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Am J Health Behav. 2008 ; 32(3): 283–294. doi:10.5555/ajhb.2008.32.3.283.

Associations Between Tobacco Marketing and Use Among Urban

Youth in India

Monika Arora, MS.,

Director, Health Related Information Dissemination Amongst Youth (HRIDAY), T-7, Green Park
Extension, New Delhi-110016, India, Ph:+91-11-26174769, Fax:+91-11-26167397
K. Srinath Reddy, MD,
President, Public Health Foundation of India, PHD House, Second Floor, 4/2, Sirifort Institutional
Area, August, Kranti Marg, New Delhi-110016, India, Ph: +91-11-460 46011 & Professor,
Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029,
India
Melissa H. Stigler, Ph.D, and
Assistant Professor, University of Texas School of Public Health, Austin Campus; 313 E 12th St,
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Suite 220; Austin, TX, 78701, Ph:512-471-9908

Cheryl L. Perry, Ph.D
Professor and Assistant Dean, Michael & Susan Dell Center for Advancement of Healthy Living,
Division of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas,
Austin Program, 313 E. 12th Street, Suite 220, Austin, TX 78701, ph: 512-482-6166, fax:
512-494-0400
Monika Arora: monika@hriday-shan.org; K. Srinath Reddy: ksrinath.reddy@phfi.org; Melissa H. Stigler:
Melissa.H.Stigler@uth.tmc.edu; Cheryl L. Perry: Cheryl.L.Perry@uth.tmc.edu

Abstract
Objectives—To study if receptivity and exposure to tobacco marketing are correlated with tobacco
use and psychosocial risk factors for tobacco use among a sample of urban Indian youth.
Methods—Analysis of cross sectional survey data from Project MYTRI, a group randomized
intervention trial, in Delhi and Chennai, India collected from 6th and 8th graders (n=11642), in 32
schools in 2004.
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Results—Exposure to tobacco advertisements and receptivity to tobacco marketing were

significantly related to increased tobacco use among students.
Conclusion—This association suggests the need to strengthen policy and program-based
interventions in India to reduce the influence of such exposures.

Keywords
tobacco use; youth; schools; receptivity to tobacco marketing; exposure to tobacco advertising

INTRODUCTION
Tobacco advertising, through various media, creates positive product imagery or associations
in the minds of young people.1 Tobacco industry marketing includes varied activities designed
to increase the sale of tobacco products. The question as to whether exposure to tobacco
advertising influences tobacco use among youth has been the subject of debate between public
health professionals and the tobacco industry. A number of cross-sectional2,3 and longitudinal
studies4,5 in the West have established an association or shown a direct causal relationship,
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respectively, between exposure to tobacco advertisements and promotions and adolescents’

decision to begin or continue smoking. Studies which evaluated the association between
receptivity to cigarette promotions and smoking uptake in adolescents revealed that the
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likelihood of smoking uptake is increased when an adolescent acquires a cigarette promotional

item or becomes willing to use one.6 There is evidence that young people smoke the most
highly advertised brands, indicating the responsiveness of youth to tobacco industry’s
marketing campaign.7,8

In contemporary India, which is experiencing rapid epidemiological transition, several factors,

particularly tobacco use, are contributing to a progressive rise in the burden of non-
communicable diseases.9 Deaths attributable to tobacco are expected to rise alarmingly in many
developing nations of the world over the next 2 decades, with India having the fastest rate of
rise in these deaths.10 Most of these deaths will occur in the productive years of adult life, as
a consequence of an addiction acquired in youth. Tobacco use in India is a much greater public
health challenge compared with other countries due to the many varieties in which tobacco is
consumed. This includes smoking (like bidis and cigarettes), and smokeless forms (such as
gutkha and mawa for chewing) and direct application of tobacco (eg, Mishri).10 Cigarette
smoking constitutes only 14% of total tobacco usage in India, and large part of overall tobacco
use is indigenous tobacco products that includes both smoked and smokeless forms.11 Since
most young people in developing countries are currently non-tobacco users, the tobacco
industry views youth as an attractive target group.
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The Global Youth Tobacco Survey, conducted in Delhi and Tamil Nadu in 2001, revealed that
exposure to pro-tobacco advertisements was very high (86.8% in Delhi and 80.5% in Tamil
Nadu) among 13 to 15 year old students.12,13 The types of exposures that have been found to
influence perceptions related to tobacco use among adolescents in India include sponsorship
of sports events, like cricket,14 media images and satellite television,15 and the portrayal of
tobacco use in Indian films.16 However there is no study in India that provides clear evidence
that increased exposure to tobacco advertising and promotional activities is associated with
increased tobacco use by youth.

