Research-based guidelines for warning design and evaluation

Effect of Frequency of Changing Point-of-Use Reminder Signs on Health Care Worker Hand Hygiene Adherence: A Cluster Randomized Clinical Trial

IMPORTANCE

Although hand hygiene (HH) is considered the most effective strategy for preventing hospital-acquired infections, HH adherence rates remain poor.

OBJECTIVE

To examine whether the frequency of changing reminder signs affects HH adherence among health care workers.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized clinical trial in 9 US Department of Veterans Affairs acute care hospitals randomly assigned 58 inpatient units to 1 of 3 schedules for changing signs designed to promote HH adherence among health care workers: (1) no change; (2) weekly; and (3) monthly. Hand hygiene rates among health care workers were documented at entry and exit to patient rooms during the baseline period from October 1, 2014, to March 31, 2015, of normal signage and throughout the intervention period of June 8, 2015, to December 28, 2015. Data analyses were conducted in April 2018.

INTERVENTIONS

Hospital units were randomly assigned into 3 groups: (1) no sign changes throughout the intervention period, (2) signs changed weekly, and (3) signs changed monthly.

MAIN OUTCOMES AND MEASURES

Hand hygiene adherence as measured by covert observation. Interrupted time series analysis was used to examine changes in HH adherence from baseline through the intervention period by group.

RESULTS

Among 58 inpatient units, 19 units were assigned to the no change group, 19 units were assigned to the weekly change group, and 20 units were assigned to the monthly change group. During the baseline period, 9755 HH opportunities were observed at room entry and 10 095 HH opportunities were observed at room exit. During the intervention period, a total of 15 855 HH opportunities were observed at room entry, and 16 360 HH opportunities were observed at room exit. Overall HH adherence did not change from baseline compared with the intervention period at either room entry (4770 HH events [48.9%] vs 3057 HH events [50.1%]; P = .14) or exit (6439 HH events [63.8%] vs 4087 HH events [65.2%]; P = .06). In units that changed signs weekly, HH adherence declined from baseline at room entry (-1.9% [95% CI, -2.7% to -0.8%] per week; P < .001) and exit (-0.8% [95% CI, -1.5% to 0.1%] per week; P = .02). No significant changes in HH adherence were observed in other groups.

CONCLUSIONS AND RELEVANCE

The frequency of changing reminder signs had no effect on HH rates overall. Units assigned to change signs most frequently demonstrated worsening adherence. Considering the abundance of signs in the acute care environment, the frequency of changing signs did not appear to provide a strong enough cue by itself to promote behavioral change.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02223455.

Taxes and front-of-package labels improve the healthiness of beverage and snack purchases: a randomized experimental marketplace

BACKGROUND

Sugar taxes and front-of-package (FOP) nutrition labelling systems are strategies to address diet-related non-communicable diseases. However, there is relatively little experimental data on how these strategies influence consumer behavior and how they may interact. This study examined the relative impact of different sugar taxes and FOP labelling systems on beverage and snack food purchases.

METHODS

A total of 3584 Canadians 13 years and older participated in an experimental marketplace study using a 5 (FOP label condition) × 8 (tax condition) between-within group experiment. Participants received $5 and were presented with images of 20 beverages and 20 snack foods available for purchase. Participants were randomized to one of five FOP label conditions (no label; 'high in' warning; multiple traffic light; health star rating; nutrition grade) and completed eight within-subject purchasing tasks with different taxation conditions (beverages: no tax, 20% tax on sugar-sweetened beverages (SSBs), 20% tax on sugary drinks, tiered tax on SSBs, tiered tax on sugary drinks; snack foods: no tax, 20% tax on high-sugar foods, tiered tax on high-sugar foods). Upon conclusion, one of eight selections was randomly chosen for purchase, and participants received the product and any change.

RESULTS

Compared to those who saw no FOP label, participants who viewed the 'high in' symbol purchased less sugar (- 2.5 g), saturated fat (- 0.09 g), and calories (- 12.6 kcal) in the beverage purchasing tasks, and less sodium (- 13.5 mg) and calories (- 8.9 kcal) in the food tasks. All taxes resulted in substantial reductions in mean sugars (- 1.4 to - 4.7 g) and calories (- 5.3 to - 19.8 kcal) purchased, and in some cases, reductions in sodium (- 2.5 to - 6.6 mg) and saturated fat (- 0.03 to - 0.08 g). Taxes that included 100% fruit juice ('sugary drink' taxes) produced greater reductions in sugars and calories than those that did not.

CONCLUSIONS

This study expands the evidence indicating the effectiveness of sugar taxation and FOP labelling strategies in promoting healthy food and beverage choices. The results emphasize the importance of applying taxes to 100% fruit juice to maximize policy impact, and suggest that nutrient-specific FOP 'high in' labels may be more effective than other common labelling systems at reducing consumption of targeted nutrients.

The Impact of Front-of-Package Label Design on Consumer Understanding of Nutrient Amounts

A between-groups experiment examined the salience of front-of-package (FOP) symbols. Adults from Canada, the US, Australia, and the UK completed an online survey (n = 11,617). Respondents were randomized to view cereal boxes displaying one of 11 FOP label conditions for 'high' levels of sugar and saturated fat: control (no FOP symbol), red circle, red 'stop sign', magnifying glass, magnifying glass + exclamation mark, and 'caution' triangle + exclamation mark, plus each of these five conditions accompanied by a 'high in' text descriptor. Participants identified the amount of saturated fat and sugar in the product ('low'/'moderate'/'high'). Participants were more likely to correctly identify the product as 'high' in saturated fat or sugar when shown the stop sign, triangle + exclamation mark, red circle, or magnifying glass + exclamation mark symbols incorporating 'high in' text (p < 0.01). The magnifying glass was the least effective symbol. The stop sign (37.7%) and triangle + exclamation mark (22.0%) were most frequently selected as the best symbol for indicating high nutrient amounts. Overall, FOP labels with 'high in' descriptions, red color and intuitive 'warning' symbols (e.g., stop signs, exclamation marks, 'caution' triangles) were more effective at communicating high levels of nutrients of public health concern in a time-limited environment.

