Scientific Journal Articles
Levy, D. T., Sweanor, D., Sanchez-Romero, L. M., O'Connor, R., Goniewicz, M. L., & Borland, R. (2020). Altria-Juul Labs deal: why did it occur and what does it mean for the US nicotine delivery product market. Tobacco control, 29(e1), e171-e174.
Showing 1-15 of 15 Results
Nargis, et al. 2019. Socioeconomic patterns of smoking cessation behavior in low and middle-income countries: Emerging evidence from the Global Adult Tobacco Surveys and International Tobacco Control Surveys [access full article]
Introduction: Tobacco smoking is often more prevalent among those with lower socio-economic status (SES) in high-income countries, which can be driven by the inequalities in initiation and cessation of smoking. Smoking is a leading contributor to socio-economic disparities in health. To date, the evidence for any socio-economic inequality in smoking cessation is lacking, especially in low- and middle-income countries (LMICs). This study examined the association between cessation behaviours and SES of smokers from eight LMICs.
Methods: Data among former and current adult smokers aged 18 and older came from contemporaneous Global Adult Tobacco Surveys (2008–2011) and the International Tobacco Control Surveys (2009–2013) conducted in eight LMICs (Bangladesh, Brazil, China, India, Mexico, Malaysia, Thailand and Uruguay). Adjusted odds ratios (AORs) of successful quitting in the past year by SES indicators (household income/wealth, education, employment status, and rural-urban residence) were estimated using multivariable logistic regression controlling for socio-demographics and average tobacco product prices. A random effects meta-analysis was used to combine the estimates of AORs pooled across countries and two concurrent surveys for each country.
Results: Estimated quit rates among smokers (both daily and occasional) varied widely across countries. Meta-analysis of pooled AORs across countries and data sources indicated that there was no clear evidence of an association between SES indicators and successful quitting. The only exception was employed smokers, who were less likely to quit than their non-employed counterparts, which included students, homemakers, retirees, and the unemployed (pooled AOR≈0.8, p<0.10).
Conclusion: Lack of clear evidence of the impact of lower SES on adult cessation behaviour in LMICs suggests that lower-SES smokers are not less successful in their attempts to quit than their higher-SES counterparts. Specifically, lack of employment, which is indicative of younger age and lower nicotine dependence for students, or lower personal disposable income and lower affordability for the unemployed and the retirees, may be associated with quitting. Raising taxes and prices of tobacco products that lowers affordability of tobacco products might be a key strategy for inducing cessation behaviour among current smokers and reducing overall tobacco consumption. Because low-SES smokers are more sensitive to price increases, tobacco taxation policy can induce disproportionately larger decreases in tobacco consumption among them and help reduce socio-economic disparities in smoking and consequent health outcomes.[download PDF]
Ngo, et al. 2019. Analysis of gender differences in the impact of taxation and taxation structure on cigarette consumption in 17 ITC countries [access full article]
Although increasing taxes has been established as the most effective tobacco control policy, it is not clear whether these policies reduce cigarette consumption equally among women and men. In this study, we examine whether the association between taxation/taxation structure and cigarette consumption differs by gender. The data is from the International Tobacco Control Policy Evaluation (ITC) Projects in 17 countries. Cigarette consumption was measured by gender for each ITC country. Generalized estimating equations (GEE) were employed to investigate gender differences in the association between cigarette consumption and tax structures, while controlling for time-variant demographic characteristics such as unemployment rates, proportions of adults, and percent of female population. Tiered tax structures are associated with higher cigarette consumption among both males and females. Female smokers are more responsive to an average tax increase than male smokers. Among males, higher ad valorem share in excise taxes is associated with lower cigarette consumption, but it is not the case for females. Females may not be as responsive to the prices raised by ad valorem taxes, despite being responsive to average taxes, suggesting that smokers by gender may face different prices.[download PDF]
Shang, et al. 2019. Association between tax structure and cigarette consumption: findings from the International Tobacco Control Policy Evaluation (ITC) Project [access full article]
Background: Recent studies show that greater price variability and more opportunities for tax avoidance are associated with tax structures that depart from a specific uniform one. These findings indicate that tax structures other than a specific uniform one may lead to more cigarette consumption.
Objective: This paper aims to examine how cigarette tax structure is associated with cigarette consumption.
