Evaluation of the Knowledge and Perceptions with Regards to Pictorial Health Warnings on Tobacco Products among Tobacco Users Diagnosed with Head and Neck Carcinoma: a Study from the Kumaon Hills of India

Background: Tobacco products continue to be used in large quantities in India despite the mandatory inclusionof pictorial health warnings (PHWs) on all tobacco packaging. The circumstances as to how people could continuethe use of tobacco to the point of developing head and neck cancer despite enhanced awareness about the illeffects of tobacco is the main focus of this study. Materials and
Methods: This study concerned patients withleast 5-years history of tobacco use, having been diagnosed with histopathologically proven malignancies of thehypopharynx, larynx, oropharynx and oral cavity presenting at the Government Medical College-Haldwani,Nainital, India. A total of 183 patients were eligible for inclusion during July 1 2013- June 30 2014. Of these,59 patients used smoked tobacco exclusively, 22 patients used smokeless tobacco exclusively, and 102 patientsused both forms of tobacco. Among users of smoked forms, 75.2% (n=121) were beedi users, and 24.8% (n=40)were cigarette users. Patients were asked direct questions as to whether they had noticed the presence of PHWsupon tobacco products. The reasons as to why PHWs were not effective in stopping the patients from tobaccouse were investigated.
Results: Of the 183 patients, 146 reported being aware about the presence of PHWs, andwhen they were asked reasons as to why they continued tobacco despite being aware of ill-effects, the commonestreason chosen (by 53.4%) was that patients had not regarded themselves as using tobacco heavy enough to causecancer. Among the 36 patients who reported as being oblivious to the presence of PHWs on tobacco products,63.9% reported that the products they used never displayed any PHWs, and 36.1% reported never having paidattention to the packaging. The awareness about PHWs was higher among cigarette smokers in comparisonto beedi smokers (100% vs 76.1%, p=0.0002).
Conclusions: Locally produced and marketed tobacco productssuch as beedis and oral tobacco often fail to display PHWs. The presence of PHWs without doubt enhancesawareness about the carcinogenic risks of tobacco. However, enhanced awareness alone may not be enough, andas elucidated by this study, some persons continue to use tobacco to the point of developing malignancies. Theneed of the hour is the implementation of legal and economic sanctions discouraging the use of tobacco products.