BACKGROUND: Limited information exists in India about the awareness and perception of the
people regarding pictorial health warnings (PHWs) and text warnings on tobacco products, more
so from rural areas. Objectives were to report the awareness of these warnings, factors predicting
awareness and perceived effectiveness of PHWs, and understanding of their content in a rural
MATERIALS AND METHODS: A community‑based cross‑sectional study was conducted in
two villages (chosen randomly out of total four) in the rural field practice area of a tertiary care
teaching hospital in Puducherry. Households were selected by systematic random sampling. All
persons ≥18 years and residing in the area for at least 6 months were included. Data regarding
awareness and perception of participants was collected through a semi‑structured interview
RESULTS: A total of 428 participants were recruited; 197 (46%) were male, and 231 (54%) were
female. The mean age of the participants was 38.9 (standard deviation 15.0) years. Awareness
of PHWs and text warnings was 39.5% (169/428) and 21% (90/428), respectively. Only 11.2%
participants perceived PHWs as effective. Most (45%) of the participants had a vague understanding
of the content of PHWs. On multivariate logistic regression, male gender, current tobacco use, and
better education emerged as predictors of greater awareness of PHWs. Extended family predicted
greater perceived effectiveness of PHWs, whereas, high socioeconomic class and middle school
completion predicted lower perceived effectiveness of PHWs.
CONCLUSION: Awareness and perceived effectiveness of adults in rural Puducherry regarding
PHWs were low. There is a need to create awareness through education and using meaningful,
larger pictures.


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