Visual advisory warnings about hidden dangers: Effects of specific symbols and spatial referencing on necessary and unnecessary warnings

Augmented reality has the potential to improve the effectiveness of collision warnings in vehicles because they inherently convey spatial information about the hazard and can guide the attention of the driver towards it. For future warning systems, which can detect sight obstructed dangers, related work already revealed some advantages. In a driving simulator study with 80 participants, we investigated the effects of three corresponding design parameters which are commonly integrated at augmented reality warnings. This study analyzes the individual contribution of specific warning symbols, warning animation, and spatial referencing. Part one of the study concentrates on the effectiveness of necessary warnings and part two on the drivers' compliance despite false alarms. Compared to the control condition with static unspecific warning symbols, static specific warning symbols depicting the type and motion direction of the hazard led to several but inconsistent advantages. The scaling animation only improved subjective evaluation. However, spatial referencing of an (unspecific) warning symbol consistently improved drivers' reactions to as well as evaluations of necessary and unnecessary warnings. The results emphasize the potential of spatial referencing, particularly for in-vehicle warnings of future collision avoidance systems.

Cognitive Load Changes during Music Listening and its Implication in Earcon Design in Public Environments: An fNIRS Study

A key for earcon design in public environments is to incorporate an individual’s perceived level of cognitive load for better communication. This study aimed to examine the cognitive load changes required to perform a melodic contour identification task (CIT). While healthy college students (N = 16) were presented with five CITs, behavioral (reaction time and accuracy) and cerebral hemodynamic responses were measured using functional near-infrared spectroscopy. Our behavioral findings showed a gradual increase in cognitive load from CIT1 to CIT3 followed by an abrupt increase between CIT4 (i.e., listening to two concurrent melodic contours in an alternating manner and identifying the direction of the target contour, p < 0.001) and CIT5 (i.e., listening to two concurrent melodic contours in a divided manner and identifying the directions of both contours, p < 0.001). Cerebral hemodynamic responses showed a congruent trend with behavioral findings. Specific to the frontopolar area (Brodmann’s area 10), oxygenated hemoglobin increased significantly between CIT4 and CIT5 (p < 0.05) while the level of deoxygenated hemoglobin decreased. Altogether, the findings indicate that the cognitive threshold for young adults (CIT5) and appropriate tuning of the relationship between timbre and pitch contour can lower the perceived cognitive load and, thus, can be an effective design strategy for earcon in a public environment.

Perceptions of cigarette pack inserts promoting cessation and dissuasive cigarettes among young adult smokers in the UK: a cross-sectional online survey

OBJECTIVES

To explore young adult smokers' perceptions of cigarette pack inserts promoting cessation and cigarettes designed to be dissuasive.

DESIGN

Cross-sectional online survey.

SETTING

UK.

PARTICIPANTS

The final sample was 1766 young adult smokers, with 50.3% male and 71.6% white British. To meet the inclusion criteria, participants had to be 16-34 years old and smoke factory-made cigarettes.

PRIMARY AND SECONDARY OUTCOME MEASURES

Salience of inserts, perceptions of inserts as information provision, perceptions of inserts on quitting, support for inserts and perceived appeal, harm and trial of three cigarettes (a standard cigarette, a standard cigarette displaying the warning 'Smoking kills' and a green cigarette).

RESULTS

Half the sample indicated that they would read inserts with three-fifths indicating that they are a good way to provide information about quitting (61%). Just over half indicated that inserts would make them think more about quitting (53%), help if they decided to quit (52%), are an effective way of encouraging smokers to quit (53%) and supported having them in all packs (55%). Participants who smoked factory-made cigarettes and other tobacco products (compared with exclusive factory-made cigarette smokers), had made a quit attempt within the last 6 months (compared with those that had never made a quit attempt) or were likely to make a successful quit attempt in the next 6 months (compared with those unlikely to make a quit attempt in the next 6 months) were more likely to indicate that inserts could assist with cessation. Multivariable logistic regression modelling suggested that compared with the standard cigarette, the cigarette with warning (adjusted OR=17.71; 95% CI 13.75 to 22.80) and green cigarette (adjusted OR=30.88; 95% CI 23.98 to 39.76) were much less desirable (less appealing, more harmful and less likely to be tried).

CONCLUSIONS

Inserts and dissuasive cigarettes offer policy makers additional ways of using the pack to reduce smoking.

Regenerative braking failures in battery electric vehicles and their impact on the driver

A unique feature of battery electric vehicles (BEV) is their regenerative braking system (RBS) to recapture kinetic energy in deceleration maneuvers. If such a system is triggered via gas pedal, most deceleration maneuvers can be executed by just using this pedal. This impacts the driving task as different deceleration strategies can be applied. Previous research has indicated that a RBS failure leading to a sudden reduced deceleration represents an adverse event for BEV drivers. In the present study, we investigated such a failure's impact on the driver's evaluation and behavior. We conducted an experiment on a closed-off test track using a modified BEV that could temporarily switch off the RBS. One half of the 44 participants in the study received information about an upcoming RBS failure whereas the other half did not. While 91% of the drivers receiving prior information noticed the RBS failure, only 48% recognized it in the "uniformed" group. In general, the failure and the perception of its occurrence influenced the driver's evaluation and behavior more than receiving prior information. Nevertheless, under the tested conditions, drivers kept control and were able to compensate for the RBS failure. As the participants drove quite simple maneuvers in our experiment, further studies are needed to validate our findings using more complex driving settings. Given that RBS failures could have severe consequences, appropriate information and warning strategies for drivers are necessary.

How to warn drivers in various safety-critical situations - Different strategies, different reactions

Technological advances allow supporting drivers in a multitude of occasions, ranging from comfort enhancement to collision avoidance, for example through driver warnings, which are especially crucial for traffic safety. This psychological driving simulator experiment investigated how to warn drivers visually in order to prevent accidents in various safety-critical situations. Collision frequencies, driving behavior and subjective evaluations of situation criticality, warning understandability and helpfulness of sixty drivers were measured in two trials of eight scenarios each (within-subjects factors). The warning type in the head-up display (HUD) varied (between-subjects) in its strategy (attention-/reaction-oriented) and specificity (generic/specific) over four warning groups and a control group without a warning. The results show that the scenarios differed in their situation criticality and drivers adapted their reactions accordingly, which underlines the importance of testing driver assistance systems in diverse scenarios. Besides some learning effects over the trials, all warned drivers showed faster and stronger brake reactions. Some warning concepts were understood better than others, but all were accepted. Generic warnings were effective, yet the warning strategy should adapt to situation requirements and/or driver behavior. A stop symbol as reaction generic warning is recommendable for diverse kinds of use cases, leading to fast and strong reactions. However, for rather moderate driver reactions an attention generic approach with a caution symbol might be more suitable. Further research should investigate multi-stage warnings with adaptive strategies for application to various situations including other modalities and false alarms.

