and analysis
Two Focus Group Discussions were conducted separately among ten first and final year male students each from the selected engineering college. Vocal and willing students were purposively chosen for the FGDs. Prior informed written consent was obtained from each participant. FGDs were conducted by the trained facilitator (first author) using a semi-structured guideline with broad open-ended questions at a time convenient to the participants. The old and new pictorial warnings on tobacco products were used as ‘stimulus material’ to evoke students’ perceptions on these warnings. The FGDs started with the briefing of participants on the purpose of the interview. It was closed with de-brief for member checking. The discussions were audio recorded and the transcripts were prepared as verbatim on the same day of the interview. Manual content analysis of the transcripts was done together by first author and one postgraduate in Community Medicine trained in qualitative research to increase the trustworthiness in the results.6 Descriptive coding was done in transcripts. Later, similar codes were merged together to form the categories. Any discrepancies between the two were resolved by mutual discussion. The FGD findings were used in developing a context-specific questionnaire for the quantitative phase of the study. Statements in Italics and square brackets signify direct quotes from the participants and the author’s words/statements respectively. Items for the questions on facilitating factors and barriers in intention to quit for tobacco products were taken from FGD findings
Phase 2: Quantitative data collection and analysis:
Sample size: Considering the prevalence of tobacco usage among males (15-24 years) to be 57.4%7 and an alpha error of 5% and a 10% non-response rate, the sample size was calculated to be 450 [calculated by Epi_info ( version 3.5.4)]
Study participants: The study participants were male undergraduate students (18-21 years) from a private engineering college at Madagadipet, Puducherry.
Study duration: The study was carried out for a period of three months from December 2016- February 2017.
Sampling: A list of courses in the engineering college and the student studying in each course was obtained from the college authorities. From the list, out of five branches, two were selected by the lottery method. There were 490 students in these two selected branches. All 490 students were invited to participate in the study. Students who were not willing to give consent or those who were absent at the time of the survey were excluded from the study.
Data collection tool:
The questionnaire used for data collection was a modified Global Youth Tobacco Survey (GYTS) questionnaire. FGD results were used to develop the items in the questionnaire to make it context-specific. This draft questionnaire was pilot tested by administering it to 40 male students belonging to branches other than the selected branches for the study. It was followed by a group discussion, where difficulties in understanding the terminologies were explored and addressed in the final questionnaire. Before starting the survey, informed written consent was obtained from the participants. After adequate prior instructions and explaining participants about the anonymous nature of the study, the data was collected by using a self administered questionnaire. The following operational definitions were used for the purpose of the study. The respondent who had consumed any tobacco products at least once in their life-time was considered as "ever user" and who had consumed any tobacco products at least once in the past 30 days was considered as "current user."8 Data was entered and analyzed in Epi-info version 3.5.4 software package. Descriptive statistics, which included frequency, mean, and percentages, were used to describe the data. Apart from this, information on demographic details, intention to quit and various influencing factors and barriers in intention to quit were measured.
Ethical Considerations: Clearance from the Research Committee and Institutional Ethics Committee of Sri Manakula Vinayagar Medical College and Hospital, Puducherry was obtained. Prior permission was obtained from the college authorities for carrying out the study and for publication of the results.
Results:
Qualitative: Of the total 20 engineering students who participated in the FGD, ten (50%) were in first year and remaining ten (50%) were in final year and all were male. The mean age of the participants was 19.25 years + 1.48 SD.
Six categories which emerged from the FGD’s were 1) Precision of pictures 2) Message conveying capacity 3) Emotional arousal 4) Impact on users and initiators 5) Issues with the pictorial warnings 6) Suggestions for the improvement.
Category-1: Precision of the pictures
When the students were shown the pictures of both old and new pictorial warnings and asked about their opinion. The students felt that the new warnings were relatively larger in size and clearer than the older warnings. According to them, it would enhance the chance of these warnings being noticed by the product users and non-users. “The pictures are big and clear enough to be noticed by the other people passing the store”
Category-2: Message conveying capacity
The students opined that since the older warnings were too technical [and implicit] it will be understood only by people with some medical background. One of them said, “People won’t understand why they have put scorpion and what it [Scorpion] represents”. When the students were shown the old pictorial warnings of X-ray lung, they misinterpreted the picture as a rabbit or a piece of coal. The old pictorial warning of scorpion was seen as zodiac sign for cancer and lung picture as a damaged liver.
