Evaluation of the effectiveness of the Indian government's policies to strengthen health warning labels on smokeless tobacco products: findings from the 2010-2019 Tobacco Control Project India Surveys.

BACKGROUND: Smokeless tobacco (SLT) packaging in India had a single symbolic (a scorpion) health warning label (HWL) in 2009 covering 40% of the front surface. In 2011, it was replaced with four pictorial images. In 2016, HWLs were enlarged to 85% on the front and back. This study aimed to assess the effectiveness of the old (symbolic and smaller images) and larger HWLs. METHODS: Data were from the Tobacco Control Project India Survey and included respondents who used SLT in Wave 1 (2010-2011, n=5911), Wave 2 (2012-2013, n=5613) and Wave 3 (2018-2019, n=5636). Using a repeated-measures design, weighted logistic regression models assessed whether there were changes in seven HWL effectiveness measures within the domains of awareness, salience, cognitive and behavioural responses. A cohort design was employed to test whether HWL effectiveness in Waves 1 and 2 was associated with quitting SLT in Waves 2 and 3, respectively. RESULTS: The 2011 HWL revision did not result in any significant changes in HWL effectiveness. There was no significant change in HWL awareness and salience after larger HWLs were introduced in 2016, but respondents were more likely to consider SLT health risks (Wave 2=17.9%, Wave 3=33.6%, p<0.001) and quitting SLT (Wave 2=18.9%, Wave 3=36.5, p<0.001). There was no change in HWLs stopping SLT use (Wave 2=36.6%, Wave 3=35.2%, p=0.829); however, respondents were more likely to avoid looking at HWLs (Wave 2=10.1%, Wave 3=40.2%, p<0.001). Effectiveness of older, symbolic and smaller pictorial HWLs was not associated with quitting SLT. DISCUSSION: There was no significant change in HWL effectiveness following the revision from a symbolic to a pictorial image, but enlarging pictorial images resulted in some improved cognitive and behavioural effects. Results suggested wear-out of HWL salience and that the effectiveness of warnings depends on both their design and time since implementation.

Awareness and Use of e-cigarettes among Adolescents and Their Adult Caregivers in Two Cities of India.

INTRODUCTION/OBJECTIVE: E-cigarette use poses an additional risk for individuals who are not cigarette smokers, especially adolescents. The marketing tactics of the industry have substantially increased the prevalence of e-cigarettes, use among adolescents. India banned e-cigarette in September 2019 that has been criticized by interested groups.  We investigated that among adults and adolescents, who are more aware and using e-cigarette more? METHODS: The data were taken from a population-based representative household survey conducted in Mumbai and Kolkata in the year 2019-2020.  A household was enrolled if it had a 12-14 year old adolescent living in it and both adolescent and adult caregivers agreed to participate in the survey. The data from 944 adolescents out of 15,436 enumerated in Mumbai and 1038 out of 24,284 enumerated in Kolkata and their caregivers were analyzed for awareness and ever use of e-cigarettes.  Result: The awareness of e-cigarettes among 12-14 year olds in Mumbai was 15.5%, almost identical among boys and girls whereas is in Kolkata it was 11.2%. In contrast, among the adolescents' adult caregivers in Mumbai, the awareness was low, 3.9% and in Kolkata, 4.6%. Overall awareness was significantly higher among adolescents than among caregivers, especially among adolescent girls than among female caregivers in both cities. CONCLUSION: The awareness and the use of e-cigarette were very little and the messages from the e-cigarette industry seem to be targeted more towards adolescents than adults.  The ban on an e-cigarette in India has helped in prevented the marketing of ENDS to adolescents.

Family functioning within the context of families with adolescent children in urban India.

