|Year : 2022 | Volume
| Issue : 2 | Page : 163-170
Effect of anti-tobacco health messages post-implemetation of COTPA 2003 in India
Laxmi Kumari1, Meenakshi Sood2, Sandhya Gupta3
1 PhD Scholar, Chitkara School of Health Sciences, Chitkara University, Patiala, Punjab, India
2 Chitkara College of Pharmacy, Chitkara University, Patiala, Punjab, India
3 Health Consultant, New Delhi, India
|Date of Submission||06-Sep-2022|
|Date of Decision||11-Oct-2022|
|Date of Acceptance||07-Nov-2022|
|Date of Web Publication||27-Dec-2022|
Ms. Laxmi Kumari
Chitkara University, Patiala, Punjab
Source of Support: None, Conflict of Interest: None
Tobacco-related deaths are rising, although it is a preventable man-made epidemic. Globally, tobacco accounts for the death of 6 million people each year. The tobacco industry very intelligently uses the mass media platform for pro-tobacco propaganda messages. India made a significant attempt to fight tobacco by endorsing the WHO Framework Convention on Tobacco Control in February 2004. The WHO has introduced the MPOWER package of six proven policies to reverse the tobacco epidemic and prevent millions of tobacco-related deaths. Surprisingly, with all the awareness about these harms related to tobacco consumption and anti-tobacco campaigns at national and international levels, tobacco users do not feel motivated to quit. Anti-tobacco health messages (ATHMs) are crucial in affecting tobacco-related health behavior. This review summarizes the effect of ATHMs on the Indian population and the influences of different types of ATHMs on motivation to quit tobacco and tobacco cessation as a whole. Depending on the group investigated, ATHM effects on smoking behavior vary. ATHMs can influence people's attitudes and beliefs, improve intentions to stop and quit attempts, and decrease tobacco use dominance. They can also play a crucial role in educating the public about the dangers of tobacco use. The government must concentrate on rational ATHMs with broad appeal, ongoing exposure, and a preference for negative health effects with visual and live testimonial ads.
Keywords: Anti-tobacco campaigns, anti-tobacco health messages, Cigarettes and Other Tobacco Products Act, intention to quit, tobacco cessation
|How to cite this article:|
Kumari L, Sood M, Gupta S. Effect of anti-tobacco health messages post-implemetation of COTPA 2003 in India. Indian J Psy Nsg 2022;19:163-70
|How to cite this URL:|
Kumari L, Sood M, Gupta S. Effect of anti-tobacco health messages post-implemetation of COTPA 2003 in India. Indian J Psy Nsg [serial online] 2022 [cited 2023 Jun 1];19:163-70. Available from: https://www.ijpn.in/text.asp?2022/19/2/163/365471
| Introduction|| |
Tobacco-related deaths are rising, although it is a preventable man-made epidemic. Globally, tobacco accounts for the death of 6 million people each year. Tobacco kills about 2500 Indians every day and almost 10 lakh per annum. Tobacco intake increases the burden of cancer in a threatening manner. The tobacco industry very intelligently uses the mass media platform for pro-tobacco propaganda messages. It was found that in 2008, tobacco companies spent $9.94 billion on the marketing of cigarettes and $547 million on the marketing of smokeless tobacco. Spending on cigarette marketing is 48% higher than in 1998. The evidence is sufficient to conclude that there is a causal relationship between the advertising and promotional efforts of tobacco companies and the initiation and progression of tobacco use among young people. On the other hand, tobacco companies' activities and programs for the prevention of youth smoking have not demonstrated an impact on the initiation or prevalence of smoking among young people.
India made a significant attempt to fight tobacco by endorsing the WHO Framework Convention on Tobacco Control (FCTC) in February 2004. To achieve the set goals by FCTC, on May 2004, India launched the Cigarettes and Other Tobacco Products Act (COTPA) 2003. The main provisions under COTPA were, ban on smoking in public places, prohibition of pro-tobacco advertisements, promotion and sponsorship of tobacco products, ban on sale of tobacco products to minors and restriction in sale of tobacco products within the area of 100 yards of any educational institute., To strengthen the COTPA and to reverse the tobacco epidemic, WHO also introduced MPOWER, a package of six proven policies. MPOWER stands for M: monitor tobacco use and prevention policies; P: protect people from tobacco smoke; O: offer help to quit tobacco use; W: warn about the dangers of tobacco; E: enforce bans on tobacco advertising, promotion, and sponsorship; and R: raise taxes on tobacco. The recent WHO report on the global tobacco epidemic in 2021 suggests a positive shift in many new countries toward the MPOWER measure.
