Perceptions of text and pictorial health warning labels for smokeless tobacco packages in Navi Mumbai, India, and Dhaka, Bangladesh: Findings from an experimental study
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Background: Globally, smokeless tobacco use is disproportionately concentrated in low-and-middle income countries like India and Bangladesh. Despite the growing evidence base linking smokeless tobacco use with adverse health outcomes, knowledge of the health effects of smokeless tobacco remains low. Health warnings are a cost-effective population-level tobacco control strategy, and represent an excellent medium for communicating health information given their reach and frequency of exposure. Pictorial warnings have been shown to promote smoking cessation, and increase health knowledge and perceptions of risk, compared to text-only warnings. Much of this research, however, is largely based in high-income countries and is specific to cigarette health warnings. The current study was among the first to experimentally evaluate text and pictorial health warning labels in India and Bangladesh. Objectives: This study examined: 1) Patterns of use and perceptions of harm for different smokeless tobacco products; 2) Awareness of current health warning labeling on smokeless tobacco, as well as the extent to which respondents supported stronger health warning labeling; 3) Perceived effectiveness of text and pictorial smokeless tobacco health warnings, and a potential mediator (negative affect) and moderator (message credibility) of this association; and lastly 4) The impact of viewing health warnings on attitudes and beliefs about smokeless tobacco. Methods: An experimental study was conducted in India (n=1,002) and Bangladesh (n=1,081), with adult (19+ years) smokeless tobacco users, and youth (16 to 18 years) users and non-users. Respondents were randomly assigned to view smokeless tobacco health warnings according to one of four experimental conditions: (1) Text-only, (2) Pictorial warning with symbolic imagery, (3) Pictorial warning with a graphic health effect, or (4) Pictorial warning with a personalized graphic health effect and a personal testimonial. Each respondent viewed five warnings within that condition for the following health effects: (1) Oral cancer, (2) Mouth disease, (3) Heart disease, (4) Addiction, and (5) Death. Warnings within each set were shown to respondents and rated one at a time (in random order) on the following outcomes: perceived effectiveness, attention, believability (credibility), importance, surprise, fright, disgust, and unpleasantness. Results: A majority (88.9%) of smokeless tobacco users reported daily use. Approximately one-fifth (20.4%) of the sample were mixed-users (used both smoked and smokeless tobacco), of which about half (54.4%) reported that they primarily used smokeless over smoked forms like cigarettes or bidis. Gutkha was the most commonly used smokeless product in India, and pan masala in Bangladesh. The most commonly reported reason for using pan masala was the belief that it was “less harmful” than other types. The findings indicate strong support for health warnings in general, and for health warnings that included pictures in India and Bangladesh. In India—the first country in the world to carry pictorial health warnings on smokeless tobacco packages—a majority of respondents still reported that health warnings should have “more health information”. More than one-third of Indian respondents reported that they made an effort to avoid smokeless tobacco packages with health warnings on them, indicating that users are noticing and reacting to warnings. With respect to the effectiveness of health warnings with different message themes: text-only warnings were perceived as less effective than each of the pictorial styles (p<0.001 for all). Graphic warnings were given higher effectiveness ratings than symbolic or testimonial warnings (p<0.001). Few country differences were observed in the adult sample. Among youth, Indian respondents tended to give higher effectiveness ratings than their Bangladeshi counterparts. The findings also indicated that negative affect (a composite measure of surprise, fright, disgust, and unpleasantness) mediated the association between viewing health warnings and ratings of perceived effectiveness for adults and youth. Among adults, moderated-mediation analyses indicated that negative affect mediated the association between viewing health warnings and ratings of perceived effectiveness at different levels of the moderator (message credibility). In other words, the association between negative affect and perceived effectiveness varied as a function of message credibility; the association was stronger when message credibility was high, and weaker when it was low. Among youth, message credibility moderated the indirect effect (mediation) only for those who had viewed warnings with graphic health effects versus personal testimonials. No differences were observed across message themes with respect to levels of agreement with negative attitudes and beliefs, or overall ‘bad’ opinions about smokeless tobacco. Conclusions: This set of findings reinforces the need to implement effective tobacco control strategies in low- and middle-income countries like India and Bangladesh. In terms of health warning message content—pictorial warnings depicting graphic health effects may have the greatest efficacy, consistent with research from high-income countries on cigarette warnings.