sejal saraf, bds, mph kevin welding, phd katherine clegg ... · • latest cotpa requirement –...
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![Page 1: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/1.jpg)
Compliance of Health Warning Labels on Smokeless Tobacco
Products in India
Sejal Saraf, BDS, MPH
Kevin Welding, PhD
Katherine Clegg Smith, PhD
Joanna Cohen, PhD
![Page 2: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/2.jpg)
© 2014, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.
Disclosures
• Funding Source: The work was supported with funding from Bloomberg Philanthropies’ Bloomberg Initiative to Reduce Tobacco Use (www.bloomberg.org)
• Industry funding to investigator in the last 5 years:
None
• Off label medication uses discussed: N/A
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© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.
Smokeless Tobacco
in India
• The smokeless tobacco
(SLT) market in India is the
world’s largest
• Smokeless form: 20% vs.
smoked form: 9%
• 9 types of smokeless
products available in the
market
• Cost of product: <1$
Photo courtesy: Indianexpress.com
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© 2014, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.
Indian Packaging and Labeling Law
We know…
• Health warning label (HWL):
• Cost-effective policy
intervention
• Excellent medium for
communicating health
information
• In 2009, India became the
first country to implement
HWLs on SLT products
• Latest COTPA requirement –
85%
2009 to 2011: Health warnings that were
implemented for smokeless tobacco (‘tobacco
kills)
2011 to 2013: Graphic Health warnings for smokeless tobacco
April 2013 to April 2015: Graphic Health warnings for smokeless tobacco
April 2016: New Health warnings (required to cover 85% of the front and back of the pack)
![Page 5: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/5.jpg)
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.
Gaps in Knowledge
• Few studies have assessed compliance with gutka
and pan masala bans in various states, and with
tobacco advertising and promotion
• Compliance with packaging and labeling law has
been only minimally explored
• Non-compliance with HWL best practices can result
in poorer knowledge about the dangers of tobacco
use, a reduction in quitting behaviors, and an
increase in new tobacco users
![Page 6: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/6.jpg)
© 2014, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.
Objective of the Study
Examine the level of compliance of health warning
labels on smokeless tobacco packages with the Indian
packaging and labeling law
![Page 7: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/7.jpg)
TPackSS Methods
![Page 8: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/8.jpg)
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Data Collection
• In 2016, data were
collected in four cities:
Mumbai, Bengaluru,
New Delhi and Chennai
• A systematic walking
protocol was developed
and used to collect the
data
![Page 9: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/9.jpg)
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= 54 unique smokeless tobacco packs
![Page 10: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/10.jpg)
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Coding Packs
• All 54 ‘unique’ packs were coded
• Packs were independently coded
by 2 trained Research Assistants
• Packs were assessed for
compliance with four key
requirements:
1. Warning location
2. Warning size
3. Warning elements
4. Language
![Page 11: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/11.jpg)
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HWL Compliance: Key Indicators
• Located at the top edge of the pack on
both sides (diametrically opposite if
pack is cylindrical)
1. Warning location
2. Warning size• HWL must cover 85% on both sides
of the principal display area of the
SLT packages
![Page 12: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/12.jpg)
© 2014, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.
HWL Compliance: Key Indicators
• Complete full color graphic.
Warning text and message in a
contrasting background color
3. Warning elements
4. Language• The warning message must
be in the same language as
used on the rest of the pack
![Page 13: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/13.jpg)
Results
![Page 14: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/14.jpg)
© 2014, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.
HWL Compliance, by indicator and overall
(n=54 packs)
Indicators Number of
compliant packs
% Compliant
1. Warning location 32/54 59%
2. Warning size 1/54 2%
3. HWL elements 41/54 76%
4. Language 50/54 93%
Fully compliant packs 1/54 2%
![Page 15: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/15.jpg)
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Additional Compliance Issues1. Significant variation in the printing quality, size and
magnification of the graphic
Variation in sizes of smokeless packages
![Page 16: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/16.jpg)
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Additional Compliance Issues
2. Split/incomplete HWL and multiple HWL’s on the
same side of the pack
English Hindi
![Page 17: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/17.jpg)
© 2014, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.
Additional Compliance Issues
3. Out of rotation graphic images (2009-11, 2011-13 &
2011-15) still present on SLT packs
![Page 18: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/18.jpg)
© 2014, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.
Summary
• Only 1 of the 54 (2%) of the unique SLT
packages were compliant with all four key
HWL requirements
• The one pack compliant with all 4
indicators used box shaped packaging
• For most packs, the compliance was poor
because of failure to meet the size
requirement to cover 85% of the principal
display area
![Page 19: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/19.jpg)
© 2014, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.
Implications and Future Research
• SLT packages are difficult to regulate
1. Structure of tobacco market
2. The heterogeneity and diversity of product
• This analysis also raises a few questions
- Is there a need for standard packaging type and
material for smokeless products?
• Our further research: HWL compliance in rural areas
might be different
![Page 20: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/20.jpg)
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.
Conclusions
• Findings from this study highlight the poor
compliance of SLT manufacturing companies with
the HWLs laws in India
• Although the Indian law aligns well with the WHO-
FCTC guidelines, this deficit in implementation
diminishes the potential health benefits of warning
label on tobacco users
![Page 21: Sejal Saraf, BDS, MPH Kevin Welding, PhD Katherine Clegg ... · • Latest COTPA requirement – 85% 2009 to 2011: Health warnings that were implemented for smokeless tobacco (‘tobacco](https://reader033.vdocuments.mx/reader033/viewer/2022042223/5ec9ed0a910d14432f3be504/html5/thumbnails/21.jpg)
© 2014, Johns Hopkins University. All rights reserved.
© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.© 2014, Johns Hopkins University. All rights reserved.©2016, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.
Acknowledgements
We would like to thank the entire TPackSS team in
Baltimore and the data collection team in India –
Healis Sekhsaria Institute for Public Health
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Questions??
Thank [email protected]
© 2014, Johns Hopkins University. All rights reserved.©2015, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.