# Standardizing smokeless tobacco packs in India to enhance health warning visibility and harm perceptions

## TL;DR

This study examines how standardizing smokeless tobacco packaging in India could improve health warning visibility and increase perceptions of harm among users.

## Contribution

The study introduces and evaluates standardized khaini pack designs to enhance health warning visibility and perceived harm.

## Key findings

- Standard packs increased health warning noticeability compared to existing packs.
- The standard paper sachet was perceived as more harmful than the tin cylinder due to larger health warnings.
- Most focus groups found health warnings on existing packs to be small, blurry, or faint.

## Abstract

Approximately 21% of adults in India use smokeless tobacco and over half use khaini, a tobacco-lime mixture. Khaini is available in a variety of pack shapes and sizes, which can affect health warning label (HWL) size and placement. This study explored consumer perceptions of existing khaini packs and two proposed standard shape/size khaini packs across dimensions of HWL noticeability and harm perceptions.

In March 2023, we conducted 24 focus groups (FGs) across India. Groups were equally numbered by residence, gender, and current khaini use. FGs were led by trained facilitators. Each FG discussed six existing khaini packs and two standard packs (paper sachet; tin cylinder). Data were collected in local languages, translated into English, and thematically analyzed.

All FGs discussed the limited visibility of HWLs on existing packs, noting that HWLs were often small, blurry, or printed too faintly to notice. Most (defined as ≥80%) FGs discussed how the HWLs on both standard packs were large and easy to see. FGs discussed how the standard packs appeared more harmful than existing packs due to the large, clearly printed HWL. Most FGs found that the standard tin cylinder was less harmful than the standard paper sachet due to its comparatively smaller HWL.

Both standard khaini packs increased HWL noticeability and perceived harm compared to existing packs, and the standard paper sachet was seen as more harmful than the standard tin cylinder. Implementing the standard sachet pack could enhance HWL visibility and increase perceptions of harm among consumers.