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Brewer NT, Jeong M, Hall MG, Baig SA, Mendel JR, Lazard AJ, Noar SM, Kameny MR, Ribisl KM. Impact of e-cigarette health warnings on motivation to vape and smoke. Tob Control 2019; 28:tobaccocontrol-2018-054878. [PMID: 31292169 PMCID: PMC6824616 DOI: 10.1136/tobaccocontrol-2018-054878] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/07/2019] [Accepted: 03/19/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND A prevailing hypothesis is that health warnings for electronic cigarettes (e-cigarettes) could drive people away from vaping and towards smoking cigarettes. We consider an alternative hypothesis that e-cigarette warnings discourage both vaping and smoking. METHODS Participants were a national convenience sample of 2218 US adults who used e-cigarettes, cigarettes or both. In August 2018, we randomised participants to one of three warning types (control text about littering, text-only e-cigarette warning or pictorial e-cigarette warning). We further randomised participants viewing e-cigarette warnings to one of three topics (nicotine addiction, health hazards of use, or both health hazards and harms of use). The preregistered primary outcome was intentions to quit vaping among e-cigarette users. Secondary outcomes included interest in smoking and Tobacco Warnings Model constructs: attention, negative affect, anticipated social interactions and cognitive elaboration. RESULTS Text warnings elicited higher intentions to quit vaping than control among e-cigarette users (d=0.44, p<0.001), and pictorial warnings elicited still higher intentions to quit vaping than text (d=0.12, p<0.05). Text warnings elicited lower interest in smoking compared with control among smokers (p<0.05); warnings had no other effects on interest in smoking among smokers or non-smokers. Text warnings about health hazards elicited higher intentions to quit vaping than nicotine addiction warnings. E-cigarette warnings also increased Tobacco Warnings Model constructs. DISCUSSION E-cigarette health warnings may motivate users to quit vaping and discourage smoking. The most promising warnings include health hazards (other than nicotine addiction) and imagery. We found no support for the hypothesis that e-cigarette warnings could encourage smoking cigarettes.
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Affiliation(s)
- Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michelle Jeong
- Center for Tobacco Studies, Rutgers School of Public Health, New Brunswick, New Jersey, USA
| | - Marissa G Hall
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sabeeh A Baig
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Sociomedical Science, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Jennifer R Mendel
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Allison J Lazard
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
- School of Media and Journalism, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Seth M Noar
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
- School of Media and Journalism, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Madeline R Kameny
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
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Thrasher JF, Brewer NT, Niederdeppe J, Peters E, Strasser AA, Grana R, Kaufman AR. Advancing Tobacco Product Warning Labels Research Methods and Theory: A Summary of a Grantee Meeting Held by the US National Cancer Institute. Nicotine Tob Res 2019; 21:855-862. [PMID: 29444268 PMCID: PMC6775856 DOI: 10.1093/ntr/nty017] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/31/2018] [Indexed: 11/12/2022]
Abstract
BACKGROUND The World Health Organization's Framework Convention on Tobacco Control recommends prominent pictorial health warnings on tobacco products. To advance research methods, theory and understanding of how tobacco product warning labels (TPWLs) work, the US National Cancer Institute convened a grantee meeting. Our article describes the key insights that emerged from the meeting, situated within the context of the scientific literature. RESULTS & RECOMMENDATIONS First, presentations confirmed that large, pictorial TPWLs motivate people to try to quit and encourage smoking cessation. Second, pictorial TPWLs increase attention, knowledge, negative affect, and thinking about the warning. Third, TPWL studies have primarily used brief-exposure laboratory studies and observational studies of sustained exposure through national policy implementation, with a few randomized trials involving several weeks of exposure-with generally consistent results found across study designs. Fourth, novel assessment methods include brain imaging, eye tracking and "best-worst" discrete choice experiments. To make TPWL even more effective, research is needed to confirm the mechanisms of their influence, their impact across vulnerable populations, and their effect on social media posts about tobacco products. Research is also needed on the effect of trial design choices, the predictive validity of new measurement approaches, and warning labels for non-cigarette tobacco products. IMPLICATIONS To improve scientific understanding of TPWL effects, this grantee meeting summary describes emerging research methods, theory and study results. Directions for future research include examination of the mechanisms of how warning labels work across diverse tobacco products and across different populations and contexts.