In September 2000, the Indian Central Government banned tobacco advertising on cable
television.10 Since then, the Indian government has made even more rapid strides towards
implementing measures to regulate tobacco use with The Cigarettes and Other Tobacco
Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production,
Supply and Distribution) Act, 2003. This Act, as enforced by the Government of India as of
May 1, 2004, calls for a complete ban on direct as well as indirect forms of tobacco advertising
and promotions. India is also a signatory to the WHO’s Framework Convention on Tobacco
Control (FCTC) and has also ratified it (http://www.fctc.org).
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The enactment of an advertising ban on all tobacco products in 2004, however, has not deterred
the tobacco industry from advertising and promoting their products by alternate means. Indian
tobacco Industries are creatively working through the loopholes in the current legislation
related to the advertising ban.10 It is important to study the influence of this changing tobacco
advertising environment on youth in India, where the Government is making efforts to protect
the youth from exposure to tobacco advertising and tobacco companies are trying hard to keep
their brands and products alive in people’s memory.

This paper presents the results of a recent study of the association of receptivity to tobacco
marketing and exposure to tobacco advertisements with tobacco use among urban youth in 2
cities of India. A survey of youth in Delhi and Chennai, India was conducted in 2004 as part
of the baseline assessment for Project MYTRI (Mobilizing Youth for Tobacco Related
Initiatives in India), which is a group randomized trial designed to evaluate the efficacy of a

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school-based, multi-component intervention to prevent and reduce tobacco use among urban
youth in grades 6–9 in India. MYTRI is a research study conducted through a partnership
between the University of Texas (USA) and 2 non-government organizations in India:
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HRIDAY (Health Related Information Dissemination Amongst Youth in Delhi) and TNVHA
(Tamil Nadu Voluntary Health Association in Chennai).

Initial analyses of the baseline data revealed that the prevalence of tobacco use was significantly
higher among students in the 6th grade versus 8th grade.17,18 This unusual finding suggested
a new trend of higher tobacco use by young persons in this rapidly changing environment of
India. Students attending Government schools (of middle-lower SES), boys, older students,
and those in 6th grade were using more tobacco in this survey as compared with students who
were in Private schools (of middle to high SES), girls, younger, and in 8th grade. In this sample,
tobacco use increased with age, but only within a grade. Within each grade level (6th v. 8th
grade), the older students were using tobacco at significantly higher rates than the younger
students. In addition, 6th grade students’ tobacco use was 2 to 4 times that of 8th grade students.
17 In this study, 24.8% of 6th graders and 9.3% of 8th grade students had ever used tobacco;
6.7% and 2.9% respectively were current users. Reasons for this differential were explored in
a follow up study that analyzed a series of etiological factors to determine (1) how they were
related to tobacco use and (2) how they were distributed across the 2 grade levels. Some of the
strongest correlates identified by this study included social susceptibility to and social norms
about tobacco use. Almost all psychosocial factors were unevenly distributed between grade
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levels, with 6th graders showing more risk than 8th graders, indicating higher overall risk for
tobacco use. Interestingly, exposure to advertising was an especially strong correlate of tobacco
use for 6th graders but not for 8th graders.18 Intrigued by this, we were interested in exploring
further relationships concerning advertising and promotions in this study sample.

The present study addresses 4 specific questions: (1) Is receptivity to tobacco advertising or
promotion related to tobacco use among youth in 2 urban cities in India? (2) Is receptivity to
tobacco advertising or promotion associated with psychosocial risk factors for tobacco use
among youth in 2 urban cities in India? (3) Is exposure to tobacco advertising related to tobacco
use among youth in 2 urban cities in India? (4) Is exposure to tobacco advertising associated
with psychosocial risk factors for tobacco use among youth in 2 urban cities in India? A series
of dose-response analyses were conducted to examine these potential associations. Grade level
and gender were also included as potential effect modifiers of the relationship between
receptivity and exposure to tobacco advertising and tobacco use.

