Introduction
Tobacco consumption remains a leading reason for disability and premature death worldwide with India accounting to a large extent to this problem. Tobacco-related mortality rate is expected to rise to 10 million/year by 2030 with developing countries accounting for 70% of the tobacco-related deaths [1]. The tobacco consumption in both the forms i.e., smoking and smokeless, can lead to death with mortality around six million people per annum [2,3]. In India, tobacco use occurs in dual forms like smoking and smokeless such as beedis, chewing pan, gutka, mishri, hookah, chutta, chillum, cigar, khaini, zarda, khiwam, and masher [4].
Both active and passive smoking is responsible for increased incidences of morbidity and mortality by causing cardiovascular disorders, cancers, respiratory diseases, peripheral vascular diseases, stroke etc., [5].
Smokers have a 20 times higher risk than non-smokers of acquiring lung carcinoma and the risk is 10 times higher for obtaining ischaemic heart disease. Pregnant women who smoke are more susceptible to premature birth, miscarriage, and low birth weight babies [6].
Tobacco contains a vast range of chemicals such as carbon dioxide, tar, phenol, cadmium, lead, hydrogen cyanide, formaldehyde, nitrosamines, acrolein etc., to have credible evidence to cause carcinogenic, cytotoxic, mutagenic, antigenic properties. This can lead to endothelial dysfunction, inflammation, thrombosis, and low-density lipoprotein cholesterol oxidation, elevation of several pro-inflammatory cytokines, and free radical-mediated oxidative stress. The active or passive intake of these toxins in the smoke of cigarette are rapidly dissolved and taken up into systemic circulation [7].
The strategy for managing tobacco-dependence includes pharmacological interventions and behavioural therapy. Nicotine causes bodily pathophysiological changes those results in the development of tolerance. Pharmacological agents such as nicotine gums and patches, bupropion, varenicline, antidepressants, anxiolytics are aimed at reducing withdrawal symptoms and interrupt the fortifying effects of nicotine [8]. Pharmacological interventions should be accompanied by psychotherapy with the active participation of the smokers, non-smokers, community and government through various policies and programs [8].
For many individuals, encouragement and support to quit attempts, regulate nicotine withdrawal symptoms and avert relapse are required. The final target of the therapy should be abstinence from smoking for a long-term. The first step towards it is to consider cessation for an initial short period of time. Behavioural therapy follows the ‘5-As’ approach which includes to ‘Ask’ patients if they smoke followed by ‘Advice’ on quitting, Assessment’ to determine willingness to stop smoking, to offer ‘Assistance’ either as pharmacotherapy or as behavioural therapy and finally, ‘Arrange’ a follow up appointment [9,10].
Mendez D et al., opine that if further actions were not initiated, it would lead to smoking prevalence amounting to 22.7% in 2020 and 22% in 2030 as per the Global InfoBase Database of the World Health Organization (WHO). The numbers would amount to 872 million smokers [3]. In 2003 the World Health Assembly adopted the Framework Convention on Tobacco Control (FCTC), which includes 174 countries, covering 85% of the world’s population [11]. To aid countries in implementation of effective interventions to reduce the demand for tobacco and its consumption in various forms, in 2008 the WHO disseminated recommendations called MPOWER, which included the following strategies: monitor tobacco use, protect people from tobacco smoke, offer help to quit tobacco use, warn about the dangers of tobacco, enforcing bans on tobacco advertising promotion and sponsorship, and raise taxes on tobacco [12].
With increasing consumption of tobacco every year, India’s first anti-tobacco legislation was passed in 1975. However, it was inefficient as the legislation restricted itself only to healthcare warnings [13]. Advertisements through different means of mass media are banned but are still advertised with some restrictions [13]. In order to strengthen the implementation of tobacco control, National Tobacco Control Programme (NTCP) was initiated in 2007-2008. This was done to improve provisions of Cigarettes and Other Products Act (COPTA) and provisions under WHO FCTC.