However, according to the participants, the newer warnings were perceived to clearly represent the harmful effect of tobacco in a simple way. One of the respondent said, “As one open the top lid of the packet, the throat of picture get slit bringing the [symbolic] effect of slitting of someone’s throat indicating [life-threatening] harmful effect of tobacco on life”
Category-3: Emotional arousal
In students’ view the older warnings fails to elicit fear among people. “Even a small baby won’t be afraid of this picture” [X-ray lungs] and some of them even felt those warnings to be attractive “It’s [scorpion] so beautiful that some would even like to have that as a tattoo on their arm”. The students mentioned, “People worry about their external [physical] appearance, more than they care for what is happening inside their body [internal organs]” Hence the depiction of harmful effects on the external part in the new warnings makes it more fear eliciting. According to some students, both old and new pictorial warnings were successful in creating a feeling of aversion. “The pictures [oral cancer, lung cancer] are so nauseating and if people still use this product, even after seeing these pictures, there is no hope for them to come out of this habit.”
Category-4: Impact on users and initiators
The students felt that though the pictorial warnings were intended to convey the health hazards of tobacco use, it might not have any impact among long-term users, but will have effect on beginners. “At first sight these pictures might create a sense of fear, but when people constantly get exposed to them, it looks like any other picture to them.” They also felt that people are more cost sensitive and less worried about the harmful effect of the product “People don’t care for the outcome, they just want to enjoy life, the only thing they care about is the cost of the product”.
Category-5: Issues with both old and new pictorial warnings
Instead of seeing as deterrents, the old pictorial warnings were perceived as mediums for brand promotion by some students. “The [attractive display of] brand name below the pictures makes the cigarette packets a portable advertisement medium for the company”. Some students opined that these pictures were seen as prestigious symbols, since it gives them a feeling of using a costly brand. In addition, these products are promoted by influential actors and players. Though relatively better, the new warnings were also not free from the issues like capturing viewer’s attention with its tempting new pack “Bright, colorful pictures might attract the attention of people”. The students felt that on seeing the new packaging the people might think that new flavors have been added to the package and might develop a curiosity among them to try it. Other issue which was pointed out by the students was when the products are brought in loose, there is no chance for the user to notice these pictures “Only people who are buying it in whole pack has a chance to notice it. A person, who is buying one or two cigarettes in loose, has no chance of seeing these pictures”.
Category-6: Suggestions by students
Participating students suggested few points to improve the effectiveness of newer warnings like making the package more unattractive by reducing its brightness and color, printing the warning on each cigarette, periodic rotation of the warnings to retain the fear, restriction to print attractive brand name below the warnings and printing of warnings in local languages.
Quantitative data:
Out of 490 male students in the two branches, 20 students were absent on the day of survey, 11 did not give consent and nine incomplete forms were discarded and the final sample size of 450 was achieved.
Table 1: Socio-demographic characteristics of male college students (18-21 years) (N=450) |
Average age (Years+SD) |
19.23 + 1.34 |
Current academic year |
I Year |
183 (40.7) |
II year |
125 (27.8) |
III year |
56 (12.4) |
IV year |
86 (19.1) |
Current place of living |
Home |
425 (95.4) |
Hostel |
25 (5.6) |
Father’s education |
Illiterate |
55 (12.2) |
Primary |
17 (3.8) |
Secondary |
239 (53.1) |
Graduate |
139 (30.9) |
Mother’s education |
Illiterate |
62 (13.8) |
Primary |
34 (7.6) |
Secondary |
260 (57.8) |
Graduate |
94 (20.9) |
Socio-economic class |
Class I |
193 (43.2) |
Class II |
187 (41.8) |
Class III |
0 (0) |
Class IV |
55 (2.3) |
| Figures in parenthesis are percentages |
As seen in Table 1, the mean age of 450 male students who participated in the study were 19.23 years + 1.34 (SD). Majority183 (40.7%) of them belong to first year. 425 (95.4%) of the students were day scholars. Most of the participant’s father 239 (53.1%) and mother 260 (57.8%) were educated up to secondary level. Based on modified B.G. Prasad classification, 193 (43.2%) & 187 (41.8%) students belonged to class I and class II socio-economic status respectively.