Surprisingly, with all the awareness about these harms related to tobacco consumption and anti-tobacco campaigns at national and international levels, tobacco users do not feel motivated to quit. Cigarette quit rates are very low, and relapse rates are high even after 1 year of abstinence.
Anti-tobacco health messages (ATHMs) are crucial in affecting tobacco-related health behavior. Studies done in the past indicate the importance of ATHMs and their significant role in tobacco initiation, cessation, and changing attitude,,,, The effect of a particular type of ATHMs is unique for every individual,, The general public not only includes nonsmokers but smokers. The needs of both groups are different; hence, ATHMs must contain proper content and information to help both groups. This review summarises the effect of ATHMs (knowledge, attitude, smoking initiation and quit intention) on the Indian population and the influence of the different types of ATHMs on motivation to quit tobacco and on smoking behaviour (tobacco initiation and tobacco cessation).
| Gaps|| |
Various studies done in India were quantitative in nature and used the data from the Global Youth Tobacco Survey (GYTS). The results indicate that youths exposed to ATHMs are less likely to be current smokers. The data do not allow us to determine which type of advertisements had the highest impact on specific populations. There is a need for a mixed-method approach to identify the needs of smokers and nonsmokers related to ATHMs.
| Methodology|| |
In order to provide an update on studies published after 2003, following the passage of the COTPA 2003 in India, the author searched PubMed, Google Scholar, and Embase databases from 2003 to February 2019. Among 45 articles after excluding studies done among children, adolescents, and professionals, 30 studies were included in this review.
| Results|| |
Review findings are classified into (a) studies focusing effect of ATHMs on the population and (b) studies focusing on message types and their effect on the study population.
[Table 1] depicts Indian studies on the effect of ATHMs on the population. A cross-sectional study by Shah et al. analyzed the GYTS data of 60001 students aged 13–15 years in 24 states of India and examined the relationship between tobacco advertisements, counter advertisements, and smoking status. Students watching anti-smoking media messages were less likely to be current smokers, which was true for both boys (odds ratio [OR] = 0.89, 95% confidence interval [CI] = 0.81–0.98) and girls (OR = 0.79, 95% CI = 0.69–0.90). This relationship was stronger among past smokers for boys (OR = 0.56, 95% CI = 0.52–0.60) and girls (OR = 0.49, 95% CI = 0.45–0.53). On the other hand, students who were exposed to cigarette brand names during sports events and other televised programs, in newspapers or magazines, and were offered free cigarettes or cigarette-branded merchandise promotions were significantly more likely to be smokers, with effects ranging from moderate (OR = 1.19) to very strong (OR = 3.83). Counter-advertising has a protective effect on youth and may function as a cessation aid. Arora et al. mentioned that nontobacco user students who were exposed to tobacco advertisements were 1.5 times (95% CI = 1.12–1.94; P = 0.05) more likely to progress toward tobacco use after 2 years, and the risk of progression to tobacco use was more than two times higher (95% CI = 1.28–4.32; P = 0.05) among boys who were highly receptive versus nonreceptive boys. Kaur et al. mentioned that anti-tobacco advertisements inspired 37% of subjects not to use tobacco. The celebrity in the advertisement influenced people's attention and improved their knowledge and attitudes toward anti-tobacco legal and public health measures, followed by exposure to the anti-tobacco messages and advertisements among cinema attendees. Surani et al. explained that anti-tobacco messages had a positive influence on users' intention to quit. More numbers of users exposed to anti-tobacco messages in newspapers/magazines (adjusted OR = 1.76, 95% CI = 1.02–3.03), restaurants (adjusted OR = 2.47, 95% CI = 1.37–4.46), radio (adjusted OR = 4.84, 95% CI = 3.01–7.78), cinema halls (adjusted OR = 9.22, 95% CI = 5.31–15.75), and public transportation (adjusted OR = 10.58, 95% =5.90–18.98) intended to quit compared to unexposed users. GYTS survey analysis of 534 secondary school students concluded that media exposure might be related to the intention to quit but not to quitting behavior (Surani et al.). An evaluation of a national television and radio mass media campaign targeted at smokeless tobacco users among 2898 smokeless tobacco users found that mass media campaign awareness was associated with better knowledge, more negative attitudes toward smokeless tobacco, and greater cessation-oriented intentions and behaviors among smokeless tobacco users Murukutla et al., Chauhan et al. assessed the impact of a state-sponsored anti-smoking mass media campaign on the smoking behavior of 1050 youth and revealed that the campaign brought long-term benefits in lessening smoking by inducing more initiating intentions among youth to quit smoking. A cross-sectional survey conducted among 600 preuniversity students on the impact of anti-tobacco advertisements in the movie theater concluded that almost 78.35% of males and 90.6% of females had a positive change in attitude toward tobacco use due to the influence of anti-tobacco advertisements. A majority of the preuniversity students opined that television and movie theaters were considered the most effective means for anti-tobacco advertisements Gadiyar et al.