Long-Run Trends in Antidepressant Use Among Youths After the FDA Black Box Warning

OBJECTIVE

In October 2004, the Food and Drug Administration directed pharmaceutical companies to issue a black box warning about the potential link between the use of antidepressants and suicidal ideation among children. This study analyzed long-run trends in antidepressant use among children before and after the black box warning for those with and without severe psychological impairment.

METHODS

The analysis used data from the Medical Expenditure Panel Survey for children ages five to 17, covering years 2000-2011 (N=75,819). The study used multivariate probit models to compare the changes in the rate of any antidepressant use in the early (2004-2007) and late (2008-2011) postwarning years with the rate in the prewarning years (2002-2003). Recycled predictions methods were used to estimate yearly predicted probabilities of use.

RESULTS

After adjustment for all covariates, there was a .5% statistically significant decline in the probability of using any antidepressants during the early postwarning years (2004-2007) compared with prewarning years. In the long run (2008-2011), however, there was no statistically significant difference. Five years after the black box warning, the adjusted rates of use increased to their prewarning levels (2.29% in 2003 and 2.26% in 2009). The initial impact of the warning differed between the severe and nonsevere populations, with a significant effect on those with nonsevere psychological impairment.

CONCLUSIONS

The return to the rates before the black box warning raises concern that the impact of the warning may have dissipated over time. More frequent updates of the warning might be necessary.

Food safety labelling of chicken to prevent campylobacteriosis: consumer expectations and current practices

Background

Campylobacter is the leading cause of bacterial gastroenteritis worldwide, and contaminated chicken is a significant vehicle for spread of the disease. This study aimed to assess consumers’ knowledge of safe chicken handling practices and whether their expectations for food safety labelling of chicken are met, as a strategy to prevent campylobacteriosis.

Methods

We conducted a cross-sectional survey of 401 shoppers at supermarkets and butcheries in Wellington, New Zealand, and a systematic assessment of content and display features of chicken labels.

Results

While 89% of participants bought, prepared or cooked chicken, only 15% knew that most (60–90%) fresh chicken in New Zealand is contaminated by Campylobacter. Safety and correct preparation information on chicken labels, was rated ‘very necessary’ or ‘essential’ by the majority of respondents. Supermarket chicken labels scored poorly for the quality of their food safety information with an average of 1.7/5 (95% CI, 1.4–2.1) for content and 1.8/5 (95% CI, 1.6–2.0) for display.

Conclusions

Most consumers are unaware of the level of Campylobacter contamination on fresh chicken and there is a significant but unmet consumer demand for information on safe chicken preparation on labels. Labels on fresh chicken products are a potentially valuable but underused tool for campylobacteriosis prevention in New Zealand.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5322-z) contains supplementary material, which is available to authorized users.

The effect of e-cigarette warning labels on college students' perception of e-cigarettes and intention to use e-cigarettes

OBJECTIVE

This study examined the effect of two e-cigarette warning labels on college students' perceived advantages and risks of e-cigarette use, as well as students' intentions to use e-cigarettes. The company-produced e-cigarette warning label carries abundant information with small font size while the governmental warning label has only two sentences presented in large font size. The effect of both labels have not yet been examined and verified.

METHODS

Data were collected in October 2015 from college students at a Midwestern university. A pretest-posttest design was employed with 338 students exposed to the warning label proposed by the FDA and 328 students exposed to the label created by e-cigarette companies. Structural equation modeling analysis was implemented to examine the effect of warning labels with the analytical model grounded in the Theory of Planned Behavior.

RESULTS

Findings showed that college students' perceived advantages of e-cigarette use were positively related to their intentions to use e-cigarettes, while perceived risks were negatively associated with their intentions. When comparing two labels, the governmental label was found to reduce college students' intentions to use e-cigarettes via increasing perceived risks of e-cigarette use (β=0.10, p<0.05), however, not via decreasing perceived advantages of e-cigarette use. The warning label currently used by e-cigarette companies showed no influence on beliefs about or intentions to use e-cigarettes.

CONCLUSIONS

The warning label proposed by the FDA is more effective than that created by e-cigarette companies, however, has room for improvement to make a greater impact on e-cigarette use intention.

Demographic determinants of chemical safety information recall in workers and consumers in South Africa: A cross sectional study

BACKGROUND

Chemical hazard communication is intended to alert users of the potential hazards of chemicals. Hazard information needs to be understood and recalled. Recall of hazard communication is critical when the written form of the information is not available at the time it is required.

METHODS

A cross-sectional study investigating associations between recall of chemical safety information on labels amongst 402 participants including 315 workers and 87 consumers in two provinces of South Africa.

RESULTS

Respondents were predominantly male (67.7%), the median age was 37 years (IQR: 30-46years) and less than half of the participants completed high school (47.5%). Multivariate analysis identified the following positive associations with the recall of all the label elements listing the strongest association: call appropriate services and industrial vs consumer sector (OR=2.4; 95% CI: 1.2; 4.6 ); call appropriate services and transport vs consumer sector (OR=4.4; 95% CI: 1.2; 16.0); flammable symbol and male vs female gender (OR=2.3; 95% CI: 1.0; 5.3); flammable symbol and home language English vs African languages (OR=6.6; 95% CI: 2.1; 21.2); any hazard statement and home language Afrikaans vs African languages (OR=14.0; 95% CI: 3.6; 54.2), any first aid statement and further education vs none (OR=3.3; 95% CI: 1.3; 8.0), correct chemical name and industry blue collar workers vs non-industry blue collar workers (OR=2.6; 95% CI: 1.1; 6.1), correct chemical name and non-industry white collar occupations vs non-industry blue collar workers (OR=2.7; 95% CI: 1.0; 7.1).