It essentially was done to improve public awareness, behavioural change, and start facilities for testing of tobacco products, research, training, and school programs [14].
The motivation and reinforcement attempt to quit smoking is done through education campaigns and tobacco control policies. Advertisements are paid communication about the product, services, idea, or an organisation by means of mass media such as newspaper, television, radio, internet etc., [15]. Advertisements for products and services are designed to communicate a message for a certain duration of time. Advertisements focus on showing the program repeatedly to persuade the consumer to change their behaviour. To avoid boring, irritating consumers with repetitive messages, advertisers use multiple advertisements with a different setup; situation etc., [16]. There is a need to collect data on the impact of these advertisements on a larger population. Hence, through self-administered questionnaires, authors aimed to study the effect of Government of India initiated anti-smoking and anti-tobacco advertisement among young adults and the responses were studied using psychological tests.
Materials and Methods
This questionnaire-based study was conducted on the general population, a sample of 250 people in Bengaluru Urban (Bengaluru South), Karnataka, India, from July 2014 to August 2014 among the age group of 18 to 25 years because it is impressionable age group or it is the most smoking age group. The Exclusion criteria of the study were: People below age group 18 years and above 25 years were excluded and the people who have not watched the Government of India initiated anti-tobacco and anti-smoking advertisements either on Cinema or television or any other media were excluded. Subjects were chosen randomly from the general public. Both tobacco users and non-users of both genders were selected for baseline data collection. A self-administered questionnaire was administered after obtaining written informed consent from each participant and the data was collected. The questionnaire was validated by 2-point validation method and checked for reliability by the Department of Public Health Dentistry and Department of Oral and Maxillofacial Pathology, The Oxford Dental College, Hospital, and Research Centre, Bengaluru, Karnataka, India.
A self-administered questionnaire was used to collect data on: i) Basic personal details; (ii) Specific questions regarding Anti-Tobacco Govt. advertisements; (iii) Psychological tests like Inkblot, TAT and Sentence completion tests to check the responses in tobacco and non-tobacco users.
Study Tool
The self-administered questionnaire [Annexure 1] with a total of 10 questions consisted of socio-demographic information, the status of smoking or tobacco use, knowledge and attitude towards tobacco use, the effectiveness of Government of India initiated anti-tobacco advertisements and the effectiveness of these advertisements in tobacco control measures. There were five questions with regard to knowledge and attitude towards tobacco use. Two options were given for each question in the questionnaire: (a) YES; and (b) NO.
Psychological tests were scored based on the classification present with respect to each test and the subjects were categorised as per the classification to which they belong, based on the answer they have given.
In this study, a total of 250 young adults between age 18 to 25 of either gender were given self-administered questionnaires. The principal investigator explained the study process and purpose to the study participants. After obtaining written informed consent from each participant, data was collected on socio-demographic information, on the impact of viewing anti-tobacco advertisements by tobacco users and non-users. Psychological tests like Inkblot, TAT and Sentence completion tests were conducted to check the different responses like emotion, imagination and personality in tobacco and non-tobacco users. The participants were questioned about attitude, as to how they accepted the messages they viewed and their opinion with respect to government advertisements about anti-tobacco [17]. Considering the effect size to be measured (ρ) at 20% i.e., Correlation coefficient between the variables at 0.20, the power of the study at 80% and the margin of the error at 0.05%, the total sample size needed was 191, and the sample was round to 200. Anticipating 20% attrition during data collection, the total sample size was rounded off to 250.
Psychological/Behavioural Assessment
Three psychological assessment tests were conducted and they were chosen as the tests are easy to perform and demonstrate, easily understood by commoner and portable. It is to be noted that there are no single tests to assess all the psychological and behavioural aspects of the study subjects.