METHODS
Subjects
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The research design of Project MYTRI is reported in detail elsewhere.17–19 Project MYTRI
includes 32 schools from 2 cities: Delhi (16 schools) and Chennai (16 schools). These schools
were selected as they represent the range of types of schools in these cities of India. The schools
included are Government (representing low - middle SES), Private (representing middle - high
SES), girls only, boys only and co-educational schools. Total eligible students in 6th and 8th
grade of 32 schools were 12,484. A self-administered, paper and pencil survey was conducted
with 11,748 students, representing 94% of the sample, at baseline (before intervention began),
during June-August 2004. After eliminating inconsistent responders (< 1%) of sample,
absentee students (4.4%) and those who did not consent (1.5%), the final sample of analysis
for this study was 11,642 students. Of these 5889 (50.6%) students were from Delhi, 7153
(61.4%) belonged to Government schools, 6386 (54.9%) were males and 6165 (52.9%) were
in grade 6 (Table 1). The mean age of the 6th and 8th graders was 11.2 and 12.9 years,
respectively (range 10–16 years).

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The survey was administered in each classroom by a trained team of 2 persons using
standardized protocols. Surveys were administered in English, Hindi and Tamil in accordance
with the medium of instruction in schools. Active student assent and informed but passive
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parent consent were obtained prior to the survey. Students were assured about the
confidentiality of their responses. Ethical approval was provided by the Independent Ethics
Committee, Mumbai, India and the Institutional Review Board, University of Minnesota,
Minneapolis.

Measures
Current tobacco use—Three questions were used to measure current use of tobacco:
“During the last 30 days, did you chew tobacco in any form?/Smoke one or more bidis?/Smoke
one or more cigarettes?” The response categories were “Yes” and “No”. Students who
responded “yes” to one or more of the questions were given a “1” on this variable (for current
use of any tobacco) while all other students received a “0” (for no current use of any tobacco).

Ever tobacco use—Three questions were used to measure ever tobacco use: “How old were
you when you first chewed tobacco?/Put a lit bidi in your mouth?/Put a lit cigarette in your
mouth?” The first response category for this question was: “I have never smoked/chewed
tobacco” The students who chose this category were coded “0” on this variable, to represent
_”no use”. The other response option categories provided included ages at which the student
could have first smoked/chewed tobacco, _7 years old or less, 8 to 9 years old, 10 to 11 years
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old,12 to 13 years old, 12 to 13 years old, 14 to 15 years old and 16 years old or more. All these
categories were collapsed and coded as “1,” to represent ever use. Similar to the measure of
current tobacco use, responses to the 3 questions were combined in this way so that ever use
of any tobacco was coded as “0” (for ‘no use’) and “1” (for ‘use’).

Psychosocial risk factors—The psychosocial risk factors analyzed in this study include:
(1) intentions to chew tobacco in future; (2) intentions to smoke tobacco in the future; (3) social
susceptibility to chewing tobacco; (4) social susceptibility to smoking tobacco; (5) reasons to
use tobacco; (6) perceived prevalence of chewing tobacco; (7) perceived prevalence of smoking
tobacco; and (8) normative beliefs about tobacco use. These factors were shown in a prior study
to be associated with increased use of tobacco among youth in India.18 Scales were created to
measure these factors using multiple items on the MYTRI survey. A brief description of each
scale, including examples of items on each scale is provided in Table 2. Details about how
these scales were constructed are provided elsewhere.18 Since the range of each scale (Table
2) varied, all scales were standardized before being used in the analyses (ie, the mean was set
to 0 and the standard deviation to 1). This allows for direct comparisons between scales in
regards to magnitude of the parameter estimates that are generated by the analyses.19
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Receptivity to tobacco advertising or promotion—An index of receptivity to tobacco

advertising or promotion was created combining responses to 3 items on the survey: “Do you
have a favorite tobacco advertisement?”, “Do tobacco advertisements show real life
situations?” and “Would you ever wear or use an item that has the name of a tobacco product
on it?”. The response categories were “Yes” and “No.” Based on the responses, 3 levels of
receptivity were created, with students being ‘highly receptive,” if they responded “Yes” to 2
or all 3 questions, being moderately receptive, if they responded “Yes” to one of the 3 questions
and being not at all receptive if they responded “No” to all 3 questions.