CONCLUSION

The study found a number of potential positive associations which influence recall of label elements of which some (e.g., sector, gender, occupation) suggest further research. Relevant policies in South Africa should ensure that the safety information on chemical labels is clearly visible to read and understandable which aids recall and the reduction in harmful chemical exposures.

User perception and interpretation of tornado probabilistic hazard information: Comparison of four graphical designs

Effective design for presenting severe weather information is important to reduce devastating consequences of severe weather. The Probabilistic Hazard Information (PHI) system for severe weather is being developed by NOAA National Severe Storms Laboratory (NSSL) to communicate probabilistic hazardous weather information. This study investigates the effects of four PHI graphical designs for tornado threat, namely, "four-color"," red-scale", "grayscale" and "contour", on users' perception, interpretation, and reaction to threat information. PHI is presented on either a map background or a radar background. Analysis showed that the accuracy was significantly higher and response time faster when PHI was displayed on map background as compared to radar background due to better contrast. When displayed on a radar background, "grayscale" design resulted in a higher accuracy of responses. Possibly due to familiarity, participants reported four-color design as their favorite design, which also resulted in the fastest recognition of probability levels on both backgrounds. Our study shows the importance of using intuitive color-coding and sufficient contrast in conveying probabilistic threat information via graphical design. We also found that users follows a rational perceiving-judging-feeling-and acting approach in processing probabilistic hazard information for tornado.

Mirage events & driver haptic steering alerts in a motion-base driving simulator: A method for selecting an optimal HMI

This paper describes a new method, a 'mirage scenario,' to support formative evaluation of driver alerting or warning displays for manual and automated driving. This method provides driving contexts (e.g., various Times-To-Collision (TTCs) to a lead vehicle) briefly presented and then removed. In the present study, during each mirage event, a haptic steering display was evaluated. This haptic display indicated a steering response may be initiated to drive around an obstacle ahead. A motion-base simulator was used in a 32-participant study to present vehicle motion cues similar to the actual application. Surprise was neither present nor of concern, as it would be for a summative evaluation of a forward collision warning system. Furthermore, no collision avoidance maneuvers were performed, thereby reducing the risk of simulator sickness. This paper illustrates the mirage scenario procedures, the rating methods and definitions used with the mirage scenario, and analysis of the ratings obtained, together with a multi-attribute utility theory (MAUT) approach to evaluate and select among alternative designs for future summative evaluation.

A Preliminary Comparison of Three Tourniquet Instructions for Just-in-Time Guidance of a Simulated Tourniquet Application

The American College of Surgeons (ACS) and the Department of Homeland Security (DHS) encourage the use of tourniquets as part of the “Stop the Bleed” campaign. Both have provided instructions for layperson tourniquet application in order to save the life of a hemorrhaging trauma victim. This study sought to compare the impact of using ACS and DHS instructions with manufacturer-provided instructions for the completion of simulated tourniquet application steps. Thirty surgical trainees completed a simulated tourniquet application with one of the three instruction sets. Their completion time and success for each step were measured. Participants that received ACS instructions failed the fewest number of steps (p < 0.01) and completed the task faster (Mean (SD) = 70 (33) seconds) compared to those with the manufacturer-provided instructions (p < 0.01). Tourniquet instruction sets need to be refined in order to optimize the success rate of just-in-time guidance for tourniquet application.

Analyzing crowdsourced ratings of speech-based take-over requests for automated driving

Take-over requests in automated driving should fit the urgency of the traffic situation. The robustness of various published research findings on the valuations of speech-based warning messages is unclear. This research aimed to establish how people value speech-based take-over requests as a function of speech rate, background noise, spoken phrase, and speaker's gender and emotional tone. By means of crowdsourcing, 2669 participants from 95 countries listened to a random 10 out of 140 take-over requests, and rated each take-over request on urgency, commandingness, pleasantness, and ease of understanding. Our results replicate several published findings, in particular that an increase in speech rate results in a monotonic increase of perceived urgency. The female voice was easier to understand than a male voice when there was a high level of background noise, a finding that contradicts the literature. Moreover, a take-over request spoken with Indian accent was found to be easier to understand by participants from India than by participants from other countries. Our results replicate effects in the literature regarding speech-based warnings, and shed new light on effects of background noise, gender, and nationality. The results may have implications for the selection of appropriate take-over requests in automated driving. Additionally, our study demonstrates the promise of crowdsourcing for testing human factors and ergonomics theories with large sample sizes.

Adverse Events and Over-the-Counter (OTC) Drugs: Is Inappropriate Labeling the Problem? - The Case of Acetaminophen

Incorrect use of acetaminophen that results in severe liver injury is among the most common adverse drug events (ADEs) in the United States of America (USA), and other countries around the world. Compared to any other drug, it is also on the top for emergency calls, emergency room visits, and acute liver failure in the USA. Consequently, regulating acetaminophen has become a heated and unresolved public debate. During the last decades, multiple efforts have taken place to address the issue, mostly focused on the premise that inappropriate labeling is a leading cause of such ADEs, for failure in communicating the associated risks through warnings. Unlike previous studies, this paper illustrates the importance of considering human factors principles. Three different warning labels were designed and evaluated. The results showed no statistically significant effect, despite the application of best practices for label warning design. Non-design factors, the warning process and why a warning could fail are also illustrated. Implications could help researchers, policy makers, and manufacturers to consider focusing less on traditional labeling interventions, and to invest efforts more systematically considering also the current trends and the current needs of consumers.

Forensic Evaluation of a Hazardous Household Product

Product liability litigation often follows injury to a person, then retention of human factors experts to evaluate causes of the injury. The nature of the investigation may require additional evaluations by other domain experts. This forensic case involved a man who died after using denatured alcohol as a fuel. Forensic analyses indicated that a flame arrestor, plastic fuel container, and adequate warnings most likely would have prevented this fatal incident. In addition, the analyses showed that the product manufacturer failed to guard consumers from the hazards of using the product and failed to warn consumers of the hazards that accompanied use of denatured alcohol.

Safety signs on agricultural machinery: Pictorials do not always successfully convey their messages to target users

This study investigated the extent to which a sample of Italian users comprehended safety pictorials used on agricultural machinery. A questionnaire with 12 safety pictorials was administered to 248 users of agricultural machinery. For each of the pictorials, the participants were asked to select the most appropriate description of four written choices. The investigated safety pictorials were, in general, not well comprehended. Two different classes of participants were identified, each with a different level of comprehension. The participants with better comprehension were characterized by the regular use of agricultural machinery and frequent previous exposure to pictorials. The need for training courses focusing on safety pictorials and their meanings, as well as the need for improvement to the pictorials themselves to make them more easily comprehended, is discussed.