1. Sentence completion test: Sentence Completion Tests are used to assess the personality of the participant which indicates attitude, beliefs, motivation, or other mental states [Annexure 1] [18,19]. The classification that was used for scoring both tobacco and non-tobacco users categories are:
(a) Optimistic; (b) Pessimistic; (c) Realistic; (d) Subjective; (e) Confused.
Example: 1. I like______
2. India is____________________
Sentence completion tests can be interpreted in two different ways: subjective-intuitive analysis: In this analysis, the underlying motivations are projected in the subject’s responses, or objective analysis: This analysis is done by means of scores assigned to each completed sentence [18,19].
2. Thematic Apperception Test (TAT): This test is used to assess the person’s emotional status. The responses of the subjects on a famous sketch were classified as ‘Positive Emotions’, ‘Negative Emotions’, and ‘Ambiguous Emotions’ [Annexure 2] [20,21]. The test consists of showing the subject a series of images or only a single image asking him/her to make up a little story or ask them like what they understand seeing that image. TAT is real pictures, which imagine something. Scoring was done based on the above classification present and the subjects were categorised as per the classification to which they belong based on the answer they have given.
3. Rorschach inkblot test: This test evaluates the subject’s response to ambiguous inkblots which in turn reveals the personality of the subject. The responses of the subjects were classified as ‘Positive Imagination’, ‘Negative Imagination’, and ‘No Imagination’ [Annexure 3] [22,23]. The tests consist of showing the subject an ambiguous image and ask them to imagine and record their opinion. Scoring was done based on the above classification present and the subjects were categorised as per the classification to which they belong based on the answer they have given.
Statistical Analysis
The Statistical Analysis was done using SPSS version 22.0 software IBM, Corp. The collected data were compared between tobacco users and non-users and presented as a percentage. The response of tobacco users and non-users towards anti-tobacco advertisements is presented in percentage. A descriptive analysis of the data was presented as frequency, mean, and Standard Deviation (SD). The level of significance was set at p<0.05. Chi-Square test analysis was applied to determine the statistical significance between the psychological tests and the effectiveness of Government of India initiated anti-tobacco advertisements among tobacco and non-tobacco users.
Results
Among 250 study participants, all the participants recalled Government of India initiated anti-tobacco messages/spots about smoking either on Cinema or television or any other media. The recall rate was high in all the participants. Out of all the participants, 158 were the tobacco users and 92 were non-Tobacco users. The response of study participants about watching anti-tobacco advertisements is represented by [Table/Fig-1]. The analysis of data collected showed that among total participants, 28% felt like giving up the habit after watching advertisements, 23% reduced the habit after watching and 49% gave up the habit after watching advertisements [Table/Fig-1].
Pie-chart showing the impact of watching advertisements when total sample was considered.
Further, in the study, [Table/Fig-2] shows the number of tobacco users among the different age groups and emotional response of participants towards anti-tobacco advertisements was depicted in [Table/Fig-3] wherein 54% of the total participants were scared to take up the habit and 46% of the total participants were not scared to take up to the habit after watching the advertisements [Table/Fig-3].
Graph showing the number of tobacco users among the different age groups.
X axis: Number of tobacco users
Y axis: Age of the subjects
Graph showing the number of respondents who were scared to take-up the habit after watching the advertisements.
Among tobacco users, 53.16% were scared to take up the habit and 46.84% were not scared. According to [Table/Fig-4], 40.8% of total participants felt that advertisements to be effective [Table/Fig-4]. Among tobacco users, 65.19% do not feel the advertisements to be effective when compared to 48.91% of tobacco non-users. In sentence completion test, 37.039% of tobacco users and 51.085% of non-tobacco users have understood the purpose of the test conducted [Table/Fig-5]. In Sentence Completion test, optimistic replies were more from non-tobacco users compared to the tobacco users. In Inkblot test, there were more positive imaginative people in the non-tobacco user group [Table/Fig-6]. In TAT, there was not much difference between the two groups either in positive or negative emotions [Table/Fig-7]. In non-tobacco users, TAT was statistically significant with respect to effectiveness of advertisements (p<0.05). Only in non-tobacco users, TAT was statistically significant with respect to effectiveness of advertisements (p<0.05). The rest were not [Table/Fig-8]. Chi-Square test analysis was applied to determine the statistical significance between the psychological tests and the effectiveness of Government of India initiated anti-tobacco advertisements among tobacco and non-tobacco users.
