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Exposure to tobacco imagery in popular films and the risk of ever smoking among children in southern India
  1. Muralidhar M Kulkarni1,
  2. Veena Ganesh Kamath1,
  3. Asha Kamath2,
  4. Sarah Lewis3,
  5. Ilze Bogdanovica3,
  6. Manpreet Bains3,
  7. Jo Cranwell4,
  8. Andrew Fogarty3,
  9. Monika Arora5,6,
  10. Gaurang P Nazar5,
  11. Kirthinath Ballal1,
  12. Rohith Bhagwath1,
  13. John Britton3
  1. 1Community Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Udupi, India
  2. 2Department of Data Science, Prasanna School of Public Health, Manipal Academy of Higher Education, Udupi, India
  3. 3Division of Epidemiology and Public Health, UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, UK
  4. 4Department of Health, University of Bath, Bath, Somerset, UK
  5. 5Health Related Information Dissemination Amongst Youth (HRIDAY), New Delhi, India
  6. 6Health Promotion, Public Health Foundation of India, New Delhi, India
  1. Correspondence to Dr Veena Ganesh Kamath, Community Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Udupi 576104, India; veenak{at}


Background Exposure to smoking in films is a recognised cause of smoking uptake among children. In India, in an attempt to protect children, films containing smoking are required to include tobacco control messaging including audiovisual disclaimers, on-screen health warnings when tobacco imagery is displayed and antitobacco ‘health spots’ before and during the film. We report a study of the association between ever smoking and exposure to tobacco imagery in locally popular films among children in Udupi district of Karnataka state in southern India.

Methods A cross-sectional questionnaire survey of all students in grades 6–8 in schools in the Udupi district ascertained smoking status and potential confounders of smoking uptake, and whether children had seen any of 27 locally popular films we had coded and found to contain imagery of actual or implied tobacco use. Ever-smoking status was defined as any reported smoking of cigarettes, beedis or other tobacco products currently or at any time in the past. Independent effects on ever-smoking status were estimated using multiple logistic regression.

Results Of 46 706 students enrolled in grades 6–8 in 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever smoking was reported by 914 (2.3%) participants and in a mutually adjusted model was significantly related to age, male sex, living in a home where smoking is allowed, having parents or siblings who smoke, low paternal education, low levels of family wealth, low self-esteem, rebelliousness and poor school performance. After allowing for these effects, the odds of ever smoking were not increased among students who had seen any of the listed films containing tobacco imagery when included in the analysis as a binary exposure (OR 0.9, 95% CI 0.4 to 2.0), and decreased in relation to level of exposure graded into tertiles of tobacco intervals seen.

Conclusions In this cross-sectional study, children in southern India who had seen films containing tobacco imagery are no more likely to smoke than those who had not, indicating that the tobacco control messaging mandated by Indian law may be attenuating the effect of tobacco imagery in films on smoking uptake.

  • advertising and promotion
  • low/middle income country
  • media
  • public policy
  • prevention

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  • Contributors JB and MMK conceptualised the study. The research plan was strengthened by SL, JC, AK, AF, MA and VGK. Questionnaire was developed by MMK, JB, AF and IB and refined with inputs from MA, GPN, KB and VGK. Movie coding analysis was done by AK, JC, RB and GPN. Data collection in the field was coordinated by RB and supervised by MMK, KB, VGK and AK. The qualitative data analysis was done by AK and SL. Interpretation of data and drafting the manuscript were done by JB, MMK, IB, VGK, AK, SL and MA. Final approval of the version was read and approved by all authors.

  • Funding This work was supported by the Medical Research Council (grant number MR/P008933/1) of the UK under the Global Alliance for Chronic Lung Diseases programme.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethics approval was granted by the Manipal and Nottingham University Ethics Committees, the Centre for Chronic Disease Control India, and the Health Ministry’s Screening Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. All the data are stored in anonymised form with the Co-PI of the research project. The metadata could be shared after obtaining regulatory approvals based on the purpose of requirement.

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