JMIR Publications

ABSTRACT

Background:

The sales of loose cigarette/bidi can undermine the purpose of requiring health warning labels (HWLs) on cigarette packs/bidi bundles by diminishing their visibility and legibility.

Objective:

This mixed-methods study examines the association between purchase behavior (loose vs pack/bundle), HWL exposure and responses to HWLs among Indian adult smokers.

Methods:

Data were analyzed from the 2018-2019 India Tobacco Control Policy (TCP) Survey and from 28 in-depth interviews conducted with Indian smokers in 2022. The TCP Survey sample included tobacco users who bought cigarettes (n=643) or bidis (n=730) either loose or in packs/bundles at their last purchase. Ordinal regression models were fit separately for cigarettes and bidis, whereby HWL variables (noticing HWLs; reading / looking closely at HWLs; forgoing a cigarette/bidi because of HWLs; thinking about health risks of smoking; and thinking about quitting smoking cigarettes/bidi because of HWLs) were regressed on last purchase (loose vs. packs/bundles=ref). In-depth interview participants from Delhi and Mumbai purchased loose cigarettes in the last month, and thematic analysis was used to analyze the interview data.

Results:

Survey findings indicated that about 75% of cigarette users and 12% of bidi users reported having bought loose sticks at their last purchase. Those who purchased loose cigarettes (vs packs) noticed HWLs less often, whereas those who purchased loose bidis (vs bundles) thought about the harms of bidi smoking and quitting more often. Interview findings indicated that exposure to HWLs was lower among those who purchased loose cigarettes. Participants reported that vendors, especially small ones, did not display statutory health warnings at their point of sale, further limiting exposure to warning messages.

Conclusions:

Survey and interview findings indicated that those who purchased loose cigarettes noticed HWLs less often. Loosie purchases likely decrease the frequency of smokers’ exposure to HWLs’ reminders about the harmful effects of smoking potentially reducing HWL effectiveness.