Methods: We used survey data taken from the International Tobacco Control Policy Evaluation Project in 17 countries to conduct the analysis. Self-reported cigarette consumption was aggregated to average measures for each surveyed country and wave. The effect of tax structures on cigarette consumption was estimated using generalised estimating equations after adjusting for sociodemographic characteristics, average taxes and year fixed effects.
Findings: Our study provides important empirical evidence of a relationship between tax structure and cigarette consumption. We find that a change from a specific to an ad valorem structure is associated with a 6%–11% higher cigarette consumption. In addition, a change from uniform to tiered structure is associated with a 34%–65% higher cigarette consumption. The results are consistent with existing evidence and suggest that a uniform and specific tax structure is the most effective tax structure for reducing tobacco consumption.[download PDF]
Shang, et al. 2018. Association between tobacco prices and smoking onset: Evidence from the TCP India Survey [access full article]
Background: Tobacco use is prevalent among youth and adults in India. However, direct evidence on how increasing taxes or prices affect tobacco use onset is scarce.
Objective: To analyse the associations between cigarette and bidi prices and smoking onset in India, and how these associations differ by socioeconomic status.
Methodology: The Wave 1 of the Tobacco Control Policy Evaluation India Survey by the International Tobacco Control Project contains information on the age at smoking onset for cigarettes and bidis. Using this information, data were expanded to a yearly pseudo-panel dataset that tracked respondents at risk of smoking onset from 1998 to 2011. The associations between bidi prices and bidi smoking onset, between cigarette prices and cigarette smoking onset, and between bidi and cigarette prices and any smoking onset were examined using a discrete-time hazard model with a logit link function. Stratified analyses were conducted to examine the difference in these associations by rural versus urban division.
Results: We found that higher bidi prices were significantly associated with a lowered hazard of bidi smoking onset (OR 0.42, 95% CI 0.35 to 0.51). Higher cigarette prices were significantly (OR 0.87, 95% CI 0.83 to 0.92) associated with a lowered hazard of cigarette smoking onset among urban residents, but this association was non-significant when SEs were clustered at the state level. In addition, the association between increasing bidis prices and lowered hazards of bidi smoking onset was greater for urban residents than for rural ones (p<0.01).
Conclusions: Under the new regime of a central goods and service system, policymakers may need to raise the prices of tobacco products sufficiently to curb smoking onset.[download PDF]
Shang, et al. 2018. The association between state value-added taxes in tobacco use in India: Evidence from GATS and TCP India Survey [access full article]
Introduction: State value-added taxes (VAT) on tobacco products have been increased significantly in recent years in India. Evidence on how these VATs were associated with smoking is highly needed.
Methods: State bidi and cigarette VAT rates were linked to Global Adult Tobacco Survey (GATS) India 2009–2010 and Tobacco Control Policy (TCP) India Survey waves 1 (2010–2011) and 2 (2012–2013), respectively. These linked data were used to analyze the associations between bidi VAT rates and bidi smoking, between cigarette VAT rates and cigarette smoking, and between the two VAT rates and dual use of bidis and cigarettes. Weighted logistic regressions were employed to examine GATS cross-sectional data, whereas Generalized Estimating Equations (GEE) were employed to examine longitudinal TCP data. We further stratified the analyses by gender.
Results: A 10% increase in cigarette VAT rates was associated with a 6.5% (p<0.001) decrease in dual use of cigarettes and bidis among adults and a 0.9% decrease (p<0.05) in cigarette smoking among males in TCP; and with a 21.6% decrease (p<0.05) in dual use among adults and a 17.2% decrease (p<0.001) in cigarette smoking among males in GATS. TCP analyses controlling for state fixed effects are less likely to be biased and indicate a cigarette price elasticity of – 0.44. As female smoking prevalence was extremely low, these associations were non-significant for females.
Conclusions: Higher state cigarette VAT rates in India were significantly associated with lower cigarette smoking and lower dual use of cigarettes and bidis. Increasing state VAT rates may significantly reduce smoking in India.[download PDF]
Puntambekar, et al. 2018. Awareness of tobacco advertising, promotion and sponsorship in four states: findings from TCP India survey - Wave 1 and Wave 2. [access full article]
Background: India's Cigarette and Other Tobacco Products Act (COTPA) of 2003 prescribes a complete ban on all forms of tobacco advertisements, promotions and sponsorships (TAPS) of events by tobacco companies across India. We examined the level of variation and predictors of awareness of TAPS in four Indian states.