Exposure to tobacco advertising—An exposure index measuring the range of venues

where tobacco advertisements usually appear in India, despite there being an advertising ban
both pre- and post-implementation of Indian Tobacco Control Act 2003, was created by
combining responses to options listed on the survey under the question “Have you seen any

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advertisement for tobacco?” The 7 options given were: “…on television”; “…in movies”; “…
in cinema halls”; “…in newspapers, magazines or other print media”; “…on hoardings
(billboards)”; “…posters or walls”; “…at sports events and at cultural events”. The response
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categories for each were “Yes” and “No”. Each question was scored as 0 for “No” and 1 for
“Yes”. Using responses to these 7 options, 3 levels of exposure to tobacco advertisements were
created with students being ‘highly exposed’, if they reported having seen tobacco
advertisements at >4 places, being ‘moderately exposed’, if they reported having seen tobacco
advertisements at 1–4 places and ‘not exposed’, if they reported not having seen tobacco
advertisements on any of the listed 7 places.

Data Analysis
Mixed-effects regression models were used to examine the following: (1) the association
between the level of receptivity to tobacco advertising or promotion and current or ever use of
tobacco; (2) the association between the level of receptivity to tobacco advertising and
psychosocial risk factors for tobacco use; (3) the association between exposure to tobacco
advertisements and current or ever use of tobacco; and (4) the association between exposure
to tobacco advertisements and psychosocial risk factors for tobacco use. Receptivity and
exposure to tobacco advertising were the independent variables in these regression models;
tobacco use and psychosocial risk factors were the dependent variables. Mixed-effects models
(which are also known as hierarchical models in other contexts) are appropriate for study
designs like these, since they appropriately account for the variability between students and
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schools in the dependent variable.21 Schools were treated as a nested random effect in the
model.22 Gender and grade were examined as potential effect modifiers in regression models
1 and 3 described above. All models were adjusted for city, type of school, age, grade, and
gender (when not stratified by the latter variables). The analyses were conducted using SAS
statistical software.

RESULTS
Receptivity to tobacco advertisements or promotion
Of the 493 students who responded that they had a favorite tobacco advertisement, 238
recollected specific brand names. A total of 52 brands were listed, including smoking and
chewing forms of tobacco products. Of the students reporting brand names, the average number
of brands reported was about one per student. While a few students (n=3) reported up to 5
brands, most reported just one (n=186), and others reported about 2 to 4 brands (n=49). There
were more favorite advertisements reported for chewing tobacco (n=236) than smoking
tobacco (n=83). Among smoking forms, “Wills,” a cigarette brand name of Indian Tobacco
Company (ITC, the Indian subsidiary of British American Tobacco), was the most reported
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tobacco brand, followed by “Gold Flakes” of ITC, and “Red and White” of Godfrey Philips
India Ltd. (an Indian subsidiary of Philip Morris). Advertisements of chewing tobacco product
brands that students reported to be their favorite included 35 brands with “Pan Parag” being
the most reported brand.

Of the 11,642 students, 99.3% (n=11,568) responded to the questions of receptivity. On the
index of receptivity to tobacco advertising, 5.8% (n=665) reported to be “highly receptive,”
29.7% (n=3438) reported to be “moderately receptive” and 64.5% (n=7465) reported to be
“not at all receptive.” Receptivity to tobacco advertising was significantly related to increased
tobacco use among these students, with evidence of a dose-response relationship (Figure 1)
(P<0.01). The prevalence of tobacco use rose progressively with higher scores on the 3
measures of receptivity to tobacco advertising and promotion (having a favorite tobacco
advertisement, believing misleading imagery created by tobacco advertisements and
willingness to use a tobacco promotional item).

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This relationship did vary by grade, for both ever tobacco use (P<0.10) and current tobacco
use (P<0.01). The dose-response relationship was steeper for students in grade 8, as compared
to grade 6, with ever use of tobacco among highly receptive students being more than twice as
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high as compared to students who reported to be moderately receptive (Table 3). This
relationship did not vary by gender, for either ever (P=0.51) or current (P=0.95) use.