Graph showing the effectiveness of advertisements on tobacco users and non-tobacco users.
Graph showing the results of Sentence Completion Test among tobacco users and non-tobacco users.
Graph showing the results of Inkblot Test among the tobacco users and non-tobacco users.
Graph showing the results of Thematic Apperception Test among tobacco users and non-tobacco users.
And the statistical test Chi-square test analysis to determine the statistical significance (p-value) with respect to this particular table and between the psychological tests and the effectiveness of Government of India initiated anti-tobacco advertisements among tobacco and non-tobacco users as mentioned in the statistical analysis section of the article. Only in Non-Tobacco users, Thematic Apperception Test (TAT) was statistically significant with respect to effectiveness of advertisements (p<0.05). The rest were not.
Discussion
The analysis of the study done by authors indicate that among 250 participants who watched Government of India initiated anti-tobacco and anti-smoking advertisements aired on television, movies, radios etc., 49% in overall participants gave up watching advertisements and among tobacco users, 48.73% gave up watching them and 51.27% continued watching the anti-tobacco advertisements. The emotional response to the advertisements showed that 54% of the total participants were scared to take up the habit and 46% were not scared. A 40.80% of total participants felt that these advertisements are effective while 59.20% felt them ineffective. This suggests that anti-tobacco advertisements have a lesser impact on the participants, especially on the tobacco users.
A lesser proportion of tobacco users (34.81%) feel that the advertisements to be effective when compared to non-tobacco users (51.09%). This indicates that these advertisements are lacking many ideas which induce motivation in targeted mass to reduce or quit the habits. This also suggests some new strategies to be introduced to attract the public towards cessation of the tobacco habits. This suggests the need for a stronger strategy to aid public especially young adults in watching the Government of India initiated anti-tobacco and anti-smoking advertisements to motivate them to stop tobacco use or stop them from starting the habit itself.
In Sentence Completion Test 37.039% of tobacco users and 51.085% of non-tobacco users have understood the purpose of the test conducted. In Inkblot Test, there were more Positive Imaginative people in the non-tobacco user group. TAT showed that there was not much difference between the two groups either in positive or negative emotions.
A study by Kaur J and Jain D, has shown that with respect to the challenges of implementation about Tobacco Control Policies of India showed that it remains a challenge [14]. According to author, the states have shown different success percentages at different levels. In another study by Kaur J et al., noted that 37% of the subjects feel the advertisements are effective and Interventional Community based Study done by Maulana Azad Medical College, New Delhi group on effectiveness of Anti-tobacco audio-visual messages on knowledge and attitudinal change towards the tobacco used showed that Mass media plays a significant role in initiation as well as in control of tobacco use [14,17].
There has been an increasing prevalence of tobacco-related diseases in India, especially among the youth. This is contributed to the addicting nature of tobacco, behavioural/psychological factors and belief and practices of an individual producing health hazards and economic burden [13].