Effect of warning symbols in combination with education on the frequency of erroneously crushing medication in nursing homes: an uncontrolled before and after study

OBJECTIVES

Residents of nursing homes often have difficulty swallowing (dysphagia), which complicates the administration of solid oral dosage formulations. Erroneously crushing medication is common, but few interventions have been tested to improve medication safety. Therefore, we evaluated the effect of warning symbols in combination with education on the frequency of erroneously crushing medication in nursing homes.

SETTING

This was a prospective uncontrolled intervention study with a preintervention and postintervention measurement. The study was conducted on 18 wards (total of 200 beds) in 3 nursing homes in the North of the Netherlands.

PARTICIPANTS

We observed 36 nurses/nursing assistants (92% female; 92% nursing assistants) administering medication to 197 patients (62.9% female; mean age 81.6).

INTERVENTION

The intervention consisted of a set of warning symbols printed on each patient's unit dose packaging indicating whether or not a medication could be crushed as well as education of ward staff (lectures, newsletter and poster).

PRIMARY OUTCOME MEASURE

The relative risk (RR) of a crushing error occurring in the postintervention period compared to the preintervention period. A crushing error was defined as the crushing of a medication considered unsuitable to be crushed based on standard reference sources. Data were collected using direct (disguised) observation of nurses during drug administration.

RESULTS

The crushing error rate decreased from 3.1% (21 wrongly crushed medicines out of 681 administrations) to 0.5% (3/636), RR=0.15 (95% CI 0.05 to 0.51). Likewise, there was a significant reduction using data from patients with swallowing difficulties only, 87.5% (21 errors/24 medications) to 30.0% (3/10) (RR 0.34, 95% CI 0.13 to 0.89). Medications which were erroneously crushed included enteric-coated formulations (eg, omeprazole), medication with regulated release systems (eg, Persantin; dipyridamol) and toxic substances (eg, finasteride).

CONCLUSIONS

Warning symbols combined with education reduced erroneous crushing of medication, a well-known and common problem in nursing homes.

Examining Interpretations of Graphic Cigarette Warning Labels Among U.S. Youth and Adults

Few studies have examined how diverse populations interpret warning labels. This study examined interpretations of 9 graphic cigarette warning labels (image plus text) proposed by the U.S. Food and Drug Administration among a convenience sample of youth (ages 13-17) and adults (18+) across the United States. Participants (N = 1,571) completed a cross-sectional survey. Participants were asked to select 1 of 3 plausible interpretations (1 preferred vs. 2 alternative) created by the research team about the particular consequence of smoking addressed in each warning label. Participants also rated each label for novelty, counterarguing, perceived effectiveness, and harm. Smokers reported their thoughts of quitting, self-efficacy, and motivation to quit. Although at least 70% of the sample chose the preferred interpretation for 7 of 9 labels, only 13% of participants chose all 9 preferred interpretations. The odds of selecting the preferred interpretation were lower among African Americans, among those with less education, and for labels perceived as being more novel. Smokers reported greater counterarguing and less perceived effectiveness and harms than nonsmokers, but results were not consistent across all labels and interpretations. The alternative interpretations of cigarette warning labels were associated with lower perceived effectiveness and lower perceived harms of smoking, both of which are important for motivating quit attempts.

Traffic and Environmental Cues and Slow-Down Behaviors in Virtual Driving

This study used a driving simulator to investigate whether the presence of pedestrians and traffic engineering designs that reported to have reduction effects on overall traffic speed at intersections can facilitate drivers adopting lower impact speed behaviors at pedestrian crossings. Twenty-eight men (M age = 39.9 yr., SD = 11.5) with drivers' licenses participated. Nine studied measures were obtained from the speed profiles of each participant. A 14-km virtual road was presented to the participants. It included experimental scenarios of base intersection, pedestrian presence, pedestrian warning sign at intersection and in advance of intersection, and perceptual lane narrowing by hatching lines. Compared to the base intersection, the presence of pedestrians caused drivers to slow down earlier and reach a lower minimum speed before the pedestrian crossing. This speed behavior was not completely evident when adding a pedestrian warning sign at an intersection or having perceptual lane narrowing to the stop line. Additionally, installing pedestrian warning signs in advance of the intersections rather at the intersections was associated with higher impact speeds at pedestrian crossings.

Review of the Literature on Determinants of Chemical Hazard Information Recall among Workers and Consumers

In many low and middle income countries (LMIC), workers’ and consumers’ only access to risk and hazard information in relation to the chemicals they use or work with is on the chemical label and safety data sheet. Recall of chemical hazard information is vital in order for label warnings and precautionary information to promote effective safety behaviors. A literature review, therefore, was conducted on determinants of chemical hazard information recall among workers and consumers globally. Since comprehension and recall are closely linked, the determinants of both were reviewed. Literature was reviewed from both online and print peer reviewed journals for all study designs and countries. This review indicated that the level of education, previous training and the inclusion of pictograms on the hazard communication material are all factors that contribute to the recall of hazard information. The influence of gender and age on recall is incongruent and remains to be explored. More research is required on the demographic predictors of the recall of hazard information, the effect of design and non-design factors on recall, the effect of training on the recall among low literate populations and the examining of different regions or contexts.

Workers' 9/11 in Pakistan: neglected sparks causing conflagration

A deadly factory fire in Karachi, Pakistan caused the death of 289 workers on September 11, 2012. The havoc played by fire could have been avoided if the concerned authorities had better fire safety measures and strategy. This article presents an exploratory study designed to obtain first-hand information about this issue in which data were collected from 135 organizations within various industries of Pakistan. The results of this study are alarming because most of the organizations are not even equipped with basic fire safety equipment and are devoid of fire exit paths. Incompetence and negligence on the part of government agencies and many stakeholders frequently allows fire to play havoc with the lives of workers in Pakistani organizations, confirming the famous saying 'Parva saepe scintilla contempta magnum excitavit incendium' (A spark neglected has often raised a conflagration).