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Affiliation(s)
- James F Thrasher
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | | | - Ellen Peters
- Department of Psychology, The Ohio State University, Columbus, OH
| | - Andrew A Strasser
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rachel Grana
- Tobacco Control Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - Annette R Kaufman
- Tobacco Control Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
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Termeh Zonouzy V, Niknami S, Ghofranipour F, Montazeri A. An educational intervention based on the extended parallel process model to improve attitude, behavioral intention, and early breast cancer diagnosis: a randomized trial. Int J Womens Health 2019; 11:1-10. [PMID: 30588127 PMCID: PMC6302829 DOI: 10.2147/ijwh.s182146] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Breast cancer is an important public health problem worldwide. This study aimed to assess the effectiveness of an educational intervention based on fear appeals using the extended parallel process model (EPPM) to improve attitudes, intention, and early breast cancer diagnosis in Iranian women. METHODS This was a cluster-randomized trial conducted in Tehran, Iran. A sample of women 40 years old and above was recruited and assigned either to intervention group or to control group. The intervention group received two pamphlets containing fear appeals specially designed for this study using the EPPM. The control group received nothing. The primary outcomes were changes in attitude, behavioral intention, and early breast cancer diagnosis. Participants responded to a questionnaire before intervention and at 3 months follow-up assessments. Independent t-tests and paired t-tests were used for comparison. RESULT In all, 600 women were entered into the study (277 in the intervention group and 323 in the control group). Of these, 162 were lost to follow-up assessment. Thus, the analysis was restricted to those for whom both baseline and follow-up information was available (n=438). The mean age of participants was 53.2 (SD=9.45) years, and the mean year education of participants was 9.4 (SD=4.12) years. There were no significant differences between two groups regarding demographic variables. However, comparing outcome variables (attitude, intention, and early breast cancer diagnosis) at baseline and follow-up assessments, we found that the intervention group showed significant improvements in attitude and intention (P=0.01 and P=0.001, respectively), but no significant improvement was observed for early breast cancer diagnosis (P=0.78). The control group did not show any changes. CONCLUSION The findings showed that fear appeals could not influence early breast cancer diagnosis among women. However, significant changes were observed for attitude and behavioral intention.
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Affiliation(s)
- Vahideh Termeh Zonouzy
- Department of Health Education and Promotion, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran,
| | - Shamsaddin Niknami
- Department of Health Education and Promotion, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran,
| | - Fazlollah Ghofranipour
- Department of Health Education and Promotion, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran,
| | - Ali Montazeri
- Population Health Research Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran,
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Owusu D, So J, Popova L. Reactions to tobacco warning labels: predictors and outcomes of adaptive and maladaptive responses. ADDICTION RESEARCH & THEORY 2019; 27:383-393. [PMID: 31511769 PMCID: PMC6738943 DOI: 10.1080/16066359.2018.1531127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND The Extended Parallel Process Model (EPPM) responses have not been evaluated from verbal reactions to cigarette warning labels. We identified the EPPM responses in reactions to cigarette warning labels and evaluated their predictors and relationship with warning perceptions. METHODS U.S. adult current smokers, transitioning smokers (quit in the past two years or currently quitting) and never smokers (n=1,838) saw nine of 81 cigarette warning labels. Participants freely wrote their thoughts after viewing the first label and reported perceived informativeness, negative emotions, and denial for this label. Responses were coded for the presence of the EPPM response categories. Multivariable logistic regression models described adaptive and maladaptive respondent characteristics, and linear regression models assessed the relationship between the response categories and label perceptions. RESULTS Participants' responses contained adaptive (65.4%), maladaptive (16.5%), no response (14.7%), and mixed responses (both adaptive and maladaptive; 3.4%). Current smokers had decreased odds of adaptive response compared to never and transitioning smokers. Compared to text warnings, pictorial warnings were associated with increased odds of adaptive and decreased odds of maladaptive responses. Adaptive response was associated with increased odds of intentions to quit smoking. Adaptive respondents reported the highest levels of informativeness and negative emotions among the four response categories. CONCLUSIONS The finding demonstrating predominantly adaptive (and few maladaptive) responses to warning labels supports the continued use of fear appeals in warning label design. The greater adaptive and lower maladaptive responses to pictorial warnings could serve as additional evidence for FDA to implement pictorial warning labels.
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Affiliation(s)
- Daniel Owusu
- Tobacco Center of Regulatory Science, School of Public Health, Georgia State University, Atlanta, GA, USA
| | - Jiyeon So
- Department of Communication Studies, University of Georgia, Athens, GA, USA
| | - Lucy Popova
- Tobacco Center of Regulatory Science, School of Public Health, Georgia State University, Atlanta, GA, USA
- Corresponding author: P.O. Box 3995, Atlanta, GA 30302.