Television advertisements that inform about the serious hazards of tobacco use are plausible to be successful with smokers and can be readily translated and adapted for local use [13]. Knowledge about psychological tests like Rorschach Inkblot test made its adjunct to psychiatric evaluation of the person’s mind and its unstructured nature made it possible to evaluate an uncooperative patient [23]. Study by Shah PB et al., has further concluded that knowledge improvement and converting it to a positive attitude about tobacco use has been attributed to anti-tobacco advertisements and they also state that the current message delivered through anti-tobacco advertisements is minimal and infers that the counter-advertising has a protective effect on youth and it may function as tobacco and smoking cessation aids [24]. The effectiveness of the advertisements is influenced by the intensity and duration of anti-tobacco advertisements and mass media campaigns, but the concurrent events and follow-up the length in the community makes it difficult to verify [25]. Bala MM et al., found that there were no consistent patterns between the age, education, ethnicity or gender of those subjects taking part in the study and the effects of the anti-tobacco advertisements and campaigns [25]. In the present study, the retention and recall of the anti-tobacco government advertisements were positive with respect to the participants and when asked about the advertisements they do recall message/spot about smoking. Tobacco users were significantly less than tobacco non-users to recall watching the advertisements since tobacco users sometimes did not care since they felt it was always monotonous.
“Youth smoking and the media” conducted by Wakefield M et al., in United States reveals that many tobacco companies have begun advertising strategies to promote a message to youth not to smoke, which gradually creating a situation, where it leads to a rise of questions regarding which anti-tobacco/anti-smoking advertising may have greater or lesser impact on youth smoking [26].
The study by Hong YH et al., found no difference between ethnic groups and its impact on the anti-smoking message. Also, they found that the internet was the best mode to dissipate anti-smoking advertisements [15]. The study by Bhatia M et al., revealed that around 17% of the drivers had tried tobacco products by observing the celebrities in mass media and peer pressure contributed to about 67% [27]. In our study, 34.81% of the subjects who were tobacco and tobacco product users felt that these anti-tobacco Government advertisements were useful which also inspired them to quit completely or to reduce the usage of tobacco products. The prevalence rate of tobacco use was the national figure of 30% [28]. Kaur J et al., found that socialization was a major factor among the professionals of public health for initiation as well as the continuation of tobacco use [17].
The level of changes in behaviour at a mass level is dependent upon factors such as values and beliefs both at the individual level as well as community-level besides the level of anti-tobacco campaign awareness [17]. Even though there are numerous anti-tobacco advertisements and campaigns initiated by the Government of India, there is an increase in tobacco consumers and the average number of quitting attempts ranges from 3-5 only [29,30].
The new strategies that need to be adopted to make anti-tobacco campaigns effective are as follows: Tobacco cessation centres within clinics can be introduced, Spreading awareness among the public about other diseases which occur due to smoking should be followed by the clinicians, new effective strategies should be employed in Anti-Tobacco Government Advertisements catering to tobacco users, the National, State and District level initiatives against the tobacco use should be implemented promptly and it should be made mandatory to put up Effective Anti-Tobacco posters in every dental clinic.
Knowledge about the harmful effects of smoking and tobacco use is a crucial element for smoking cessation and prevention. According to the knowledge-attitude-practice model, [31] acquiring relevant knowledge, changing related attitudes and altering practices are the important components involved in the assessment of change in the behaviour. Researches from China have found only weak associations between knowledge about smoking and actual smoking behaviour. Studies from Western countries revealed that, than the current smokers, the ex-smokers were twice as likely as to be aware of the harmful effects of tobacco smoking, [32,33] but comparable studies in China found a much weaker relationship between smoking status and knowledge of the health consequences of tobacco use and smoking [34-37].
There is an urgent need to take an effectual step on school children and the public, especially by launching community awareness programs to alert them about the consequences of tobacco use, and on assessing their effectiveness in reducing the problem. It is also necessary to keep updated of the policies and conventions of the international agencies like World Health Organization (WHO), United Nations Office on Drugs and Crime (UNDCP) and other similar agencies on tobacco use, to utilize their skill and proficiency in curbing this problem [38]. Study in India conducted by Imtiaz D et al., among the rural population in Dehradun district Of Uttarakhand revealed that most of them were aware of the hazardous effects of tobacco and also knew that the tobacco consumption can lead to lung cancer and oral consumption of tobacco can lead to oral cancer but still there is a need for initiating community awareness programmes targeting the rural population and making them aware of various health consequences of smoking and tobacco use [39].
