Association Between Cigarette and Bidi Purchase Behavior (Loose vs Pack) and Health Warning Label Exposure: Findings From the Tobacco Control Policy India Survey and In-Depth Interviews With People Who Smoke

BACKGROUND: The sale of loose cigarettes or bidis can undermine the purpose of requiring health warning labels (HWLs) on cigarette packs and bidi bundles by diminishing their visibility and legibility. OBJECTIVE: This mixed-methods study aims to examine the association between purchase behavior (loose vs pack or bundle), HWL exposure, and responses to HWLs among Indian adults who smoke. METHODS: Data were analyzed from the 2018-2019 India Tobacco Control Policy Survey and from 28 in-depth interviews conducted with Indian adults who smoked in 2022. The Tobacco Control Policy Survey sample included tobacco users who bought cigarettes (n=643) or bidis (n=730), either loose or in packs or bundles at their last purchase. Ordinal regression models were fit separately for cigarettes and bidis, whereby HWL variables (noticing HWLs, reading and looking closely at HWLs, forgoing a cigarette or bidi because of HWLs, thinking about health risks of smoking, and thinking about quitting smoking cigarettes or bidis because of HWLs) were regressed on last purchase (loose vs packs or bundles). In-depth interviews with participants from Delhi and Mumbai who purchased loose cigarettes in the last month were conducted, and thematic analysis was used to analyze the interview data. RESULTS: Survey findings indicated that about 74.3% (478/643) of cigarette users and 11.8% (86/730) of bidi users reported having bought loose sticks at their last purchase. Those who purchased loose cigarettes (vs packs) noticed HWLs less often (estimate -0.830, 95% CI -1.197 to -0.463, P<.001), whereas those who purchased loose bidis (vs bundles) read and looked closely at HWLs (estimate 0.646, 95% CI 0.013-1.279, P=.046), thought about the harms of bidi smoking (estimate 1.200, 95% CI 0.597-1.802, P<.001), and thought about quitting bidi smoking (estimate 0.871, 95% CI 0.282-1.461, P=.004) more often. Interview findings indicated lower exposure to HWLs among those who purchased loose cigarettes, primarily due to vendors distributing loose cigarettes without showing the original cigarette pack, storing them in separate containers, and consumers' preference for foreign-made cigarette brands, which often lack HWLs. While participants were generally aware of the contents of HWLs, many deliberately avoided them when purchasing loose cigarettes. In addition, they believed that loose cigarette purchases reduced the HWLs' potential to deliver consistent reminders about the harmful effects of cigarette smoking due to reduced exposure, an effect more common among those who purchased packs. Participants also noted that vendors, especially small ones, did not display statutory health warnings at their point of sale, further limiting exposure to warning messages. CONCLUSIONS: Survey and interview findings indicated that those who purchased loose cigarettes noticed HWLs less often. Loose purchases likely decrease the frequency of exposure to HWLs' reminders about the harmful effects of smoking, potentially reducing the effectiveness of HWLs.