Methods: We used data from the International Tobacco Control Policy (TCP) Survey India from Wave1 (Aug 2010- Dec 2011) and Wave2 (Aug 2012-Dec 2013) consisting of 10,585 and 10,501 respondents, respectively, surveyed from Madhya Pradesh (MP), Bihar (BR), Maharashtra (MH) and West Bengal (WB). Bivariate analysis and multivariable logistic regression was used to investigate associations between sociodemographic factors, states and TAPS awareness. All analyses were performed using SPSS V. 20.0
Results: Noticing tobacco advertisements was highest in MH (78.5%) and lowest in WB (50.1%) in Wave 1, while in Wave 2, it was highest in MP (83.5%) and lowest in WB (32.6%). Noticing tobacco promotions and sponsorships was highest in MP (promotions: 35.7%, sponsorships: 14.4%) in Wave 1, while in Wave 2, it was highest in WB (promotions:15.0%, sponsorships:10.8%). Across waves, education was a predictor of noticing tobacco advertisements, promotions and sponsorships. In Wave 1, but not Wave 2, noticing tobacco advertisements (OR:2.11) and promotions (OR:2.02) was highest among the youngest age group (15-17yrs) compared to corresponding oldest age group (55yrs+). Noticing advertisements and sponsorships remained consistent in urban areas across both waves. In Wave 1 tobacco promotions were observed twice as frequently among rural population as compared urban population but the association was reversed in Wave 2.
Conclusions: Awareness of tobacco marketing varied across the four states of India to observe a greater impact of the tobacco control legislation. This study suggests that even though policies are the same in all states, a coordinated effort is required to implement the law on TAPS ban consistently.[download PDF]
Objective: There is strong evidence showing that pictorial health warnings are more effective than text-only warnings. However, much of this evidence comes from high-income countries and is limited to cigarette packaging. Moreover, few studies have identified mechanisms that might explain the impact of warnings.
Methods: The current study examined the potential mediating role of negative affect and the moderating influence of message credibility in perceived effectiveness of smokeless tobacco warnings in two low- and middle-income countries (LMICs). Field interviews were conducted in India and Bangladesh, with adult (19 + years) smokeless tobacco users (n = 1053), and youth (16–18 years) users (n = 304) and non-users (n = 687). Respondents were randomly assigned to view warnings in one of four conditions: (1) Text-only, (2) pictorial with symbolic imagery, (3) pictorial with graphic images of health effects, or (4) pictorial with personalized graphic images plus a personal testimonial.
Results: The findings provide support for the mediating influence of negative affect in perceived effectiveness, for adult and youth smokeless tobacco users who viewed pictorial warnings (vs. text-only), and graphic health warnings (vs. personal testimonials). Among adults, message credibility moderated the indirect effect; the association was stronger when credibility was high and weaker when it was low. Among youth users and non-users, message credibility did not moderate the indirect effect.
Conclusions: Consistent with research from high-income countries, these findings highlight the importance of selecting imagery that will elicit negative emotional reactions and be perceived as credible. Differential effects among adults and youth highlight the importance of pre-testing images.[download PDF]
Gravely, et al. 2016. An examination of the effectiveness of health warnings on smokeless tobacco products in India: Findings from the TCP India Cohort Survey [access full article]
Background: In 2009, after many delays and changes, India introduced a single pictorial health warning label (HWL) on smokeless tobacco (SLT) packing—a symbolic image of a scorpion covering 40% of the front surface. In 2011, the scorpion was replaced with 4 graphic images. This paper tested the effectiveness of SLT HWLs in India and whether the 2011 change from symbolic to graphic images increased their effectiveness.
Methods: Data were from a cohort of 4733 adult SLT users (age15+) of the Tobacco Control Project (TCP) India Survey from 4 states. The surveys included key indicators of health warning effectiveness, including warning salience, and cognitive, emotional, and behavioral responses to the warnings.
Results: The HWL change from symbolic to graphic did not result in significant increases on any of the HWL outcome indicators. A substantial minority of SLT users were unaware that SLT packages contained HWLs (27% at both waves). Noticing the warnings was also remarkably low at both waves (W1 = 34.3%, W2 = 28.1%). These effects carried over to the cognitive and behavioural measures, where among those who noticed HWLs, about one-third reported forgoing SLT at least once because of the HWLs, and fewer than 20% reported that HWLs made them think about SLT risks or about quitting SLT. Even fewer reported avoiding HWLs (8.1 to 11.6%). Among those who quit using SLT by post-policy, awareness that SLT packaging contained HWLs was significantly greater at post-policy (86.8%) compared to pre-policy (77.8%, p = 0.02). Quitters were also significantly more aware of the post-policy HWLs compared to those who continued to use SLT (p < 0.001).