Limitation
This pilot study was conducted among general population aged between 18-25 years in South Bangalore. Hence, the present sample may not represent all young smokers. There is a need for collection of data of urban and rural dwellers, relation to education status, the standard of living etc, which present study lacks. The study was a self-administered questionnaire; hence there are high chances of recall basis. Only an overlook on behavioural response of participants about anti-tobacco advertisements has been obtained, but a more detailed behavioural assessment is required.
Apart from the combined pharmacological therapy and psychotherapy for tobacco use, there is need of support from the friends, family, community and the government with the continuous conduct of studies on the anti-tobacco measures so that adequate data are collected. A good strategy, use of multimedia, set up of regulations and community participation are important for the anti-tobacco campaign.
Conclusion
From the above study it can be elucidated that though anti-tobacco advertisements are effective in quitting tobacco use, still, there is a need of more systematic, strategised implementation of the anti-tobacco measure to facilitate stop of tobacco use. Media sources like television, radio, theatre and newspapers help to curb tobacco menace as an effective strategy to improve knowledge and change attitudes.
[1]. Peto RLA, The future worldwide health effects of current smoking patterns. In: Koop EC, Pearson CE, Schwarz PM, eds Global Health in the 21st Century 2000 New York, NYJossey-Bass:154-161. [Google Scholar]
[2]. WHO. WHO Report on the Global Tobacco Epidemic. Warning about the dangers of Tobacco. WHO, Bloomberg Philanthropies, 2011 [Google Scholar]
[3]. Mendez D, Alshanqeety O, Warner KE, The potential impact of smoking control policies on future global smoking trends Tobacco Control 2013 22(1):46-51.10.1136/tobaccocontrol-2011-05014722535364 [Google Scholar] [CrossRef] [PubMed]
[4]. Mehta FS, Sahiar BE, Daftary DK, Gupta PC, Pindborg JJ, A correlative Histocytological study of carcinoma and epithelial atypia of the palate among Indian reverse smokers Br J Cancer 1972 26:230-33.10.1038/bjc.1972.315047146 [Google Scholar] [CrossRef] [PubMed]
[5]. Ambrose JA, Barua RS, The pathophysiology of cigarette smoking and cardiovascular disease: an update Journal of the American College of Cardiology 2004 43(10):1731-37.10.1016/j.jacc.2003.12.04715145091 [Google Scholar] [CrossRef] [PubMed]
[6]. Centre for Population Health NMoH. Managing Nicotine Dependence: A guide for NSW staff. 2015 [Google Scholar]
[7]. Fowles J, Noiton D, The Chemical Constituents in Cigarettes and Cigarette Smoke: Priorities for Harm Reduction A Report to the New Zealand Ministry of Health March 2000 [Google Scholar]
[8]. Jiloha RC, Pharmacotherapy of smoking cessation Indian Journal of Psychiatry 2014 56(1):87-95.10.4103/0019-5545.12472624574567 [Google Scholar] [CrossRef] [PubMed]
[9]. Ruwisch SMJ, Abroms CL, Bernstein SL, Heminger CL, A content analysis of Electronic Health Record (EHR) functionality to support tobacco treatment Transl Behav Med 2017 7(2):148-56.10.1007/s13142-016-0446-027800564 [Google Scholar] [CrossRef] [PubMed]
[10]. Kumar S, Ward C, Wilson L, Mangi A, Ischemic cardiomyopathy is an independent predictor of mortality in patients presenting for Heart Mate II left ventricular assist device implantation Lung India 2005 22(2):68-73. [Google Scholar]