Awareness of energy drink intake guidelines and associated consumption practices: a cross-sectional study

BACKGROUND

Despite concern regarding harms of energy drink (ED) consumption, no research has been conducted to determine awareness and compliance with ED intake guidelines displayed on product packaging in Australia (a novel approach internationally).

METHODS

A convenience sample of 1922 people completed an online survey. Participants reported their knowledge of maximum recommended daily ED intake according to Australian guidelines.

RESULTS

Guideline awareness was reported by 38, 23 and 19% of past year consumers, lifetime, and non-consumers, respectively. Amongst past year consumers, 'accurate estimators' reported greater ED intake and were more likely to exceed intake guidelines and consume alcohol mixed with ED (AmED). After controlling for demographics and frequency of use, guideline awareness predicted increased likelihood of exceeding guidelines in ED sessions, but was not associated with exceeding ED guidelines in AmED sessions.

CONCLUSIONS

Australia is considered to have the most stringent regulatory approach to EDs internationally. However, advisory statements are not associated with greater awareness and compliance with intake guidelines. Failure to comply with standards for efficacious product labelling, and absence of broader education regarding guidelines, needs to be addressed.

Differential effects of traffic sign stimuli upon speeding in school zones following a traffic light interruption

Motorists whose journey has been interrupted by signalized traffic intersections in school zones resume their journey at a faster vehicle speed than motorists who have not been required to stop. Introducing a flashing "check speed" sign 70m after the traffic intersections counteracts this interruptive effect. The present study examined which aspects of a reminder sign are responsible for reducing the speeding behavior of interrupted motorists. When a sign that combines both written text and flashing lights was introduced, interrupted motorists did not speed, traveling on average 0.82km/h below the 40km/h speed limit when measured 100m from traffic intersections. Alternatively, when only the flashing lights were visible the interrupted motorists sped 3.36km/h over the 40km/h speed limit. Similar vehicular speeds were observed when only the written text was visible and when no sign was present (7.67 and 7.49km/h over the 40km/h speed limit, respectively). This indicates that static reminder signs add little value over the absence of a school zone reminder sign; the presence of both cues is necessary to fully offset the interruptive effect. This study also highlights the benefit of using exogenous visual cues in traffic signs to capture drivers' attention. These findings have practical implications for the design and use of traffic signs to increase compliance with posted speed limits.

Eye movements and brain oscillations to symbolic safety signs with different comprehensibility

Background

The aim of this study was to investigate eye movements and brain oscillations to symbolic safety signs with different comprehensibility.

Methods

Forty-two young adults participated in this study, and ten traffic symbols consisting of easy-to-comprehend and hard-to-comprehend signs were used as stimuli. During the sign comprehension test, real-time eye movements and spontaneous brain activity [electroencephalogram (EEG) data] were simultaneously recorded.

Results

The comprehensibility level of symbolic traffic signs significantly affects eye movements and EEG spectral power. The harder to comprehend the sign is, the slower the blink rate, the larger the pupil diameter, and the longer the time to first fixation. Noticeable differences on EEG spectral power between easy-to-comprehend and hard-to-comprehend signs are observed in the prefrontal and visual cortex of the human brain.

Conclusions

Sign comprehensibility has significant effects on real-time nonintrusive eye movements and brain oscillations. These findings demonstrate the potential to integrate physiological measures from eye movements and brain oscillations with existing evaluation methods in assessing the comprehensibility of symbolic safety signs.

Comprehension of safety pictograms affixed to agricultural machinery: A survey of users

INTRODUCTION

Pictograms affixed to agricultural machinery are important tools to reduce the occurrence of accidents and injuries when correctly noticed, comprehended, and followed. This study investigated the knowledge of safety pictograms used in agricultural machinery in a sample of farmers and farm workers and examined the factors influencing their comprehension.

METHOD

A questionnaire with 12 safety pictograms used for agricultural machinery was administered to 281 owners or users of agricultural machinery. For each of the pictograms, the participants had to select the most appropriate verbal description from among four choices.

RESULTS

The pictograms examined yielded poor comprehension scores, including warnings related to the most frequent accidents involving agricultural machinery. Familiarity with the pictograms and years of experience with agricultural machinery significantly increased users' comprehension of the meaning of the pictograms.

CONCLUSIONS

Specific training programs should be designed to draw attention to safety pictograms and to instill their meaning.

The effectiveness of using pictures in teaching young children about burn injury accidents

This study utilized the "story grammar" approach (Stein and Glenn, 1979) to analyze the within-corpus differences in recounting of sixty 6- and 7-year-old children, specifically whether illustrations (5-factor accident sequence) were or were not resorted to as a means to assist their narration of a home accident in which a child received a burn injury from hot soup. Our investigation revealed that the message presentation strategy "combining oral and pictures" better helped young children to memorize the story content (sequence of events leading to the burn injury) than "oral only." Specifically, the content of "the dangerous objects that caused the injury", "the unsafe actions that people involved took", and "how the people involved felt about the severity of the accident" differed significantly between the two groups.

Hazard levels of warning signal words modulate the inhibition of return effect: evidence from the event-related potential P300

Warning signal words are often used to convey valuable information about potential dangers in everyday life. In this study, we explored whether and how the hazard level of warning signal words modulated participants' attention to subsequent targets. Event-related potentials with high temporal resolution were employed in a cue-target paradigm. In this task, warning signal words with different hazard levels were used as cues. Participants were required to judge whether targets were presented on the screen horizontally or vertically. We found an inhibition of return (IOR) effect, i.e., participants had longer reaction times to validly cued targets than to invalidly cued targets. Accordingly, the IOR effect was reflected by a smaller P300 amplitude for invalidly cued targets compared to validly cued targets. Furthermore, the IOR effect was eliminated when the cues were high-hazard words. The dampening effect on the P300 was eliminated when the cues were high-hazard warning signal words. The lack of an IOR was attributed to participants' attentional bias to high-hazard stimuli, which are difficult for participants to disengage their attention from. The current study suggests that warning signal words are a particular type of stimulus that can override the IOR effect. Warning signal words with a high hazard level are more effective in successfully alerting people to risk in a hazardous environment.