Conclusions: Health warnings on SLT packages in India are low in effectiveness, and the change from the symbolic warning (pre-policy) to graphic HWLs (post-policy) did not lead to significant increases of effectiveness on any of the HWL indicators among those who continued to use SLT products, thus suggesting that changing an image alone is not enough to have an impact. There is a critical need to implement SLT HWLs in India that are more salient (large in size and on the front and back of the package) and impactful, which following from studies of HWLs on cigarette packaging, would have strong potential to increase awareness of the harms of SLT and to motivate quitting.[download PDF]
Background: Social impacts on tobacco use have been reported but not well quantified. This study investigated how strongly the use of smoked and smokeless tobacco may be influenced by other users who are close to the respondents.
Methods: The International Tobacco Control Project (TCP), India, used stratified multistage cluster sampling to survey individuals aged ≥15 years in four areas of India about their tobacco use and that of their close associates. The present study used logistic regression to calculate odds ratios (ORs) for tobacco use for each type of close associate.
Results: Among the 9780 respondents, tobacco use was significantly associated with their close associates’ (father’s, mother’s, friends’, spouse’s) tobacco use in the same form. After adjusting for confounding variables, women smokers were nine times more likely to have a mother who ever smoked (OR: 9.0; 95% confidence interval [CI]: 3.3–24.7) and men smokers five times more likely (OR: 5.4; 95% CI: 2.1–14.1) than non-smokers. Men smokers were seven times more likely to have close friends who smoked (OR: 7.2; 95% CI: 5.6–9.3). Users of smokeless tobacco (SLT) were five times more likely to have friends who used SLT (OR: 5.3; 95% CI: 4.4–6.3 [men]; OR: 5.0; 95% CI: 4.3–5.9 [women]) and four times more likely to have a spouse who used SLT (OR: 4.1; 95% CI: 3.0–5.8 [men]; OR: 4.3; 95% CI: 3.6–5.3 [women]), than non-users. The ORs for the association of the individuals’ tobacco use, whether smoked or smokeless, increased with the number of close friends using it in the same form.
Conclusion: The influence of family members and friends on tobacco use needs to be appropriately addressed in tobacco-control interventions.[download PDF]
Bansal-Travers, et al. 2014. Awareness of pro-tobacco advertising and promotion and beliefs about tobacco use: Findings from the Tobacco Control Policy (TCP) India Pilot Survey
Tobacco companies are utilizing similar strategies to advertise and promote their products in developing countries as they have used successfully for over 50 years in developed countries. The present study describes how adult smokers, smokeless tobacco users, and non-users of tobacco from the Tobacco Control Project (TCP) India Pilot Survey, conducted in 2006, responded to questions regarding their perceptions and observations of pro-tobacco advertising and promotion and beliefs about tobacco use. Analyses found that 74% (n = 562) of respondents reported seeing some form of pro-tobacco advertising in the last six months, with no differences observed between smokers (74%), smokeless tobacco users (74%), and nonsmokers (73%). More than half of respondents reported seeing pro-tobacco advertising on store windows or inside shops. Overall, this study found that a significant percentage of tobacco users and non-users in India report seeing some form of pro-tobacco advertising and promotion messages. Additional analyses found that smokers were more likely to perceive tobacco use as harmful to their health compared with smokeless tobacco users and non-users (p < 0.01). The findings from this study reiterate the need for stronger legislation and strict enforcement of bans on direct and indirect advertising and promotion of tobacco products in India.[download PDF]
Pawar, et al. 2014. The relation between price and daily consumption of cigarettes and bidis: Findings from the Tobacco Control Policy (TCP) Evaluation Wave 1 Survey [access full article]
Context: In India, 14% of the population use smoked tobacco products. Increasing prices of these products is one of the measures to curb their consumption. AIMS: This study analyzes “unit price” and “daily consumption” of cigarettes and bidis and investigates their relation with each other.