[11]. WHO. WHO Framework Conventionon Tobacco Control Printed by the WHO Document Production Services, Geneva, Switzerland., World Health Organization 2003, updated reprint 2004, 2005 [Google Scholar]
[12]. WHO. WHO Report on the Global Tobacco Epidemic, 2008. The MPOWER package [Google Scholar]
[13]. McVey D, Stapleton J, Can anti-smoking television advertising affect smoking behaviour? Controlled trial of the Health Education Authority for England’s anti-smoking TV campaign Tobacco Control 2000 9(3):273-82.10.1136/tc.9.3.27310982571 [Google Scholar] [CrossRef] [PubMed]
[14]. Kaur J, Jain D, Tobacco Control Policies in India: Implementation and Challenges Indian Journal of Public Health 2011 55(3):220-27.10.4103/0019-557X.8994122089690 [Google Scholar] [CrossRef] [PubMed]
[15]. Hong YH, Khan N, Soh PCH, Teh BH, Effectiveness of anti-smoking advertising: the roles of message and media International Journal of Business and Management 2013 8(19)ISSN 1833-3850 E-ISSN 1833-811910.5539/ijbm.v8n19p55 [Google Scholar] [CrossRef]
[16]. Pechmann C, Reibling ET, Anti-smoking advertising campaigns Targeting youth: case studies from USA and Canada Tobacco Control 2000 9(Suppl2):ii18-ii31.10.1136/tc.9.suppl_2.ii1810841588 [Google Scholar] [CrossRef] [PubMed]
[17]. Kaur J, Kishore J, Kumar M, Effect of Anti-Tobacco Audiovisual Messages on Knowledge and Attitude towards Tobacco Use in North India Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive & Social Medicine 2012 37(4):227-31.10.4103/0970-0218.10347023293436 [Google Scholar] [CrossRef] [PubMed]
[18]. Hoppe CF, Loevinger J, Ego development and conformity: a construct validity study of the Washington University Sentence Completion Test Journal of Personality Assessment 1977 41(5):497-504.10.1207/s15327752jpa4105_616367204 [Google Scholar] [CrossRef] [PubMed]
[19]. Torstrick A, McDermut W, Gokberk A, Bivona T, Walton KE, Associations Between the Rotter Incomplete Sentences Blank and Measures of Personality and Psychopathology Journal of Personality Assessment 2015 97(5):494-505.10.1080/00223891.2015.101567925803203 [Google Scholar] [CrossRef] [PubMed]
[20]. Morgan WG, Origin and history of the earliest Thematic Apperception Test pictures Journal of Personality Assessment 2002 79(3):422-45.10.1207/S15327752JPA7903_0312511014 [Google Scholar] [CrossRef] [PubMed]
[21]. Langan-Fox J, Grant S, The Thematic apperception test: toward a standard measure of the big three motives Journal of Personality Assessment 2006 87(3):277-91.10.1207/s15327752jpa8703_0917134336 [Google Scholar] [CrossRef] [PubMed]
[22]. Wood JM, Lilienfeld SO, Nezworski MT, Garb HN, Allen KH, Wildermuth JL, Validity of Rorschach Inkblot scores for discriminating psychopaths from non-psychopaths in forensic populations: ameta-analysis Psychological Assessment 2010 22(2):336-49.10.1037/a001899820528061 [Google Scholar] [CrossRef] [PubMed]
[23]. Dimsdale JE, Use of Rorschach tests at the Nuremberg war crimes trial: A forgotten chapter in history of medicine Journal of Psychosomatic Research 2015 78(6):515-18.10.1016/j.jpsychores.2015.04.00125896214 [Google Scholar] [CrossRef] [PubMed]
[24]. Shah PB, Pednekar MS, Gupta PC, Sinha DN, The relationship between tobacco advertisements and smoking status of youth in India Asian Pacific Journal of Cancer Prevention: APJCP 2008 9(4):637-42. [Google Scholar]