Receptivity to tobacco use was also significantly related to all psychosocial risk factors
evaluated in this study (P<0.01). Table 4 presents the differences in various psychosocial risk
factors with rising levels of receptivity to tobacco advertising among these students. Students
who reported to be “not at all receptive” scored lower on all of the factors, indicating that they
were at less risk compared with students who reported to be “moderately receptive” who in
turn had a lower risk than those who reported to be “highly receptive”.

There was variation in the strength of association of psychosocial risk factors with the level of
receptivity as shown by the standardized scores in Table 4. Among the students who reported
to be highly receptive to tobacco advertising, the strongest influence was observed on students’
reasons to use tobacco (eg, “Does using tobacco make a person appear to be more grown up?”)
followed by their normative beliefs about tobacco (eg, “Is it okay for film actors and actresses
to promote tobacco products?”)

Exposure to tobacco advertising—Of the 11,642 students, 10,877 (93.4%) responded to

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the questions related to exposure to tobacco advertising. About 37% students reported having
seen tobacco advertisements at more than 4 places, about 50% reported to have seen tobacco
advertisements at 1–4 places and 13.2% reported not having seen any tobacco advertisement
on any of the 7 places listed in the survey. The index of exposure to tobacco advertising (as
indicated by number of places where students reported to have seen tobacco advertisements)
was significantly associated with current use of any tobacco product among this sample of
students (Figure 2), with evidence of a dose-response relationship between the number of
venues of exposure and the percentage of students who currently use any tobacco product
(P<0.01). There were no significant differences with regard to ever use of tobacco.

The relationship between exposure to advertising and tobacco use did vary by grade for both
ever tobacco use (P<0.06) and current tobacco use (P<0.05). The dose response relationship
was present for 6th graders, but not for 8th graders (see Table 5). The relationship between
exposure to advertising and ever tobacco use also varied by gender (P<0.05). The prevalence
of ever tobacco use increased with exposure levels among girls (P=0.02), but not among boys
(P=0.66). The relationship did not vary by gender, however, for current tobacco use (P=0.36).
The prevalence of current tobacco use increased with increased exposure to tobacco advertising
for both boys and girls.
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All of the psychosocial factors studied showed a significant positive association with the
exposure index, except for intentions to chew tobacco (eg, “Do you think that you will try
chewing tobacco when you enter college?”) and social susceptibility to chewing tobacco (eg,
“If one of your close friends gave you chewing tobacco would you chew it?”) (Table 6).
Students who reported greater exposure (having seen tobacco advertisements at 1–4 places or
> 4 places) scored higher on all psychosocial risk factors, indicating that they were at greater
risk for tobacco use as compared to students who reported having not seen any tobacco
advertisement at any of the 7 places mentioned in the survey.

Among various psychosocial risk factors, exposure to advertising had the strongest relationship
with perceived prevalence of chewing tobacco (eg, “How many boys of your age in India do
you think chew tobacco regularly?”) and smoking tobacco (eg, “How many adult males in
India do you think smoke tobacco regularly?”).

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DISCUSSION
This study provides evidence that tobacco advertising and promotion are associated with
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tobacco use among this sample of urban youth from 2 cities in India. These data suggest that
advertising and promotion may contribute to an environment that makes young people more
susceptible to tobacco use, by negatively influencing the psychosocial risk factors strongly
predictive of subsequent use.1,4 Our findings replicate what has been shown in cross sectional
studies in western countries.3,23 Such epidemiologic studies have not been conducted in large
developing countries, especially in the context of changes in the socio-demographic profile of
the population and rapidly changing tobacco control environment.