|Table 1: Studies focusing effect of anti.tobacco health messages on the population|
Click here to view
The impact of various anti-tobacco messages on the Indian population is illustrated in [Table 2]. Samu et al. studied the direct and indirect sources of anti-smoking messages (mass media or friends) and influence of individual characteristics like gender on the attitude formation. It was reported that female tobacco users were more likely to develop negative attitude towards tobacco from fear generating anti-tobacco advertisements. The effectiveness of the country's current cigarette visual warnings was examined by Oswal et al. It was discovered that because they are not fully comprehended, the legally required visual warnings do not achieve the desired result. In a nonscientific way, the scorpion is connected to the product. Nobody really understands lung X-rays and tobacco companies don't utilise images of unhealthy lungs. The effectiveness of pictorial health warnings placed over tobacco products were assessed by Arora et al it was reported that negative health warnings were not able to generate quit intetions among tobacco users aged between 10 to 50 years. Pischke et al. conducted a study to determine the impact of several messaging formats for informing school instructors who use tobacco about their use. It was discovered that communicating risk information via unpleasant feelings was very appealing to instructors and was thought to be the most efficient way to raise risk perception. For spreading the word about the advantages of quitting, anecdotes of teachers' own experiences were found to be beneficial. In order to understand the effects of the existing visual warnings on tobacco consumers, Karinagannanavar et al. researched the elements impacting tobacco consumers' awareness of the pictorial warnings used on cigarette products. Only 25.5% of the individuals had correctly evaluated the results, and only 63 (14.5%) had considered reducing or quitting their cigarette use. Younger age groups, higher educational levels, residents of metropolitan areas, members of upper socioeconomic classes, and tobacco use for shorter periods of time (5 years) were found to be significantly associated with knowledge of visual warnings on tobacco products. The effect of photos on cutting down or stopping smoking, however, was quite minimal. A national television and radio mass media campaign in India that warned about the risks of using smokeless tobacco was broadcast for 6 weeks in November and December 2009, and its effect was evaluated by Murukutla et al. Results revealed that users of smokeless tobacco were impacted by the program as intended: specifically, through television delivery, 63% of smokeless-only users and 72% of dual users (i.e. those who consumed both smoking and smokeless forms) remembered the campaign advertising. Over 70% of individuals who were aware of the campaign said that it provoked thought in them, was relevant to their life, and gave them new information. Mutti et al. assessed the perceived efficacy of text and visual health warnings on the packaging of smokeless tobacco, revealing that all of the visual warning styles were deemed to be more effective than text-only warnings. A multicentric study conducted by Hammond et al. revealed similar results, showing that visual warnings were judged to be more effective than text-only warnings. Health impacts that are “graphic” were judged to be more persuasive than warnings that show “lived experience” or “symbolic” imagery. When compared to the same images with didactic text, pictorial warnings with personal testimonies were found to be more effective.