Research on family functioning within given cultural contexts is needed. This study aims to describe salient dimensions of family functioning in two urban contexts in India and to examine differences in family functioning by sociodemographic groups. We measured differences in family functioning using cross-sectional survey questionnaire data collected from 13 to 15-year-old adolescents and one of their parents/primary caregivers in Mumbai (n = 843) and Kolkata (n = 913) during 2019-2020. We drew a multi-stage sample representative of neighborhoods and households in both cities. We assessed a multi-dimensional family functioning latent factor that included parent-reported measures (parent-adolescent communication, family cohesion, and parent monitoring of peers) and adolescent-reported measures (parent support, family cohesion, and parent supervision). Our results support an overall measure of family functioning manifested by multiple dimensions for parent- and adolescent-reported data. Families with male adolescents had worse adolescent-reported family functioning in Mumbai and parent-reported family functioning in Kolkata. Higher socioeconomic status was associated with better parent-reported family functioning in both cities and better adolescent-reported family functioning in Kolkata. Muslim religious identification in Kolkata and the Hindi native language in both cities were associated with better adolescent-reported family functioning. Our findings indicate heterogeneity in family functioning across demographic and social-cultural groups within the two urban contexts of India. This study may inform the development of culturally congruent prevention interventions for families with adolescents in India.

South Asia's evolving tobacco hydra: moving from quandary to hope.

The South Asian region occupies a unique place in global tobacco control because of a broad spectrum of widely used tobacco products and the consequent mix of local and transnational tobacco industries. Cigarette use is especially high among males in many countries, while bidis are widely used in India, Bangladesh and Sri Lanka, and are very inexpensive. Smokeless tobacco use is a global problem, but the bulk of use is in South Asia and there is emerging promotion of newly developed tobacco and nicotine products across the region. With the transnational cigarette industry contributing a significant amount in taxes, the bidi industry employing millions of workers and many farmers engaged in tobacco farming, the industry is powerful and exploits this when countering proposed advancements in tobacco control policy. Despite industry interference and major challenges, this region has achieved remarkable successes in tobacco control, including large pictorial warnings that cover up to 80%-90% of the pack in some countries, stringent rules on depiction of tobacco in movies, bans on advertising and promotion, and smoke-free public places. Key challenges include increasing the tax component of retail prices and reducing tax concessions, regulating newly developed products and countering the aggressive tactics of the tobacco industry. Strategies to advance tobacco control in the region may also include standardised packaging of tobacco products, sustained mass media campaigns to warn the population of the harms of tobacco use and promote use of available cost-covered cessation services, and supply-side measures such as vendor licensing.

Neighbourhood tobacco retail access and tobacco use susceptibility in young adolescents in urban India.

BACKGROUND: Neighbourhood tobacco retail access may influence adolescent tobacco use. In India, we examined the association between neighbourhood tobacco retail access and cognitive risks for tobacco use during early adolescence. METHODS: In 2019-2020, a population-based sample (n=1759) of adolescents aged 13-15 years was surveyed from 52 neighbourhoods in Mumbai and Kolkata. Neighbourhood tobacco retail access was measured as the frequency of visits to tobacco retailers, mapped tobacco retailer density and perceived tobacco retailer density. We estimated associations between neighbourhood tobacco retail access and cognitive risks for tobacco use (perceived ease of access to tobacco, perceived peer tobacco use and intention to use tobacco). RESULTS: There was high neighbourhood tobacco retail access. Tobacco retailer density was higher in lower income neighbourhoods (p<0.001). Adolescent frequency of tobacco retailer visits was positively associated with cognitive tobacco use risks. Mapped tobacco retailer density was associated with perceived ease of access in Kolkata but not in Mumbai, and it was not associated with perceived peer tobacco use nor intention. Perceived tobacco retailer density was associated with perceived ease of access and perceived peer use, but not with intention. In Kolkata, higher perceived retailer density and frequency of tobacco retailer visits were negatively associated with perceived ease of access. CONCLUSIONS: Efforts to reduce neighbourhood tobacco retail access in India may reduce cognitive tobacco use risk factors in young adolescents. The frequency of tobacco retailer visits and perceived tobacco retailer density increased cognitive risks, though there were some exceptions in Kolkata that further research may explain.

Beyond Gutka: Evidence of Illegal Smokeless Tobacco in Rural and Semi-urban Areas in India.

