This editorial is an invited commentary on an article published in the issue of the Indian Journal of Medical and Pediatric Oncology authored by Madewell et al.,[1] that has pertinently addressed the relationship of mass media campaign with smokeless tobacco (SLT) cessation.

To quote the authors, India is the third largest producer of tobacco. There are over 300 million SLT users worldwide, of which 206 million (68.7%) live in India.[1],[2] Being the second largest consumer of SLT[1], we have one of the highest incidences of oral cavity cancers in the world arising every year.[3] Therefore, tobacco control measures are mandatory to halt this epidemic. Mass media warning is an effective tool to provide a health warning to the public,[4],[5] but whether it translates effectively into cessation of SLT is yet to be answered.

As mentioned by Madewell et al., to address the use and consequences of tobacco products, India initiated the National Tobacco Control Programme in 2007–2009 in 21 states, which was expanded to 29 states by 2013.[1] Literature shows that mass media campaigns effectively inform the public of the dangers of smoking tobacco and promote quitting while campaign awareness is associated with better knowledge and more negative attitudes toward SLT.[6] However, studies addressing the effect–cause relationship between antitobacco campaign and SLT cessation are lacking.

The Global Adult Tobacco Survey (GATS) is a nationally representative household survey driven by the World Health Organization, which enables countries to collect data on adult tobacco use and key tobacco control measures. GATS 1 (2009–2010) monitored adult tobacco use, tracked tobacco control indicators, and assessed the impact of tobacco control efforts, including the Cigarettes and Other Tobacco Products Act of 2003, whereas GATS 2 (2016–2017) measured the impact of tobacco control legislation since GATS-1.[7] In this series of Indian Journal of Medical and Pediatric Oncology, recognized stalwarts of cancer research in India and global experts have addressed the association of mass media campaign and cessation of SLT users. This series provides an explicit appraisal of SLT cessation in India and is a valuable addition to the published work for cancer control in low- and middle-income countries.

This study has assessed the relations between SLT health warnings in mass media and intention and attempts to quit using SLT.[1] They also evaluated the changes between the two major surveys (GATS 1 and GATS 2). Approximately 1.6 lakh participants were screened with a response rate of more than 95% among both the parts. More participants noticed SLT warnings on SLT packages, television, billboards, and newspapers/magazines in GATS-2 than GATS-1, but fewer heard warnings on the radio (P< 0>

Along with media, health warning labels (HWLs) have a significant influence on tobacco habit cessation.[8] Evidence suggests that pictorial warning captures attention, increases the level of effectiveness, creates awareness of health risks, and creates unfavorable associations with the habit, as well as perceived effectiveness, negative affect, and motivation to quit.[9],[10] It has been shown in the literature that the enhanced size of HWLs significantly increases the level of effectiveness. From GATS 1 to GATS 2, the size of HWLs has increased from 40% on single side to 85% on both sides of the packet. As the size of HWLs grew, this led to a significant impact on both intention and attempt to quit SLT. Antitobacco messages on television, billboards, public vehicles, and walls were also associated with greater SLT cessation behavior. This is modestly represented in this analysis comparing GATS 1 and GATS 2. Thus, this study which is nationally representing samples of Indian SLT users has enough evidence to show SLT warnings in mass media may promote SLT cessation behaviour.[1]

Finally, we fully agree with the Madewell et al. that health warnings in mass media would definitely play an important role in the overall strategy to reduce the morbidity and mortality associated with SLT use.[1]

• References

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1.  Madewell ZJ, Kolaja CA. Smokeless tobacco warnings in Indian mass media: Intention and attempts to quit. Indian J Med Paediatr Oncol 2019; 40: 413-9
2.  Gupta-Smith V. 90% of Smokeless Tobacco Users Live in South-East Asia. World Health Organization Regional Office for South-East Asia; 2013.. http://www.searo.who.int/mediacentre/releases/2013/pr1563/en/ Available from: [Last accessed on 2019 Jul 24]
3.  Chaturvedi P, Singhavi H, Malik A, Nair D. Outcome of head and neck squamous cell cancers in low-resource settings: Challenges and opportunities. Otolaryngol Clin North Am 2018; 51: 619-29
4.  Brennan E, Durkin SJ, Cotter T, Harper T, Wakefield MA. Mass media campaigns designed to support new pictorial health warnings on cigarette packets: Evidence of a complementary relationship. Tob Control 2011; 20: 412-8
5.  Bala MM, Strzeszynski L, Topor-Madry R. Mass media interventions for smoking cessation in adults. Cochrane Database Syst Rev 2013; 6: CD004704 Doi: 10.1002/14651858.CD004704.pub3
6.  Murukutla N, Turk T, Prasad CV, 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
7.  Tata Institute of Social Sciences. Global Adult Tobacco Survey GATS 2 India 2016-2017. Government of India: Mumbai and Ministry of Health and Family Welfare; 2018
8.  Klein EG, Quisenberry AJ, Shoben AB, Cooper S, Ferketich AK, Berman M. et al. Health warning labels for smokeless tobacco: The impact of graphic images on attention, recall, and craving. Nicotine Tob Res 2017; 19: 1172-7
9.  Kees J, Burton S, Andrews JC. Tests of graphic visuals and cigarette package warning combinations: Implications for the framework convention on tobacco control. J Public Policy Mark 2006; 25: 212-23
10.  Schneider S, Gadinger M, Fischer A. Does the effect go up in smoke? A randomized controlled trial of pictorial warnings on cigarette packaging. Patient Educ Couns 2012; 86: 77-83

1.  Madewell ZJ, Kolaja CA. Smokeless tobacco warnings in Indian mass media: Intention and attempts to quit. Indian J Med Paediatr Oncol 2019; 40: 413-9
2.  Gupta-Smith V. 90% of Smokeless Tobacco Users Live in South-East Asia. World Health Organization Regional Office for South-East Asia; 2013.. http://www.searo.who.int/mediacentre/releases/2013/pr1563/en/ Available from: [Last accessed on 2019 Jul 24]
3.  Chaturvedi P, Singhavi H, Malik A, Nair D. Outcome of head and neck squamous cell cancers in low-resource settings: Challenges and opportunities. Otolaryngol Clin North Am 2018; 51: 619-29
4.  Brennan E, Durkin SJ, Cotter T, Harper T, Wakefield MA. Mass media campaigns designed to support new pictorial health warnings on cigarette packets: Evidence of a complementary relationship. Tob Control 2011; 20: 412-8
5.  Bala MM, Strzeszynski L, Topor-Madry R. Mass media interventions for smoking cessation in adults. Cochrane Database Syst Rev 2013; 6: CD004704 Doi: 10.1002/14651858.CD004704.pub3
6.  Murukutla N, Turk T, Prasad CV, 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
7.  Tata Institute of Social Sciences. Global Adult Tobacco Survey GATS 2 India 2016-2017. Government of India: Mumbai and Ministry of Health and Family Welfare; 2018
8.  Klein EG, Quisenberry AJ, Shoben AB, Cooper S, Ferketich AK, Berman M. et al. Health warning labels for smokeless tobacco: The impact of graphic images on attention, recall, and craving. Nicotine Tob Res 2017; 19: 1172-7
9.  Kees J, Burton S, Andrews JC. Tests of graphic visuals and cigarette package warning combinations: Implications for the framework convention on tobacco control. J Public Policy Mark 2006; 25: 212-23
10.  Schneider S, Gadinger M, Fischer A. Does the effect go up in smoke? A randomized controlled trial of pictorial warnings on cigarette packaging. Patient Educ Couns 2012; 86: 77-83