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Informing drinkers: Can current UK alcohol labels be improved? Drug Alcohol Depend 2018; 192:163-170. [PMID: 30265999 PMCID: PMC6204577 DOI: 10.1016/j.drugalcdep.2018.07.032] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 05/07/2018] [Accepted: 07/06/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Alcohol labeling provides a relatively low-cost, population-level approach to providing information about alcohol's content and harms. METHOD We conducted an online between-subjects experiment with two tasks to examine the impact of alcohol labels (n = 1884). In one task, participants were randomized to view one of four different unit labels (including labels currently used by the alcohol industry and novel labels which provide more information about how the number of units relates to recommended drinking guidelines). We assessed participants' accuracy of estimating weekly serving limits of alcohol. In a second task, participants were randomized to view one of eight health warnings (which varied according to message content, specificity, and framing). We assessed the motivation to quit after viewing the health warning. RESULTS Accuracy of estimating weekly serving limits of alcohol was greater for participants who viewed novel unit labels compared to the industry standard labels. Motivation to drink less was higher amongst participants who had viewed both cancer and negatively framed messages, compared to mental health and positively framed messages. CONCLUSION Existing unit labels used by the alcohol industry can be improved; the inclusion of unit information per serving and how these relate to low-risk drinking guidelines may be important for facilitating consumer understanding. Health warning labels should be included alongside units to provide consumers with information about the harms associated with alcohol and discourage riskier drinking behavior.
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Mostafa A, Mohammed HT, Hussein WM, Elhabiby M, Safwat W, Labib S, Aboul Fotouh A, Hoek J. Plain packaging of waterpipe tobacco? A qualitative analysis exploring waterpipe smokers' and non-smokers' responses to enhanced versus existing pictorial health warnings in Egypt. BMJ Open 2018; 8:e023496. [PMID: 30355793 PMCID: PMC6224725 DOI: 10.1136/bmjopen-2018-023496] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/20/2018] [Accepted: 08/08/2018] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Despite the global increase in waterpipe tobacco smoking (WTS) including in Egypt, few studies have assessed the effectiveness of waterpipe tobacco (WT) health warnings. Egypt has used pictorial health warnings (PHWs) on waterpipe tobacco packs (WTPs) and has rotated these every two years since 2008. We explored in this qualitative study how participants perceived existing PHWs on WTPs, assessed how they interpreted novel plain packaging of WT featuring enhanced PHWs, and probed perceptions of how existing and novel sets would affect uptake or cessation of WTS. DESIGN We conducted ten qualitative focus groups and ten in-depth interviews. We explored participants' views of the four existing PHWs (occupied 50% of the front and back of WTPs, displayed cancers, and featured colourful fruits and flavors) and four novel PHWs (occupied 80% of the front and back of WTPs, displayed different topical content, with plain packaging). Transcripts were analyzed using thematic analysis. SETTING Rural Menoufia, urban and semi-urban Cairo, Egypt. PARTICIPANTS 90 waterpipe smokers and non-smokers, men and women, aged 18 years or older. OUTCOMES Perceived potential effect on WTS uptake or cessation, probing factors related to PHW content and WTP design. RESULTS Participants in focus groups and in-depth interviews thought existing WT PHWs elicited affective responses, but found them unclear or unrealistic and thought the colourful packaging detracted from the warnings. In contrast, they thought novel and larger WT PHWs presented in plain packaging might prevent WTS initiation or trigger quit attempts. Participants regarded warnings featuring proximal health risks as most likely to be acceptable. CONCLUSIONS Our exploratory study suggests larger WT PHWs featuring proximal risks and presented on plain WTPs could potentially deter experimentation with WT products among non-users and promote cessation among existing users.
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Affiliation(s)
- Aya Mostafa
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Heba Tallah Mohammed
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- School of Pharmacy, University of Waterloo, Ontario, Canada
| | - Wafaa Mohamed Hussein
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mahmoud Elhabiby
- Department of Psychiatry Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Wael Safwat
- Egyptian Tobacco Control Coalition, Cairo, Egypt
- Egypt Health Foundation, Cairo, Egypt
| | - Sahar Labib
- Tobacco Control Unit, Ministry of Health, Cairo, Egypt
| | - Aisha Aboul Fotouh
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Janet Hoek
- Departments of Public Health and Marketing, University of Otago, Otago, New Zealand
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Hall MG, Mendel JR, Noar SM, Brewer NT. Why smokers avoid cigarette pack risk messages: Two randomized clinical trials in the United States. Soc Sci Med 2018; 213:165-172. [PMID: 30096636 DOI: 10.1016/j.socscimed.2018.07.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 07/10/2018] [Accepted: 07/29/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Message avoidance (e.g., trying not to look at the message) may be motivated by reactance, a maladaptive rejection of the message. An alternative view is that avoidance indicates that a message is eliciting fear and other negative affect, thereby increasing the likelihood of behavioral change. We sought to identify which psychological mechanism-reactance or fear and other negative affect-explains message avoidance. We also examined whether avoidance was associated with more forgoing or butting out of cigarettes. METHOD Trial 1 randomly assigned 2149 adult U.S. smokers to receive either pictorial warnings (intervention) or text-only warnings (control) on their cigarette packs for four weeks in 2014 and 2015. Trial 2 randomly assigned 719 adult U.S. smokers to receive either messages about toxic chemicals in cigarette smoke (intervention) or messages about not littering cigarette butts (control) for three weeks in 2016 and 2017. Negative affect included fear, anxiety, disgust, sadness, and guilt. Reactance included perceived threat to freedom, anger, and counterarguing. RESULTS Intervention messages led to greater message avoidance in both trials (both p < .001). In Trial 1, intervention messages elicited greater negative affect, which in turn was associated with greater avoidance (mediated effect = 0.21, p < .001). In contrast, reactance explained only a small part of the effect in Trial 1 (mediated effect = 0.03, p < .001). Similarly, in Trial 2, intervention messages elicited greater negative affect, which was associated with more avoidance (mediated effect = 0.12, p < .001); reactance did not explain any of the effect. In both trials, avoidance was associated with more forgoing or butting out of cigarettes (ps < .001). CONCLUSIONS Smokers may avoid cigarette pack risk messages because they evoke aversive types of emotion. These studies add to a growing body of evidence that, in the context of cigarette pack messages, avoidance is not a form of defensive processing but instead a sign of deeper processing.