Table 2: Tobacco products used by college students (N=450) |
Tobacco usage |
Ever |
Current |
Tobacco usage among college students |
57 (12.7) |
39 (8.7) |
Tobacco products used by college students |
n=57 |
n=39 |
Manufactured cigarettes |
55 (96.5) |
38 (97.4) |
Cigar |
12 (21.1) |
4 (10.3) |
Bidi |
9 (15.8) |
1 (2.6) |
Water pipe, hookah, shisha |
9 (15.8) |
1 (2.6) |
Pipe |
9 (15.8) |
- |
Pan masala |
5 (8.8) |
3 (7.7) |
Dry tobacco leaves |
3 (5.3) |
- |
Snuff, snus |
3 (5.3) |
- |
Khaini |
2 (3.5) |
- |
Gutkha |
1 (1.8) |
- |
| Figures in parenthesis are percentages |
Based on Table 2, the prevalence of ever and current tobacco usage among students were 57 (12.7%) and 39 (8.7%) respectively. Among 57 ever users, the common smoking form of tobacco used was cigarettes 55 (96.5) followed by cigar 12 (21.1) and the common smokeless form was pan masala five (8.8). The most common smoking form of tobacco among current users was cigarettes 38 (97.4%), followed by cigar four (10.3%). The only smokeless product used by currents users was pan masala three (7.7%).
Table 3: Intention to quit, barriers and influencing factors for quitting among current users (multiple responses) |
Intention to quit among current users (N=39) |
n (%) |
Current users with Intention to quit tobacco |
30 (76.9) |
Ever tried to quit among current users |
27 (69.2) |
Reasons for intention to quit among current users (N=30) |
n (%) |
Fear regarding the ill health impacts of tobacco usage |
16 (53.3) |
Pressure by girl friend |
13 (43.3) |
Negative social implications of tobacco use |
11 (36.7) |
Self realization |
8 (26.7) |
Exposure to anti tobacco messages in public places |
5 (16.7) |
Pictorial warning on tobacco packages |
3 (10) |
Advice by closed ones |
2 (6.7) |
Economic factors |
1 (3.3) |
Barriers for intention to quit among current users (N=39) |
n (%) |
Addictive smell and attractive sight of tobacco products |
11 (28.2) |
Peer pressure |
11 (28.2) |
Enjoyment |
11 (28.2) |
Habit |
10 (25.6) |
Lack of self motivation |
8 (20.5) |
Withdrawal symptoms |
7 (17.9) |
Stress management |
7 (17.9) |
Cravings |
7 (17.9) |
Fear of failure |
4 (10.3) |
Concern about weight gain |
2 (5.1) |
Out of 39 current users, 30 (76.9%) had intention to quit the habit. Of that 30 respondents, fear regarding health impacts of tobacco16 (53.3%), pressure by girlfriends 13 (43.3%) and negative social implications of tobacco usage 11 (36.7%) was stated as common reasons for deciding to quit. Only three of current users had recorded pictorial warnings on tobacco packages as a factor for their intention to quit.
Out of 39 current users, 11 (28.2%) each mentioned addictive smell and attractive sight of tobacco products, peer pressure and enjoyment as major barriers in quitting and ten (25.6%) stated it as chronic habit. The other barriers such as lack of self motivation by eight (20.5%) respondents, craving, withdrawal symptoms and stress were stated by seven (17.9%) respondents each. Fear of failure and concern about weight gain was stated by four (10.3%) and two (5.1%) respectively(Table 3).
Table 4: Perceived effectiveness of pictorial warnings among male college students aged (18-21 yrs) |
Awareness about pictorial warnings (N=450) |
n (%) |
Awareness about presence of pictorial warning on tobacco packages |
279 (62) |
Noticed health warnings on tobacco packages in past 30 days |
184 (41.1) |
Perceived effectiveness of pictorial warnings (N=184) |
n(%) |
The effectiveness of health warnings in conveying health risks |
132 (71.7) |
The effectiveness of health warnings in encouraging its users to quit |
50(27.2) |
As per Table 4, Out of 450 total participants, 279 (62%) were aware of the presence of health warnings on tobacco packages and 184 (41.1%) of them had noticed the health warnings on tobacco packages in the past 30 days. Out of 184 students, 132 (71.7%) reported that the pictorial warnings on tobacco packages effectively convey the health risks and 50 (27.2%) students reported to encourage the users to quit.