The finding that few students (493 out of 11,642) reported having a favorite tobacco
advertisement and only 238 of them could recall a specific brand name, suggests that currently
a small percentage of young people are aware of tobacco advertisements. This situation,
however, can and may be rapidly change(ing), if tobacco advertising in India is not
comprehensively restricted and the restrictions subsequently enforced. This study
demonstrates that levels of receptivity to tobacco advertising or promotion and exposure to
tobacco advertising are correlated with the prevalence of tobacco use (particularly current
tobacco use). Current use of tobacco products was 5 times lower among students who were
not at all receptive to tobacco advertising or promotion as compared to students who reported
to be highly receptive, with the moderately receptive group having an intermediate risk. This
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finding is also in line with a cross–sectional study in the West, where a dose response
relationship has been observed between the number of cigarette promotional items owned by
an adolescent and their likelihood of being a smoker.24 Similar results were observed in this
study with exposure to tobacco advertising and current tobacco use. This is consistent with a
previous study in the West, which reported that youth seeing cigarette advertisements in
magazines increased their likelihood of experimenting with smoking.25

The data from this study about association between receptivity and exposure to tobacco
advertisement and tobacco use, adds to the evidence that tobacco advertising may target and
impact young adolescents.1,8 This finding has serious implications for India, which has a 51%
population below the age of 25 years. Studies have shown that smoking initiation largely occurs
before the age of 18 and since the results of this study highlight that younger adolescents are
more vulnerable, protecting the youth from the influence of tobacco advertising and promotion
becomes an urgent public health concern in India. Due to the cross–sectional nature of this
study, it is important to note that the association observed here could be bidirectional with no
clear evidence of exposure (ie, receptivity to tobacco advertising and exposure index)
preceding the response (ie, increased tobacco use). The fact that this study demonstrates that
students have reported exposure to tobacco advertising at places where it is banned since
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September 2000 (on television), and at other places, where it is banned (like print media etc.)
after a complete ban on advertising was enacted in 2004, suggests that a comprehensive ban
on advertising (and subsequent enforcement of that ban) may be required to protect youth from
this exposure. The current law allows point of sale advertising; therefore students could have
reported seeing advertisements on hoardings. Thus, the results of our study provide additional
support for the policy recommendation for enforcement of a comprehensive ban on tobacco
advertising in order to effectively lower tobacco prevalence rates. However, one limitation of
this study is the items forming the exposure index, do not assess their exposure to tobacco
advertising within a timeframe, therefore it is difficult to assess if the students are reporting
exposure before the ban on tobacco advertising was enacted in India, in 2004 or are reporting
a new exposure.

Pursuant to implementation of a ban on direct and indirect tobacco advertising in India, since
May 1, 2004, some tobacco brands continue to be advertised through surrogate means (eg,

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“brand stretching”). This was evident in the favorite tobacco advertisements reported by
students (“Pan Parag” and “Wills”), which are the most advertised oral and smoked tobacco
brands, respectively even after enactment of ad ban. These brands are extensively projected
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on television and print media by employing “brand stretching” onto non-tobacco products (eg,
advertising for clothing with “Wills” brand name and having chewing pan masala product with
“Pan Parag” brand name). Promoting tobacco use through attractive schemes of scratch
coupons, accompanying gifts and product placement in films are a few strategies being
employed by the Indian tobacco companies to circumvent the legislation of advertising ban in
India.10

The results of this study support the hypothesis that tobacco product advertising and promotions
may be an important influence contributing to the increase in tobacco use and change in tobacco
use patterns among urban Indian adolescents.17 Such influences may have been strengthened
by sophisticated western images used by cigarette companies to target women and youth in
India.26 Because of the cross sectional nature of this study, causal conclusions cannot be made
without further longitudinal investigation. We cannot rule out the possibility of a reverse
association in this study’s findings, suggesting that tobacco use behavior may influence youth’s
receptivity to tobacco advertising or promotions.

The associations established in this study provide evidentiary support for regulatory controls
on all direct and indirect methods by which tobacco products are advertised and promoted to
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youth, in order to protect young people from tobacco industry’s tactics of targeting the youth
in developing countries through increased product exposure. Current legislation in India needs
to be effectively enforced and loopholes in the legislation need to be plugged to avoid
advertising and promotion of tobacco products through surrogate means such as “brand
stretching”. The influence of advertising and promotion on tobacco use by young persons
should be eliminated by effectively closing all channels of advertising and promotion of
tobacco products.

