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Using a smokeless tobacco control mass media campaign and other synergistic elements to address social inequalities in India

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The burden of tobacco-related morbidity and mortality in India is substantial, with smokeless tobacco being the predominant form of tobacco use. Use of smokeless tobacco (for example gutkha, paan, khaini, and pan masala) is linked to a host of socioeconomic and cultural factors including gender, regional differences, educational level, and income disparities. Given the scale of the problem, a national social marketing campaign was developed and implemented. The creative approach used testimonials from a surgeon and patients at Tata Memorial Hospital in Mumbai. The communication message approach was designed to reflect the realities of disfiguring, disabling, and fatal cancers caused by smokeless tobacco. Evaluation of the campaign identified significant differences across a range of campaign behavioral predictors by audience segments aware of the campaign versus those who were “campaign unaware”. Significant findings were also identified regarding vulnerable groups by gender (female/male) and rural/urban disparities. Findings are discussed in relation to the powerful impact of using graphic, emotive, and testimonial imagery for tobacco control with socially disadvantaged groups.

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  1. The PSA may be viewed at

  2. We used the modern SES definition which uses education and occupation of the chief wage earner to classify households in urban areas. The chief wage earner is defined as the person who contributes the most to the total family income. On the basis of various combinations of these variables, the households are classified into different socioeconomic classes from A–E (in that order, from affluent to deprived). Households in rural areas are classified using the chief wage earner’s education and type of house (“pucca” houses are those built of concrete and steel; “kaccha” include thatched houses or huts; and, “semi pucca” are those that are a mix of concrete and thatching). Occupation as a variable is not used in rural areas because this can be similar in most households across most Indian villages. Rural SEC is categorized into four groups on the basis of the education and type of household, viz. R1, R2, R3 and R4. R1 denotes the upper-most rural SEC and R4 the lowest SEC.(The definition can be viewed at: Socio-economic status was further categorized into “High” (A and R1), “Medium” (B, C and R2), and “Low” (D, E, R3 and R4).

  3. The website may be viewed at


  1. World Health Organisation [WHO] (2010) Global adult tobacco survey [GATS] India Report 2009–2010

  2. Panchamukhi PR, Woolery T, Nayantara SN (2008) Economics of Bidis in India. In: Gupta PC, Asma S (eds) Bidi Smoking and Public Health. Ministry of Health and Family Welfare, Government of India, pp 167–195.

  3. Jha P et al (2008) A nationally representative case–control study of smoking and death in India. N Eng J Med 358:1137–1147

    Article  CAS  Google Scholar 

  4. Datamonitor (2010) Market insights: tobacco in India; An insight into the Indian tobacco market Accessed 27 June 2011

  5. Parkin DM, et al (2005) Global cancer statistics, 2002. CA: Cancer J Clin 55(2): 74–108. Accessed 30 June 2011

  6. Engstrom PE, Clapper M, Schnoll RA et al (2000) Prevention of tobacco-related cancers. In: Bast RC, Kufe D, Pollock RE et al (eds) Cancer medicine, 5th edn. BC Decker, Hamilton, pp 127–140

    Google Scholar 

  7. Ray CS, Gupta PC (2009) Bidis and smokeless tobacco. Curr Sci 96(10):1324–1333

    Google Scholar 

  8. International agency for research on cancer monographs on the evaluation of carcinogenic risks to humans (2007) Smokeless tobacco and some tobacco-specific N-Nitrosamines. 89, WHO, Lyon

  9. European Commission (2007) Health effects of smokeless tobacco products. Preliminary report, Brussels

    Google Scholar 

  10. UN Development Programme (2010) Human development report 2010–2020th anniversary edition. The real wealth of nations: pathways to human development Accessed 10 Nov 2010

  11. Hausmann R, Tyson LD, Zahidi S (2010) The global gender gap report 2010. World Economic Forum Accessed 10 Nov 2010

  12. Parasuraman S, Kishor S, Singh SK, Vaidehi, Y (2009) A profile of youth in India. National Family Health Survey [NFHS-3] India 2005–2006. ICF Macro, Calverton

  13. Gupta PC (1996) Survey of sociodemographic characteristics of tobacco use among 99,598 individuals in Bombay, India using handheld computers. Tob Control Summer 5(2):114–120

    Article  CAS  Google Scholar 

  14. John RM (2008) Crowding out effect of tobacco expenditure and its implications on household resource allocation in India. Soc Sci Med 66(6):1356–1367