[25]. Bala MM, Strzeszynski L, Topor-Madry R, Cahill K, Mass media interventions for smoking cessation in adults The Cochrane Data Base of Systematic Reviews 2013 (6):Cd00470410.1002/14651858.CD004704.pub3 [Google Scholar] [CrossRef]
[26]. Wakefield M, Flay B, Nichter M, Giovino G, Effects of anti-smoking advertising on youth smoking: a review Journal of Health Communication 2003 8(3):229-47.10.1080/1081073030568612857653 [Google Scholar] [CrossRef] [PubMed]
[27]. Bhatia M, Mishra A, Agrawal AK, Prevalence and pattern of tobacco addiction among auto-rickshaw drivers of North Central India Asian Pac J Health Sci 2014 1(4):312-18.e-ISSN:2349-0659,p-ISSN:2350-096410.21276/apjhs.2014.1.4.2 [Google Scholar] [CrossRef]
[28]. NFHS. National Family Health Survey (NFHS-3); Volume I. 2005-06 [Google Scholar]
[29]. Biener L, Anti-tobacco advertisements by Massachusetts and Philip Morris: what teenagers think Tobacco Control 2002 11(Suppl2):ii43-46. [Google Scholar]
[30]. WHO. Gender, women, and the tobacco epidemic: World Health Organization; [4/26/2017]. Available from: http://www.who.int/tobacco/publications/gender/women_tob_epidemic/en/ [Google Scholar]
[31]. Ward MM, Vaughn TE, Uden-Holman T, Doebbeling BN, Clarke WR, Woolson RF, Physician knowledge, attitudes and practices regarding a widely implemented guideline J Eval Clin Pract 2002 8:155-62.10.1046/j.1365-2753.2002.00337.x12180364 [Google Scholar] [CrossRef] [PubMed]
[32]. Finney Rutten LJ, Augustson EM, Moser RP, Beckjord EB, Hesse BW, Smoking knowledge and behaviour in the United States: sociodemographic, smoking status, and geographic patterns Nicotine Tob Res 2008 10:1559-70.10.1080/1462220080232587318946775 [Google Scholar] [CrossRef] [PubMed]
[33]. Nobile CG, Anfosso R, Pavia M, Angeliio IF, Cigarette smoking: knowledge, attitudes and behaviour in an adult population in Italy Public Health 2000 114:348-52.10.1016/S0033-3506(00)00362-0 [Google Scholar] [CrossRef]
[34]. Han MY, Chen WQ, Chen X, Do smoking knowledge, attitudes and behaviours change with years of schooling? A comparison of medical with non-medical students in China J Community Health 2011 36:966-74.10.1007/s10900-011-9396-021452029 [Google Scholar] [CrossRef] [PubMed]
[35]. Lin YS, Wu DM, Lai HR, Shi ZP, Chu NF, Influence of knowledge and attitudes on smoking habits among young military conscripts in Taiwan J Chin Med Assoc 2010 73:411-18.10.1016/S1726-4901(10)70089-7 [Google Scholar] [CrossRef]
[36]. Klink K, Lin S, Elkin Z, Strigenz D, Liu S, Smoking cessation knowledge, attitudes, and practice among community health providers in China Fam Med 2011 43:198-200. [Google Scholar]
[37]. Wen X, Chen W, Qian Z, Muscat JE, Lu C, Ling W, Differences in students’ smoking-related knowledge, attitudes, and behaviours among public, factory, and private secondary schools in Guangzhou, China J Sch Health 2008 78:46-53.10.1111/j.1746-1561.2007.00265.x18177300 [Google Scholar] [CrossRef] [PubMed]
[38]. Chadda RK, Sengupta SN, Tobacco use by Indian adolescents Tobacco Induced Diseases 2002 1(2):111-19.10.1186/1617-9625-1-2-11119570251 [Google Scholar] [CrossRef] [PubMed]
[39]. Imtiaz D, Kandpal SD, Juyal R, Shrotriya VP, A study on awareness about harmful effects of tobacco use among rural population in Dehradun district of Uttarakhand National Journal of Community Medicine 2015 6(2):270-73. [Google Scholar]