Settings and Design: A cross‑sectional survey was conducted in four states of India (Bihar, West Bengal, Madhya Pradesh and Maharashtra) as a part of the International Tobacco Control Policy (TCP) Evaluation Project (the TCP India Project) during 2010–2011.
Methods: Information was collected from adult (aged ≥15) daily exclusive smokers of cigarette/bidi regarding (a) last purchase (purchase in pack/loose, brand and price) and (b) daily consumption. Average unit price and daily consumption was calculated for different brands and states. Regression model was used to assess the impact of price on daily consumption.
Results: Bidis were much less expensive (₹0.39) than cigarettes (₹3.1). The daily consumption was higher (14) among bidi smokers than cigarette smokers (8). The prices and daily consumption of bidis (₹0.33–0.43; 12–15) and cigarettes (₹2.9–3.6; 5–9) varied across the four states. The unit prices of bidis and cigarettes did not influence their daily consumption. Smokers purchasing bidis in packs paid substantially less per unit and purchase of bidis and cigarettes in packs influenced their consumption positively.
Conclusions: Cigarettes although more expensive than bidis, seem very cheap if compared internationally. Hence, prices of both cigarettes and bidis do not influence their consumption. Recommended[download PDF]
Dhumal, et al. 2014. Quit history, intentions to quit, and reasons for considering quitting among tobacco users in India: Findings from the Tobacco Control Policy (TCP) Evaluation India Wave 1 Survey
Background: Global Adult Tobacco Survey India 2009-2010 revealed that more than one-third (35%) of adults in India use tobacco in some form: 21% use smokeless tobacco, 9% smoke, and 5% are mixed users (they smoke and use smokeless tobacco), and the quit rate is very low. In an effort to decrease prevalence of tobacco use, it is thus important to understand the factors that are related to intention to quit among Indian tobacco users. Research has shown consistently that intention to quit is a strong predictor of future quitting. The present study reports the factors encouraging quitting tobacco products in India.
Subjects and Methods: Cross-sectional data from Wave 1 of the International Tobacco Control Policy Evaluation India Survey conducted in four cities and surrounding rural areas (i.e. Mumbai [Maharashtra], Patna [Bihar], Indore [Madhya Pradesh], and Kolkata [West Bengal]) between August 2010 and December 2011 were analyzed. A total of 8051 tobacco users (15+ years) were randomly sampled from 8586 households: 1255 smokers, 5991 smokeless users, and 805 mixed (smoke and smokeless) users. Validated, standardized questions were asked about current tobacco use, intention to quit, and factors encouraging quitting.
Results: Overall, 19.6% of tobacco users intended to quit. Smokers had less intention to quit as compared to smokeless tobacco users whereas mixed users had more intention to quit (odds ratio [OR] =1.48, 95% confidence interval [CI] =1.12-1.97) compared to smokeless tobacco users. Highly educated people were more likely to report intention to quit (OR = 1.82, 95% CI = 1.09-3.02) compared to less educated. Advice by doctors to quit tobacco had a strong impact on intention to quit (OR = 1.68, CI = 1.29-2.15). Tobacco users who were exposed to antitobacco messages at work places (OR = 1.74, CI = 1.23-2.46), at restaurants (OR = 1.65, CI = 1.12-2.43), bars (OR = 1.81, CI = 1.07-3.06), on public transportation (OR = 2.14, CI = 1.49-3.08) and on tobacco packages (OR = 1.77, CI = 1.29-2.14) also expressed greater intention to quit tobacco use.
Conclusion: Around one-fifth of tobacco users in India intended to quit tobacco use. Higher education, doctor's advice, and antitobacco messages were positively associated with users' intention to quit tobacco.[download PDF]
Surani, et al. 2013. Intention to quit among Indian tobacco users: Findings from International Tobacco Control Policy Evaluation India Pilot Survey [access full article]
Introduction: Tobacco users face barriers not just in quitting, but also in thinking about quitting. The aim of this study was to understand factors encouraging intention to quit from the 2006 International Tobacco Control Policy (TCP) Evaluation India Pilot Study Survey.
Materials and Methods: A total of 764 adult respondents from urban and rural areas of Maharashtra and Bihar were surveyed through face-to-face individual interviews, with a house-to-house approach. Dependent variable was "intention to quit tobacco." Independent variables were demographic variables, peer influence, damage perception, receiving advice to quit, and referral to cessation services by healthcare professionals and exposure to anti-tobacco messages. Logistic regression model was used with odds ratio adjusted for location, age, gender, and marital status for statistical analysis.