Discussion:
The prevalence of ever and current tobacco usage among male college students were 12.7% and 8.7% respectively. The common tobacco products used by the students were cigarettes (96.5%) and cigar (12.1%). Three-fourth of the current tobacco users had an intention to quit the habit and the most common reasons for intention to quit were fear of adverse effect on health and peer pressure by girlfriends. Only 10% of the users acknowledged pictorial warnings as a factor influencing them to quit. The common barriers to intention to quit were addictive smell and attractive sight of tobacco product and peer pressure. Only one fourth of the students thought that the health warnings would encourage its users to quit. Our qualitative findings states, though the new pictorial warnings are relatively effective as compared old warnings, it might be useful in inducing a sense of fear among initiators. However, it might fail to bring about a behavioral change among chronic users.
In the present study, ever and current tobacco usage among male college students was reported to be 12.7% and 8.7% respectively which is lower than the prevalence of current tobacco usage among adult males > 15 years (23.5%) reported in GATS (2009-10) in Puducherry.9 The difference in prevalence can be attributed to difference in literacy level and age group of participants in these two surveys. The lower prevalence in the present study might also be due to social desirability bias. In a study conducted by Bhojani UM10 among pre-university male students in a college in Bangalore showed the prevalence of 'ever use' of tobacco as 15.7% of which 5.3% were current users of tobacco which is little closer to our findings.
In spite of experiencing peer pressure and other barriers related to the attraction and enjoyment, a relatively higher proportion (75%) of students in our study had an intention to quit the habit. Our result is consistent with the previously reported finding from the same geographical area where 65.8% adults (15-24 years) had an intention to quit.11 Noteworthy; in West Bengal 63.3% adults(> 18 years) had an intention to quit.12 This indicates alarge unmet need in tobacco cessation services. Based on the recommendation of WHO Framework Convention on Tobacco Control (FCTC), Government of India along with WHO provides technical support to health care institutes to set up tobacco cessation facilities in their respective premises utilizing the existing infrastructure.13 Hence this opportunity can be utilized by the health care institutions to provide accessible tobacco cessation services. In addition to this, providing cessation support in non-health care settings by suitably trained non-health care providers can be considered as an alternate option to ensure wide access to tobacco users who wish to quit the habit. Publicizing the existing tobacco cessation facilities is also an important step in tobacco control measures.
We found that the most common reason for intention to quit was fear regarding the ill health effects of tobacco. Pictorial warnings are intended to bring about behavioral change like quitting through its fear appeals and by informing its users and non users regarding the health hazards of tobacco. 2 Unfortunately, only 10% of current tobacco users mentioned it as a reason for their intention to quit. This scenario emphasizes on the importance of improving the effectiveness of the present pictorial warnings by frequently changing the pictures to sustain the fear and also to print the warnings in each cigarette, to enhance its chances of being noticed. Addictive smell and attractive site of tobacco products and Peer pressure were stated as common barriers for intention to quit tobacco. Hence providing a tobacco free environment to prevent cue reactivity and involving parents and friends in tobacco cessation services are essential to break these barriers.
The strength of the present study is that it is a mixed-method study, which provides a more complete and comprehensive understanding of the research problem in the given context. Since self-administered questionnaire is used, it might have given a confidence to express their views without any fear of consequences. However, as the study was done in a single engineering college in Puducherry, its findings cannot be generalized to the wider population in the given geographical area.
Conclusion:
Since many students had an intention to quit tobacco, information regarding appropriate organizations providing cessation counseling or support can be provided to the students to bail them out of this habit. The cessation services should be appropriately tailored to the needs of the individual student. To bring about a behavioral change like quitting, the pictorial health warnings should be further improved and also should be supplemented with other tobacco control strategies.
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- Guidelines for the implementation of article 14 of the WHO Framework Convention on Tobacco Control (demand reduction measures concerning tobacco dependence and cessation). [Online]. [cited 2017 July 6]; Available from: http://www.who.int/fctc/Guidelines.pdf.
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