Teen worker safety training: methods used, lessons taught, and time spent

Safety training is strongly endorsed as one way to prevent teens from performing dangerous tasks at work. The objective of this mixed methods study was to characterize the safety training that teenagers receive on the job. From 2010 through 2012, focus groups and a cross-sectional survey were conducted with working teens. The top methods of safety training reported were safety videos (42 percent) and safety lectures (25 percent). The top lessons reported by teens were "how to do my job" and "ways to spot hazards." Males, who were more likely to do dangerous tasks, received less safety training than females. Although most teens are getting safety training, it is inadequate. Lessons addressing safety behaviors are missing, training methods used are minimal, and the time spent is insignificant. More research is needed to understand what training methods and lessons should be used, and the appropriate safety training length for effectively preventing injury in working teens. In addition, more research evaluating the impact of high-quality safety training compared to poor safety training is needed to determine the best training programs for teens.

Standardised (plain) cigarette packaging increases attention to both text-based and graphical health warnings: experimental evidence

Objective

To investigate whether standardised cigarette packaging increases the time spent looking at health warnings, regardless of the format of those warnings.

Study design

A factorial (two pack styles x three warning types) within-subject experiment, with participants randomised to different orders of conditions, completed at a university in London, UK.

Methods

Mock-ups of cigarette packets were presented to participants with their branded portion in either standardised (plain) or manufacturer-designed (branded) format. Health warnings were present on all packets, representing all three types currently in use in the UK: black & white text, colour text, or colour images with accompanying text. Gaze position was recorded using a specialised eye tracker, providing the main outcome measure, which was the mean proportion of a five-second viewing period spent gazing at the warning-label region of the packet.

Results

An opportunity sample of 30 (six male, mean age = 23) young adults met the following inclusion criteria: 1) not currently a smoker; 2) <100 lifetime cigarettes smoked; 3) gaze position successfully tracked for > 50% viewing time. These participants spent a greater proportion of the available time gazing at the warning-label region when the branded section of the pack was standardised (following current Australian guidelines) rather than containing the manufacturer's preferred design (mean difference in proportions = 0.078, 95% confidence interval 0.049 to 0.106, p < 0.001). There was no evidence that this effect varied based on the type of warning label (black & white text vs. colour text vs. colour image & text; interaction p = 0.295).

Conclusions

During incidental viewing of cigarette packets, young adult never-smokers are likely to spend more time looking at health warnings if manufacturers are compelled to use standardised packaging, regardless of the warning design.

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Standardised cigarette packs could increase the saliency of health warnings.

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Eye tracking can reveal how visual attention is allocated.

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Previous studies only assessed combined image-and-text health warnings.

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We found standardised packs increased attention to all current UK warning types.

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This provides additional support for statutory standardised cigarette packaging.

Vibrotactile Stimuli Parameters on Detection Reaction Times

Signaling system designers are leveraging the tactile modality to create alarms, alerts, and warnings. The purpose of this research was to map detection reaction times (RT) toward tactile stimuli with various parameter manipulations. We employed a 3 (wave form) × 3 (inter-pulse interval) × 3 (envelope) within subjects design. The dependent measure was detection RT. Twenty participants (15 female) responded to 270 tactile stimuli. ANOVAs indicated three two-way interactions. Generally, shorter inter-pulse intervals led to quicker RT and the fade-in envelope led to longer RT, when compared to envelopes starting at the maximum amplitude. Square and sinusoidal waves tended to prompt quicker RT than the noise wave. The strength of these relationships, however, depended upon the presence of the other parameters. Designers can use the results of this study to effectively and appropriately assign tactile parameter manipulations to signals that require varied levels of response urgencies.

Facilitating pictorial comprehension with color highlighting

Pictorials can aid in communicating warning information, but viewers may not always correctly comprehend them. Two experiments focused on whether the use of relevant highlighting could benefit pictorial comprehension. A set of warning-related pictorials were manipulated according to three-color highlighting conditions: highlighting areas more relevant to correct comprehension, highlighting areas less relevant to comprehension, and no highlighting. Participants were asked to describe the purpose and meaning of each pictorial presented to them. The findings from both experiments indicate that comprehension of warning pictorials is higher for the relevant highlighting condition than the other two conditions. The highlighting of less relevant areas reduced comprehension compared to no highlighting. Use of appropriately placed highlighting could benefit the design of a complex symbol by pointing out pertinent areas to aid in determining its intended conceptual meaning.

Perceived urgency mapping across modalities within a driving context

Hazard mapping is essential to effective driver-vehicle interface (DVI) design. Determining which modality to use for situations of different criticality requires an understanding of the relative impact of signal parameters within each modality on perceptions of urgency and annoyance. Towards this goal we obtained psychometric functions for visual, auditory and tactile interpulse interval (IPI), visual color, signal word, and auditory fundamental frequency on perceptions of urgency, annoyance, and acceptability. Results indicate that manipulation of IPI in the tactile modality, relative to visual and auditory, has greater utility (greater impact on urgency than annoyance). Manipulations of color were generally rated as less annoying and more acceptable than auditory and tactile stimuli; but they were also rated as lower in urgency relative to other modality manipulations. Manipulation of auditory fundamental frequency resulted in high ratings of both urgency and annoyance. Results of the current investigation can be used to guide DVI design and evaluation.

Evaluating the application of research-based guidance to the design of an emergency preparedness leaflet

Guidelines for the design of emergency communications were derived from primary research and interrogation of the literature. The guidelines were used to re-design a nuclear emergency preparedness leaflet routinely distributed to households in the local area. Pre-test measures of memory for, and self-reported understanding of, nuclear safety information were collected. The findings revealed high levels of non-receipt of the leaflet, and among those who did receive it, memory for safety advice was poor. Subjective evaluations of the trial leaflet suggested that it was preferred and judged easier to understand than the original. Objective measures of memory for the two leaflets were also recorded, once after the study period, and again one week or four weeks later. Memory for the advice was better, at all time periods, when participants studied the trial leaflet. The findings showcase evaluation of emergency preparedness literature and suggest that extant research findings can be applied to the design of communications to improve memory and understandability.

STATEMENT OF RELEVANCE

Studies are described that showcase the use of research-based guidelines to design emergency communications and provide both subjective and objective data to support designing emergency communications in this way. In addition, the research evaluates the effectiveness of emergency preparedness leaflets that are routinely distributed to households. This work is of relevance to academics interested in risk communication and to practitioners involved in civil protection and emergency preparedness.

