were males and 73 were females [Table 1]. In the age group of 11-15 years the mean age of the participants was 13 ± 2.8 years and that of age group of 16-19 years 17.5 ± 2.12 years (P < 0.001). The sample consisted of total 373 males and 127 females (P < 0.001).
Only 168 (33.6%, P < 0.05) had often "noticed warnings on tobacco packs in the last month," 137 (27.4%, P > 0.05) had "sometimes" read or looked closely at the warnings on tobacco packs in the last month, 131 (26.2%, P > 0.05) had "rarely" thought about what warnings on the tobacco packs are telling them with the pack in sight/out of sight in the last month, 155 (31%, P > 0.05) had rarely "talked with anyone about these warnings" [Table 2].
|Table 2: Distribution of participants based on the response of the questions |
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In the last month, majority 415 (83%, P > 0.05) found these "pictures were not easy to understand," 421 (84.2%, P > 0.05) found these "images were not believable," 403 (80.6%, P < 0.05) found these "images were not truthful in respect to the health risks associated with tobacco use," 432 (86.4%, P < 0.05) found these "images did not deter them from the likely use of tobacco," 446 (89.2%, P > 0.05) found it "did not stop them from using tobacco" [Table 3].
|Table 3: Distribution of participants based on the response of the questions |
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| Discussion|| |
This study was conducted to assess the adolescent response to pictorial and textual warnings on a reverse panel of tobacco products. In this study, it was observed that very small portion of the study sample hardly ever thought about the warnings or discussed about it. Such a finding points toward the lack of seriousness or lack of sensitization of the adolescents regarding such habits.
Similarly, majority of the study participants found these warnings as unbelievable, not easy to understand or truthful and that these warnings did not deter them from using tobacco. This study is first of its kind to be conducted in India. Most of the studies have been conducted regarding the prevalence of tobacco usage but none about the impact of warnings on the individuals. These findings are similar to those observed by Moodie et al.  that these warnings have negligible impact on daily users of tobacco and are contrary to findings in a study by Callery et al. 
Attractiveness of the packaging and small display areas of the warnings have always been considered to the reasons for the initiation of the tobacco as most of the adolescents mistook it as a mouth freshener and once they initiated the habit it was difficult to stop the same. This fact definitely highlights the importance of stopping the initiation of the tobacco habit. Government of India has come up with measures to reduce the attractiveness of the packages by mandating plain packaging in years to come.  Yet definitively awareness among the students regarding the seriousness of the warnings can be a definitive step toward our goal. ,
Through the preliminary observation we can infer the textual and pictorial warnings fail to have desired deterrent impact on the adolescent who tend to initiate tobacco use despite the warning. Drawback can be the lack of inclusion of school dropouts in the study sample. Further research with a larger sample and inclusion of adolescents from diverse social demographic profiles are needed to come up with measures to enhance the comprehension of them regarding the pictorial and textual warnings. The study was an attempt to understand the perceptions of adolescents regarding the health risk warning on tobacco packs. Furthermore, it is recommended to sensitize adolescents by including vices of tobacco use as part of education system.
| Conclusions|| |
Based on the findings of this study, it can be concluded that there is need for more attention in educating and sensitizing the adolescents of this region to the seriousness of the textual and pictorial warnings, so that they can make responsible decisions regarding the initiation or continued use of tobacco products.
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