    Google Scholar 

  15. Chaturvedi HK, Phukan RK, Zoramtharga K, Hazarika NC, Mahanta J (1998) Tobacco use in Mizoram, India: sociodemographic differences in pattern. Southeast Asian J Trop Med Pub Health 29(1):66–70

    CAS  Google Scholar 

  16. Narain R, Sardana S, Gupta S, Sehgal A (2011) Age at initiation and prevalence of tobacco use among school children in Noida, India: a cross-sectional questionnaire based survey. Indian J Med Res 133:300–307

    PubMed  Google Scholar 

  17. Bhalla AS (1990) Rural-urban disparities in India and China. World Dev 18(8):1097–1110. doi:10.1016/0305-750X(90)90090-K

    Article  Google Scholar 

  18. John R, et al (2011) Counting 15 million more poor in India, thanks to tobacco. Tob Control 20:349–352

    Google Scholar 

  19. Terry-McElrath Y, Wakefield M, Ruel E, Balch GI, Emery S, Szczypka G, Clegg-Smith K, Flay B (2005) The effect of antismoking advertisement executional characteristics on youth comprehension, appraisal, recall, and engagement. J Health Commun 10(2):127–143

    Article  PubMed  Google Scholar 

  20. Wakefield M, Bayly M, Durkin S, Cotter T, Mullin S, Warne C, for the International Anti-Tobacco Advertisement Rating Study Team (2011) Smokers’ responses to television advertisements about the serious harms of tobacco use: pre-testing results from 10 low- to middle-income countries. Tob Control; tobaccocontrol-2011-050171. doi:10.1136/tobaccocontrol-2011-050171

  21. Berlo D, Lemert J, Mertz R (1969) Dimensions for evaluating the acceptability of message source. Pub Opin Quart 33:563–576

    Article  Google Scholar 

  22. Cooper J, Croyle R (1984) Attitudes and attitude change. Ann Rev Psych 35:395–426

    Article  CAS  Google Scholar 

  23. National Cancer Institute (NCI) (2008) The role of the media in promoting and reducing tobacco use. In: Davis RM, Gilpin EA, Loken B, Viswanath K, Wakefield MA (eds) Tobacco control monograph No. 19. U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. NIH Pub No 07-6242, Bethesda

  24. Clow KE, Baack D (2007) Integrated advertising, promotion, and marketing communications, 3rd edn. Pearson Ed, Upper Saddle River, NJ

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The authors gratefully acknowledge senior staff at the Ministry of Health and Family Welfare, Government of India (GOI), the management of TATA Memorial Hospital, India, and Dr Vinayak Prasad (formerly at GOI and currently with the World Health Organization), for their vision in supporting the Surgeon campaign; Bloomberg Philanthropies and the Bill and Melinda Gates Foundation, as part of the Bloomberg Initiative to Reduce Tobacco Use, for their generous support that enabled several aspects of the Surgeon campaign, including pretesting research, advertisement production, and the impact evaluation study; the dedicated researchers and field staff at ORG Centre for Social Research, most particularly Mr Prasad, for his guidance in the development of the rigorous methodology and analysis for this study; and, World Lung Foundation communications staff, particularly Alexey Kotov and Rebecca Perl, for their input and review through the campaign and publication process.

Conflicts of interest

The following are all the competing financial interests among authors of this paper. Ranjana Saradhi: ORG Center for Social Research (The Nielsen Company) received payment from the World Lung Foundation for conducting the impact evaluation study described in this paper. Dr Tahir Turk, World Lung Foundation, Dr Nandita Murukutla, World Lung Foundation, Shefali Gupta, formally World Lung Foundation, Sandra Mullin, World Lung Foundation, Dr Jagdish Kaur, Ministry of Health and Family Welfare, (GOI), Dr Pankaj Chaturvedi, Tata Memorial Hospital, declare they have no conflict of interest. The smokeless campaign was primarily funded by the Ministry of Health and Family Welfare, Government of India (GOI). The World Lung Foundation supported the campaign by providing campaign materials and by evaluating the campaign. The author declares there are no other conflicts of interest.

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Correspondence to Tahir Turk.

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Turk, T., Murukutla, N., Gupta, S. et al. Using a smokeless tobacco control mass media campaign and other synergistic elements to address social inequalities in India. Cancer Causes Control 23 (Suppl 1), 81–90 (2012).

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