title: 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.
abstract: BACKGROUND
  Tobacco products continue to be used in large quantities in India despite the mandatory inclusion of pictorial health warnings (PHWs) on all tobacco packaging. The circumstances as to how people could continue the use of tobacco to the point of developing head and neck cancer despite enhanced awareness about the ill effects of tobacco is the main focus of this study.
  
  
  METHODS
  This study concerned patients with least 5-years history of tobacco use, having been diagnosed with histopathologically proven malignancies of the hypopharynx, 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 patients used 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 PHWs upon tobacco products. The reasons as to why PHWs were not effective in stopping the patients from tobacco use were investigated.
  
  
  RESULTS
  Of the 183 patients, 146 reported being aware about the presence of PHWs, and when they were asked reasons as to why they continued tobacco despite being aware of ill-effects, the commonest reason chosen (by 53.4%) was that patients had not regarded themselves as using tobacco heavy enough to cause cancer. 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 paid attention to the packaging. The awareness about PHWs was higher among cigarette smokers in comparison to beedi smokers (100% vs 76.1%, p=0.0002).
  
  
  CONCLUSIONS
  Locally produced and marketed tobacco products such as beedis and oral tobacco often fail to display PHWs. The presence of PHWs without doubt enhances awareness about the carcinogenic risks of tobacco. However, enhanced awareness alone may not be enough, and as elucidated by this study, some persons continue to use tobacco to the point of developing malignancies. The need of the hour is the implementation of legal and economic sanctions discouraging the use of tobacco products.
authors.affiliation: Department of Radiotherapy, Government Medical College-Haldwani, Haldwani, India E-mail : swarooptheone@gmail.com.
authors.forename: Nirdosh Kumar
authors.initials: NK
authors.lastname: Pant
authors.forename: Kailash Chandra
authors.initials: KC
authors.lastname: Pandey
authors.forename: Irappa
authors.initials: I
authors.lastname: Madabhavi
authors.forename: Vinod
authors.initials: V
authors.lastname: Pandey
authors.forename: Swaroop
authors.initials: S
authors.lastname: Revannasiddaiah
mesh_terms: D002294:Carcinoma, Squamous Cell / Q000175:diagnosis / Q000209:etiology / Q000523:psychology; D003430:Cross-Sectional Studies; D005260:Female; D005500:Follow-Up Studies; D006258:Head and Neck Neoplasms / Q000175:diagnosis* / Q000209:etiology / Q000523:psychology; D007722:Health Knowledge, Attitudes, Practice; D006293:Health Promotion / Q000379:methods*; D006801:Humans; D007194:India; D008297:Male; D010465:Perception; D011356:Product Labeling / Q000379:methods*; D011379:Prognosis; D012907:Smoking / Q000523:psychology*; D016540:Smoking Cessation / Q000523:psychology; D062789:Tobacco Products; D014029:Tobacco Use Disorder / Q000150:complications* / Q000523:psychology