INTRODUCTION: Gutka, a popular smokeless tobacco (SLT) product combining chewing tobacco, areca nut, and spices, was banned by states in India beginning in 2012. Gutka can be recreated by the user mixing twin packets of tobacco and spice mixtures. We examine the availability of premixed gutka, the sale of twin packets (chewing tobacco and spice mixture sold together but in separate packets) and whether SLT was sold without legally mandated health warning labels (HWLs), without the printed maximum retail price (MRP), and above the MRP. AIMS AND METHODS: In October/November of 2017, unique SLT packets were purchased using a systematic protocol in 25 localities with populations under 50 000 across five Indian states. Purchase information (location, twin packets, price paid) and packaging information (SLT type, printed MRP, type of HWL) were used to assess legality. RESULTS: Of the 240 purchases of unique SLT packets, three were premade gutka. Twin packets were half of the sample, sold in every state, and illegally sold in Maharashtra where they were banned. Over half (62%) of single packets and 27% of twin packets did not feature a legal HWL. While only 5% of packets did not have a printed MRP, 29% of single packets, and 38% of twin packets were sold illegally for more than the MRP. CONCLUSIONS: SLT without the proper HWL or sold above the MRP were common. Twin packets were widely available. India should consider a country-wide restriction to ban single serving tobacco packets that would decrease affordability. IMPLICATIONS: This study is the earliest and that first outside of Mumbai that we are aware of to present evidence of tobacco products being sold above the MRP in India. While finding little evidence of premade gutka being sold, we found twin packets (chewing tobacco and spice mixture packets sold together) are widely available even in Maharashtra, which has a policy in place to ban twin packets. This study also finds evidence of SLT products sold without the correct HWL and without a MRP listed which shows that implementation and enforcement of regulations are as important as passing regulations.

The Market for Bidis, Smokeless Tobacco, and Cigarettes in India: Evidence From Semi-Urban and Rural Areas in Five States.

Objectives: Compare the brand availability, pricing and presence of illicit products in semi-urban and rural areas in India across product types and states. Methods: In late 2017, 382 unique tobacco products were purchased from localities with populations under 50,000 in the states of Assam, Karnataka, Maharashtra, Rajasthan, and Uttar Pradesh. Brand, printed maximum retail price, price paid, tax, and health warning labels (HWLs) were used to compare the market for bidis, smokeless tobacco (SLT), and cigarettes. Results: Brand availability and pricing of SLT products was similar to cigarettes. Brand availability and pricing of bidis was consistent with having many small producers. Bidis and single serving SLT with spice mixtures were more affordable than cigarettes and SLT sold alone. 2% of SLT and 10% of cigarettes did not feature an India HWL. Conclusion: The elimination of single serving SLT packets and the removal of tax exemptions for small producers, often exploited by bidi producers, could reduce their respective affordability. State differences in illegal and illicit products could indicate a greater need for enforcement in some states.

Longitudinal study of adolescent tobacco use and tobacco control policies in India.

BACKGROUND: This project will use a multilevel longitudinal cohort study design to assess whether changes in Community Tobacco Environmental (CTE) factors, measured as community compliance with tobacco control policies and community density of tobacco vendors and tobacco advertisements, are associated with adolescent tobacco use in urban India. India's tobacco control policies regulate secondhand smoke exposure, access to tobacco products and exposure to tobacco marketing. Research data about the association between community level compliance with tobacco control policies and youth tobacco use are largely unavailable, and are needed to inform policy enforcement, implementation and development. METHODS: The geographic scope will include Mumbai and Kolkata, India. The study protocol calls for an annual comprehensive longitudinal population-based tobacco use risk and protective factors survey in a cohort of 1820 adolescents ages 12-14 years (and their parent) from baseline (Wave 1) to 36-month follow-up (Wave 4). Geographic Information Systems data collection will be used to map tobacco vendors, tobacco advertisements, availability of e-cigarettes, COTPA defined public places, and compliance with tobacco sale, point-of-sale and smoke-free laws. Finally, we will estimate the longitudinal associations between CTE factors and adolescent tobacco use, and assess whether the associations are moderated by family level factors, and mediated by individual level factors. DISCUSSION: India experiences a high burden of disease and mortality from tobacco use. To address this burden, significant long-term prevention and control activities need to include the joint impact of policy, community and family factors on adolescent tobacco use onset. The findings from this study can be used to guide the development and implementation of future tobacco control policy designed to minimize adolescent tobacco use.