Results: Of 493 tobacco users, 32.5% intended to quit. More numbers of users who were unaware about their friends' tobacco use intended to quit compared to those who were aware (adjusted OR = 8.06, 95% CI = 4.58-14.19). Higher numbers of users who felt tobacco has damaged their health intended to quit compared to those who did not feel that way (adjusted OR = 5.62, 95% CI = 3.53-8.96). More numbers of users exposed to anti-tobacco messages in newspapers/magazines (adjusted OR = 1.76, 95% CI = 1.02-3.03), restaurants (adjusted OR = 2.47, 95% CI = 1.37-4.46), radio (adjusted OR=4.84, 95% CI = 3.01-7.78), cinema halls (adjusted OR = 9.22, 95% CI = 5.31-15.75), and public transportation (adjusted OR = 10.58, 95% = 5.90-18.98) intended to quit compared to unexposed users.
Conclusion: Anti-tobacco messages have positive influence on user's intentions to quit.[download PDF]
Sansone, et al. 2012. Knowledge of health effects and intentions to quit among smokers in India: Findings from the Tobacco Control Policy (TCP) India Pilot Survey
Awareness of the health risks of smoking is an important factor in predicting smoking-related behaviour; however, little is known about the knowledge of health risks in low-income countries such as India. The present study examined beliefs about the harms of smoking and the impact of health knowledge on intentions to quit among a sample of 249 current smokers in both urban and rural areas in two states (Maharashtra and Bihar) from the 2006 TCP India Pilot Survey, conducted by the ITC Project. The overall awareness among smokers in India of the specific health risks of smoking was very low compared to other ITC countries, and only 10% of respondents reported that they had plans to quit in the next six months. In addition, smokers with higher knowledge were significantly more likely to have plans to quit smoking. For example, 26.2% of respondents who believed that smoking cause CHD and only 5.5% who did not believe that smoking causes CHD had intentions to quit (χ2 = 16.348, p < 0.001). Important differences were also found according to socioeconomic factors and state: higher levels of knowledge were found in Maharashtra than in Bihar, in urban compared to rural areas, among males, and among smokers with higher education. These findings highlight the need to increase awareness about the health risks of smoking in India, particularly in rural areas, where levels of education and health knowledge are lower.[download PDF]
Raute, et al. 2011. Knowledge of health effects and Intentions to quit among smokeless tobacco users in India: Findings from the International Tobacco Control Policy Evaluation (ITC) India Pilot Survey [access full article]
Introduction and background: The prevalence of smokeless tobacco use in India is the highest in the world, with 26% of adults reporting being users of smokeless tobacco only. But to date, there are few of beliefs, knowledge, and other psychosocial measures relating to smokeless tobacco use in India. The aim of the present study was to use data from the ITC India Pilot Study conducted in 2006 to examine beliefs about the harms of smokeless tobacco use, knowledge of health effects, and intentions to quit among current smokeless tobacco users in two states, Maharashtra and Bihar.
Methods: Data from the ITC India Pilot Study, a face-to-face cross-sectional survey of 248 adults reporting exclusive current use of smokeless tobacco in Maharashtra and Bihar, were analyzed with respect to the knowledge of health effects, beliefs about harmfulness, and intentions to quit smokeless tobacco use.
Results: Around three quarters (36%) of smokeless tobacco users from Maharashtra and two thirds (62%) from Bihar had a ‘bad’ opinion about smokeless tobacco use. About 77% believed that smokeless tobacco use causes mouth cancer, followed by gum disease (66%) and difficulty in opening the mouth (56%). Significant differences were found in health knowledge between urban and rural smokeless tobacco users in both states. Only 38% of smokeless tobacco users reported having intentions to quit, and only 11% had intentions to quit within the next 6 months. Smokeless tobacco users who reported higher knowledge of the specific health effects from smokeless tobacco use were more likely to have intentions to quit.
Conclusion: Despite the fairly high levels of awareness of health effects from smokeless tobacco use in Maharashtra and Bihar, the majority of smokeless users had no intentions to quit. Increased educational efforts about the detrimental health effects from smokeless tobacco use may result in higher levels of knowledge about the harms of smokeless tobacco and this in turn could increase quit intentions and subsequent quitting among users.[download PDF]