Manipulated: graphic health warnings on smokeless tobacco in rural India

India is unique in its dual burden of tobacco use. Nearly 200 million individuals use smokeless tobacco (SLT) products in India,1 with almost 200 000 deaths attributed to SLT use in 2010.2 SLT users tend to live in rural areas and have lower levels of education.1 India has made substantial strides in tobacco control in recent years, including the 2016 increase in health warning label (HWL) coverage to 85% on all tobacco products sold, including SLT. The Tobacco Pack Surveillance System (TPackSS) has been monitoring HWL compliance in India and other low-income and middle-income countries since 2013. After 5600 tobacco products purchased globally, we noticed something truly unique. Following data collection of 240 unique SLT products purchased in rural India in 2017, 133 (55%) packs had the current SLT-specific Indian HWL. We observed that several current HWLs on packs appeared to be altered (figure 1). After …