Acknowledgments
The research reported was funded by a grant from the Fogarty International Center (R01TW05952-01; Perry CL, PI).
All contributing authors declare that none of them had any competing interest that would influence the results of this
study. Funding agency had no role in the study design, in the collection, analysis, and interpretation of data; in the
writing of the report; and in the decision to submit the paper for publication. Authors’ work was independent of the
funding agency’s involvement. A section of this manuscript was presented as a poster at 13th World Conference on
Tobacco or Health, July 2006 in Washington.

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Figure 1.
Difference in tobacco use, by receptivity to tobacco advertising among students in Project
MYTRI (N=11642)
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NIH-PA Author Manuscript

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 Arora et al. Page 11
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Figure 2.
Difference in tobacco use, by exposure to advertising venues among students in Project MYTRI
(N=11642)
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NIH-PA Author Manuscript

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Table 1

Demographics of Sample at Baseline (n = 11,642)a

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Frequency Percent
City/Centre
Delhi n = 5889 50.6%
Chennai n = 5753 49.4%
School Type
Private n = 4489 38.6%
Government n = 7153 61.4%
Class/Grade
Class 6 n = 6165 52.9%
Class 8 n = 5477 47.1%
Gender
Male n = 6386 54.9%
Female n = 5256 45.2%

Age (completed)b
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<=10 years n = 1598 13.8%

11 years n = 3035 26.2%
12 years n = 2792 24.1%
13 years n = 2580 22.3%
14 years n = 1075 9.3%
15 years n = 345 3.0%
>= 16 years n = 161 1.4%

a
This is the sample for analysis, which includes all students who completed a survey at baseline (n = 11748) minus those who responded inconsistently
to more than 3 questions on the survey (n = 106)
b
Some students did not report their age (n=56)
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Table 2
Description of multi-item scales used to measure psychosocial risk factors
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Scales Items α Range Examples of items on scales

Intentions to use tobacco (chewing) 4 0.85 0–12 “Do you think you will chew tobacco when you
are an adult?”
Intentions to use tobacco (smoking) 4 0.87 0–12 “Do you think you will try smoking cigarettes or
bidis in the next year?”
Social susceptibility (chewing) 4 0.87 0–12 “If one of your close friends gave you chewing
tobacco, would you chew it?”
Social susceptibility (smoking) 4 0.88 0–12 “If a group of friends gave you a cigarette or a
bidi, would you smoke it?”
Reasons to use tobacco 6 0.73 0–18 “Does using tobacco make a person appear to be
more grown up?”
Perceived prevalence (chewing) 4 0.64 0–12 “How many boys of your age in India do you think
chew tobacco?”
Perceived prevalence (smoking) 4 0.66 0–12 “How many boys of your age in India do you think
smoke tobacco?”
Normative beliefs 6 0.79 0–18 “Is it okay for boys of your age to try tobacco out
of curiosity?”
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Table 3

Relationship between receptivity to advertising and tobacco use by gradea

Grade 6 Grade 8
Arora et al.

NOT AT ALL RECEPTIVE NOT AT ALL RECEPTIVE

(n=3895) MODERATELY RECEPTIVE (n=1851) HIGHLY RECEPTIVE (n=361) (n=3570) MODERATELY RECEPTIVE (n=1587) HIGHLY RECEPTIVE (n=304)

Percentage Percentage Percentage P-valueb Percentage Percentage Percentage P-valueb

Ever use of 21.0 (± 2.4) 24.9 (± 2.6) 41.6 (± 4.6) < 0.01 8.2 (± 1.6) 10.1 (± 2.0) 24.7 (± 3.6) < 0.01
any tobacco
Current use of 4.2 (± 1.4) 8.3 (± 1.6) 21.4 (± 2.8) < 0.01 2.0 (± 0.8) 3.5 (± 1.0) 11.6 (± 2.0) < 0.01
any tobacco

a
Estimates generated from mixed-effects models adjusted for city, school type, gender, and age.
b
P value for trend

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Table 4

Differences in psychosocial risk factors for tobacco use, by receptivity to tobacco advertising, among students in Project MYTRI(n=11642)a

NOT AT ALL RECEPTIVE (n=7465) MODERATELY RECEPTIVE (n=3438) HIGHLY RECEPTIVE (n=665)
Arora et al.