|Table 2: Studies focusing on message types and their effect on the study population|
Click here to view
| Discussion|| |
Studies primarily focus on the impact of televised tobacco health messages on knowledge and attitude toward tobacco use.,, ATHMs, however, are also available in a variety of other formats, including audio (on radio), visual (on posters and signboards), and audio-visual (cinemas and T.V.). The effectiveness of the Government of India's anti-tobacco advertising on smokers' and nonsmokers' smoking behavior was examined in a study conducted in 2020. According to the study, those who do not use tobacco respond more favourably to anti-tobacco ads than those who use tobacco. A qualitative investigation is required to ascertain the reasons why the anti-tobacco advertising produced by the Indian government had no impact on this particular population (tobacco users). The body of knowledge regarding how media messages to quit smoking affect smokers, however, is seriously lacking. The available study primarily examined the consequences of quitting efforts on nonsmokers as opposed to cessation behavior. Adolescents are prone to starting to smoke, and they feel that tobacco-related marketing is not appropriate for their age group. The content of anti-tobacco health messaging needs to be taken into account immediately. Age-appropriate health messages are necessary. Overall, studies show conflicting evidence that ATHMs can encourage smoking cessation or reduce frequency. Success may be influenced by ATHMs and their various varieties (pictorial, text, pictorial + text, testimonies, fear, and guilt signals). Movies and movie theaters, as well as television and radio, are the main media outlets that effectively manipulate the general audience. The messages emphasizing harmful health impacts were the most successful at encouraging cessation. However, there is a serious gap in the literature on the effects of cessation media messages on smokers. Available research mostly focused on quit attempts and effects on nonsmokers rather than cessation behavior. Adolescents are vulnerable to tobacco initiation and consider advertisements inappropriate for their age group. This requires immediate consideration of the content of ATHMs. Health messages must be age appropriate. Overall, studies have mixed support that ATHMs can endorse quitting or diminish smoking frequency. ATHMs and their different types (pictorial, text, pictorial + text, testimonials, fear, and guilt messages) may influence success. Prime channel that efficiently manipulates the general public is movies and cinema theaters, television, and radio. Negative health effect (NHE) messages were most effective at generating quitting intention. Most of the studies are cross-sectional; hence, casual relationships cannot be commented on here. The advertisements' intensity, frequency of delivery, recall and effect on knowledge and attitude, and quit intentions are not assessed in many studies. Since most studies are cross-sectional, it cannot remark on casual relationships in this context. Numerous studies do not evaluate the intensity, frequency, recall, impact on knowledge, attitude, and quit intentions of the commercials.
| Conclusions|| |
Depending on the group investigated, ATHM effects on smoking behavior vary. ATHMs can influence people's attitudes and beliefs, improve intentions to stop and quit attempts, and decrease tobacco use dominance. They can also play a crucial role in educating the public about the dangers of tobacco use. The government must concentrate on rational ATHMs with broad appeal, ongoing exposure, and a preference for NHEs with visual and live testimonial ads.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mishra GA, Pimple SA, Shastri SS. An overview of the tobacco problem in India. Indian J Med Paediatr Oncol 2012;33:139-45.
] [Full text]
Yadav R, Garg R, Manoharan N, Swasticharan L, Julka P, Rath G. Evaluation of Delhi population based cancer registry and trends of Tobacco related cancers. Asian Pac J Cancer Prev 2016;17:2841-6.
NC for CDP and HP (US) O on S and Health. The Tobacco industry's influences on the use of Tobacco among youth. In: Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. US: Centers for Disease Control and Prevention; 2012. Available from: https://www.ncbi.nlm.nih.gov/books/NBK99238/.
[Last accessed on 2022 May 13].
World Health Organization. WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER Package. Geneva: World Health Organization; 2008. p. 342.
O'Leary R, Polosa R. Tobacco harm reduction in the 21st
century. Drugs Alcohol Today 2020;20:219-34.
White V, Tan N, Wakefield M, Hill D. Do adult focused anti-smoking campaigns have an impact on adolescents? The case of the Australian National Tobacco Campaign. Tob Control 2003;12 Suppl 2:i23-9.
Shah PB, Pednekar MS, Gupta PC, Sinha DN. The relationship between tobacco advertisements and smoking status of youth in India. Asian Pac J Cancer Prev 2008;9:637-42.
Emery S, Kim Y, Choi YK, Szczypka G, Wakefield M, Chaloupka FJ. The effects of smoking-related television advertising on smoking and intentions to quit among adults in the United States: 1999-2007. Am J Public Health 2012;102:751-7.