The development of guidelines for the design and evaluation of warning signs for young children

We report a study which aimed to provide further development and refinement of a set of guidelines (Waterson et al., 2012) for the design and evaluation of warning signs and other visual material for young children (i.e., aged 5-11 years). The study involved a set of semi-structured interviews and focus groups with the parents of young children, teachers, human factors experts and other groups (n = 38). The findings from the study provided broad support for the guidelines, as well as highlighting a number of issues which need to be addressed. These included the need to consider the target audience in more detail and provide additional guidance covering possible tie-ins with safety campaigns, sign location, age differences, gender and children's special needs. Similar findings were obtained with regard to the evaluation guidelines and their coverage of methods and activities for testing signs (e.g., simulation, role playing). We discuss our findings within the context of a revised set of guidelines and a set of suggestions aimed at working towards a more comprehensive approach to the design/evaluation of signs for young children. The paper concludes with a set of future topics for research including a discussion of ways forward in terms of improving support for design and evaluation including behavioural testing with children, their parents and other care givers.

Interpretation of way-finding healthcare symbols by a multicultural population: navigation signage design for global health

The interpretation of way-finding symbols for healthcare facilities in a multicultural community was assessed in a cross-sectional study. One hundred participants recruited from Al Ain city in the United Arab Emirates were asked to interpret 28 healthcare symbols developed at Hablamos Juntos (such as vaccinations and laboratory) as well as 18 general-purpose symbols (such as elevators and restrooms). The mean age was 27.6 years (16-55 years) of whom 84 (84%) were females. Healthcare symbols were more difficult to comprehend than general-purpose signs. Symbols referring to abstract concepts were the most misinterpreted including oncology, diabetes education, outpatient clinic, interpretive services, pharmacy, internal medicine, registration, social services, obstetrics and gynecology, pediatrics and infectious diseases. Interpretation rates varied across cultural backgrounds and increased with higher education and younger age. Signage within healthcare facilities should be tested among older persons, those with limited literacy and across a wide range of cultures.

Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation

OBJECTIVE

To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors.

MATERIALS AND METHODS

We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug-allergy, drug-drug interaction, and drug-disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors.

RESULTS

Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1-5) compared to original alerts: 4 (1-7); p=0.024).

DISCUSSION

Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts.

CONCLUSIONS

This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes.

History and evolution of warning labels for automotive friction products

There have been claims over the years that asbestos-containing product manufacturers did not sufficiently warn end users early enough regarding the potential health hazards associated with their products (1930s-1990s). To address this issue, we compared the content of the warnings associated with asbestos-containing friction products (brakes, clutches, and gaskets) manufactured by the US automotive industries to what was expected by regulatory agencies during the time period in which an understanding of asbestos health hazards was being developed. We ended our evaluation around 1990, since asbestos-containing manufacturer supplied automotive products were functionally removed from commerce by 1985 in the United States. We assessed the warnings issued in users' manuals, technical service bulletins, product packaging materials, and labels placed on products themselves. Based on our evaluation, regulatory agencies had no guidelines regarding specific warning language for finished friction products, particularly when a product contained encapsulated asbestos fibers (i.e., modified by a bonding agent). Even today, federal regulations do not require labeling on encapsulated products when, based on professional judgment or sampling, user exposure is not expected to exceed the OSHA PEL. We concluded that, despite limited regulatory guidance, the US automotive industry provided adequate warnings with regards to its friction products.

Supporting interruption management and multimodal interface design: three meta-analyses of task performance as a function of interrupting task modality

OBJECTIVE

The aim of this study was to integrate empirical data showing the effects of interrupting task modality on the performance of an ongoing visual-manual task and the interrupting task itself. The goal is to support interruption management and the design of multimodal interfaces.

BACKGROUND

Multimodal interfaces have been proposed as a promising means to support interruption management.To ensure the effectiveness of this approach, their design needs to be based on an analysis of empirical data concerning the effectiveness of individual and redundant channels of information presentation.

METHOD

Three meta-analyses were conducted to contrast performance on an ongoing visual task and interrupting tasks as a function of interrupting task modality (auditory vs. tactile, auditory vs. visual, and single modality vs. redundant auditory-visual). In total, 68 studies were included and six moderator variables were considered.

RESULTS

The main findings from the meta-analyses are that response times are faster for tactile interrupting tasks in case of low-urgency messages.Accuracy is higher with tactile interrupting tasks for low-complexity signals but higher with auditory interrupting tasks for high-complexity signals. Redundant auditory-visual combinations are preferable for communication tasks during high workload and with a small visual angle of separation.

CONCLUSION

The three meta-analyses contribute to the knowledge base in multimodal information processing and design. They highlight the importance of moderator variables in predicting the effects of interruption task modality on ongoing and interrupting task performance.

APPLICATIONS

The findings from this research will help inform the design of multimodal interfaces in data-rich, event-driven domains.

Responses of young adults to graphic warning labels for cigarette packages

BACKGROUND

In 2010, the US Food and Drug Administration (FDA) proposed a series of 36 graphic warning labels for cigarette packages. We sought to evaluate the effects of the labels on fear-related emotions about health consequences of smoking and smoking motivations of young adults.

METHODS

We conducted an experimental study in 2010-2011 with 325 smokers and non-smokers ages 18-30 years whom we recruited through community distribution lists in North Carolina and through a national survey company. Each participant viewed 27 labels (18 of the proposed labels with graphic images and text warnings and 9 with text-only warnings) in a random order, evaluating each label on understandability and its effects on fear-related reactions and discouragement from wanting to smoke.

RESULTS

Respondents found most of the proposed labels easy to understand. Of the 36 labels, 64% induced greater fear-related reactions and 58% discouraged respondents from wanting to smoke more than the corresponding text-only labels did. Labels with the greatest effects had photographs (as compared with drawings or other art graphics) or depicted diseased body parts or suffering or dead people. In almost every comparison, smokers reported lower fear-related reactions and feeling less discouraged from wanting to smoke relative to non-smokers.

CONCLUSIONS

Most of the proposed labels enhanced fear-related reactions about health consequences of smoking and reduced motivations to smoke relative to text-only labels, although some had larger effects than others. All but one of the nine warning labels recently adopted by the FDA enhanced fear-related reactions and reduced smoking motivations.