Meanc SE Meanc SE Mean3 SE P-value

Intentions to use tobacco(chewing)b − 0.042 (0.025) 0.090 (0.027) 0.633 (0.044) < 0.01

Social susceptibility(chewing)b − 0.023 (0.028) 0.107 (0.031) 0.651 (0.046) < 0.01

Intentions to use tobacco(smoking)b − 0.076 (0.020) 0.061 (0.023) 0.713 (0.041) < 0.01

Social susceptibility(smoking)b − 0.057 (0.022) 0.074 (0.026) 0.640 (0.043) < 0.01

Reasons to use tobaccob − 0.095 (0.019) 0.130 (0.022) 0.839 (0.041) < 0.01

Normative beliefsb − 0.065 (0.023) 0.137 (0.026) 0.735 (0.043) < 0.01

Perceived prevalence(chewing)b − 0.026 (0.026) 0.079 (0.029) 0.214 (0.045) < 0.01

Perceived prevalence(smoking)b − 0.052 (0.019) 0.074 (0.023) 0.230 (0.042) < 0.01

a
Estimates generated from mixed-effects models adjusted for city, school type, gender, age, andgrade.
b
Scale scores are standardized. A higher score (eg, positive number) denotes more risk (or conversely, is less protective).
c
Estimate represents the mean score for each scale (eg, intentions to use tobacco), in a particular category of receptivity to advertising (eg, not at all receptive). A larger estimate (eg, positive number) denotes
more risk (eg, more intentions to use tobacco) (or conversely, is less protective).

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Table 5

Relationship between exposure to advertising and tobacco use by gradea

> 4 PLACES > 4 PLACES

Arora et al.

Grade 6 0 PLACES (n=959) 1–4 PLACES (n=2702) (n=1943) Grade 8 0 PLACES (n=480) 1–4 PLACES (n=2699) (n=2094)

Percentage Percentage Percentage P-valueb Percentage Percentage Percentage P-valueb

Ever use of 19.4 (± 3.2) 23.0 (± 2.6) 23.3 (± 2.8) < 0.05 Ever use of 11.6 (± 3.0) 8.6 (± 1.6) 10.2 (± 1.8) < 0.05
any tobacco any tobacco
Current use 3.0 (± 2.0) 6.3 (± 1.6) 7.2 (± 1.6) < 0.01 Current use 2.2 (± 1.8) 2.5 (± 0.8) 3.3 (± 1.0) 0.20
of any of any
tobacco tobacco

a
Estimates generated from mixed-effects models adjusted for city, school type, gender, and age.
b
P value for trend

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Table 6
Differences in psychosocial risk factors for tobacco use, by exposure to tobacco advertising, among 6th and 8th grade students in Project MYTRI (n=11642)
a
Arora et al.

0 PLACES (n=1439) 1–4 PLACES (n=5401) > 4 PLACES (n=4037)

Meanc SE Meanc SE Meanc SE P-value

Intentions to use tobacco (chewing)b − 0.015 (0.034) 0.033 (0.025) 0.035 (0.026) 0.23

Social susceptibility(chewing)b 0.016 (0.037) 0.060 (0.028) 0.039 (0.030) 0.29

Intentions to use tobacco (smoking)b − 0.100 (0.032) 0.011 (0.023) 0.035 (0.024) < 0.01

Social susceptibility(smoking)b − 0.051 (0.033) 0.014 (0.025) 0.037 (0.026) 0.01

Reasons to use tobaccob − 0.188 (0.031) 0.045 (0.021) 0.047 (0.022) < 0.01

Normative beliefsb − 0.080 (0.034) 0.040 (0.025) 0.063 (0.026) < 0.01

Perceived prevalence(chewing)b − 0.129 (0.036) − 0.023 (0.027) 0.125 (0.028) < 0.01

Perceived prevalence(smoking)b − 0.176 (0.031) − 0.039 (0.020) 0.120 (0.022) < 0.01

a
Estimates generated from mixed-effects models adjusted for city, school type, gender, age, and grade.
b
Scale scores are standardized. A higher score (eg, positive number) denotes more risk or conversely, is less protective.
c
Estimate represents the mean score for each scale (eg, intentions to use tobacco), in a particular category of exposure to advertising (eg, not at all receptive). A larger estimate (eg, positive number) denotes
more risk (eg, more intentions to use tobacco) (or conversely, is less protective).

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