Kaur J, Kishore J, Kumar M. Effect of anti-tobacco audiovisual messages on knowledge and attitude towards tobacco use in North India. Indian J Community Med 2012;37:227-31.
] [Full text]
Davis KC, Nonnemaker JM, Farrelly MC, Niederdeppe J. Exploring differences in smokers' perceptions of the effectiveness of cessation media messages. Tob Control 2011;20:26-33.
Durkin SJ, Biener L, Wakefield MA. Effects of different types of antismoking ads on reducing disparities in smoking cessation among socioeconomic subgroups. Am J Public Health 2009;99:2217-23.
Nonnemaker JM, Dench D, Homsi G, MacMonegle A, Duke J. The effect of exposure to media campaign messages on adult cessation. Addict Behav 2015;49:13-9.
Arora M, Gupta VK, Nazar GP, Stigler MH, Perry CL, Reddy KS. Impact of tobacco advertisements on tobacco use among urban adolescents in India: results from a longitudinal study. Tob Control 2012;21:318-24.
Surani NS, Gupta PC, Fong TG, Pednekar MS, Quah AC, Bansal-Travers M. Intention to quit among Indian tobacco users: findings from International Tobacco Control Policy evaluation India pilot survey. Indian J Cancer 2012;49:431-7.
] [Full text]
Surani NS, Shroff HP. Mass media exposure to tobacco messages among secondary school children in Mumbai. Indian J Public Health 2012;56:159-62.
] [Full text]
Murukutla N, Turk T, Prasad CVS, Saradhi R, Kaur J, Gupta S, et al
. Results of a national mass media campaign in India to warn against the dangers of smokeless tobacco consumption. Tob Control 2012;21:12-7.
Chauhan A, Sharma R. Impact of Anti Smoking Campaigns on Youth. Procedia Comput Sci 2017;122:941-8.
Gadiyar A, Ankola A, Rajpurohit L. Awareness of anti-tobacco advertisements and its influence on attitude toward tobacco use among 16 to 18-year-old students in Belgaum city: A Cross-sectional study. J Educ Health Promot 2018;7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6052775/.
[Last accessed on 2022 Oct 10].
Samu S, Bhatnagar N. The efficacy of anti-smoking advertisements: the role of source, message, and individual characteristics. Int J Nonprofit Volunt Sect Mark 2008;13:237-50.
Oswal KC, Raute LJ, Pednekar MS, Gupta PC. Are current tobacco pictorial warnings in India effective? Asian Pac J Cancer Prev APJCP 2011;12:121-4.
Pischke CR, Galarce EM, Nagler E, Aghi M, Sorensen G, Gupta PC, et al.
Message formats and their influence on perceived risks of tobacco use: a pilot formative research project in India. Health Educ Res 2013;28:326-38.
Karinagannanavar A, Raghavendra B, Hemagiri K, Goud TG. Awareness about pictorial warnings on tobacco products and its impact on tobacco consumers in Bellary, India. Asian Pac J Cancer Prev APJCP 2011;12:2485-9.
Murukutla N, Bayly M, Mullin S, Cotter T, Wakefield M, for the international Anti-SHS Advertisement Rating Study Team. Male smoker and non-smoker responses to television advertisements on the harms of secondhand smoke in China, India and Russia. Health Educ Res 2015;30:24-34.
Mutti S, Reid JL, Gupta PC, Pednekar MS, Dhumal G, Nargis N, et al.
Perceived effectiveness of text and pictorial health warnings for smokeless tobacco packages in Navi Mumbai, India and Dhaka, Bangladesh: findings from an experimental study. Tob Control 2016;25:437-43.
Bhat S, Bhadranna A, Prasad S, Rao S, Pai A. Are the media enabled anti-tobacco campaigns effective? A pilot study. Cochrane Library. J Clin Diagn Res JCDR 2018;12:42-7.
Hammond D, Reid JL, Driezen P, Thrasher JF, Gupta PC, Nargis N, et al
. Are the Same Health Warnings Effective Across Different Countries? An Experimental Study in Seven Countries. Nicotine Tob Res Off J Soc Res Nicotine Tob 2019;21:887-95.
[Table 1], [Table 2]