Perceived effectiveness of text and pictorial health warnings for smokeless tobacco packages in Navi Mumbai, India, and Dhaka, Bangladesh: findings from an experimental study

Objective To examine the perceived effectiveness of text and pictorial smokeless tobacco health warnings in India and Bangladesh, including different types of message content. Methods An experimental study was conducted in Navi Mumbai, India (n = 1002), and Dhaka, Bangladesh (n = 1081). Face-to-face interviews were conducted on tablets with adult (>= 19 years) smokeless tobacco users and youth (16-18 years) users and non-users. Respondents viewed warnings depicting five health effects, within one of the four randomly assigned warning label conditions (or message themes): (1) text-only, (2) symbolic pictorial, (3) graphic pictorial or (4) personal testimonial pictorial messages. Results Text-only warnings were perceived as less effective than all of the pictorial styles (p<0.001 for all). Graphic warnings were given higher effectiveness ratings than symbolic or testimonial warnings (p<0.001). No differences were observed in levels of agreement with negative attitudes and beliefs across message themes, after respondents had viewed warnings. Conclusions Pictorial warnings are more effective than text-only messages. Pictorial warnings depicting graphic health effects may have the greatest impact, consistent with research from high-income countries on cigarette warnings.