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Affiliation(s)
- Marissa G Hall
- Lineberger Comprehensive Cancer Center, University of North Carolina, USA; Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, USA.
| | - Jennifer R Mendel
- Lineberger Comprehensive Cancer Center, University of North Carolina, USA
| | - Seth M Noar
- School of Media and Journalism, University of North Carolina, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, USA
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, USA
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Brennan E, Maloney EK, Ophir Y, Cappella JN. Potential Effectiveness of Pictorial Warning Labels That Feature the Images and Personal Details of Real People. Nicotine Tob Res 2018; 19:1138-1148. [PMID: 27932628 DOI: 10.1093/ntr/ntw319] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 11/28/2016] [Indexed: 11/14/2022]
Abstract
Introduction Pictorial warning labels (PWL) that use photographs and the personal details of real people whose health has been affected by smoking (testimonial PWL) provide factual information about the consequences of tobacco use. Methods Nine hundred and twenty-four adult current smokers participated in an online experiment that tested responses to four types of warning labels: (1) non-testimonial text warning labels (currently on packs in the United States); (2) non-testimonial PWL (previously proposed by the United States Food and Drug Administration); (3) image only testimonial PWL (created for study); (4) image + personal details testimonial PWL (created for study). Participants were randomly assigned to condition and then exposed to up to five warning labels addressing different health effects. Differences between conditions were assessed using emotional responses and a set of intention measures immediately following exposure, and self-reported behavior change at 5-week follow-up. Results Compared to the non-testimonial text warning labels, all PWL elicited stronger emotional responses and intentions to forgo cigarettes and avoid the warning labels. Non-testimonial PWL and image + personal details testimonial PWL elicited stronger intentions to quit, whereas image only testimonial PWL generated a greater amount of quitting activity in the weeks following exposure. There were no significant differences in responses when comparing the non-testimonial PWL with both types of testimonial PWL. Conclusions PWL that use images of real people convey factual information about the health effects of tobacco use. These testimonial PWL may be a promising alternative to the images previously proposed for use on PWL in the United States. Implications In the United States, the PWL developed by the Food and Drug Administration (FDA) in 2011 were found by the courts to be unconstitutional, in part because they were deemed to present an opinion rather than fact. Findings from this experimental study indicate that PWL that use the images and personal details of real people to convey factual information about the health effects of tobacco use may satisfy the FDA's requirement for a set of PWL that (1) have the potential to positively impact the determinants of smoking cessation behavior, (2) meet legislative requirements under the Family Smoking Prevention and Tobacco Control Act and (3) may be more acceptable to the courts than the previously proposed and now dismissed PWL that carried non-factual images.
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Affiliation(s)
- Emily Brennan
- Centre for Behavioural Research in Cancer, Cancer Council Victoria,Melbourne,Australia
| | - Erin K Maloney
- Penn Tobacco Center of Regulatory Science, Annenberg School for Communication, University of Pennsylvania,Philadelphia, PA
| | - Yotam Ophir
- Penn Tobacco Center of Regulatory Science, Annenberg School for Communication, University of Pennsylvania,Philadelphia, PA
| | - Joseph N Cappella
- Penn Tobacco Center of Regulatory Science, Annenberg School for Communication, University of Pennsylvania,Philadelphia, PA
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Osman A, Thrasher JF, Yong HH, Arillo-Santill�n E, Hammond D. Disparagement of health warning labels on cigarette packages and cessation attempts: results from four countries. HEALTH EDUCATION RESEARCH 2017; 32:524-536. [PMID: 29136169 PMCID: PMC5914446 DOI: 10.1093/her/cyx065] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 10/06/2017] [Indexed: 05/03/2023]
Abstract
Health warning labels (HWLs) on cigarette packs that use strong fear appeals may evoke defensive responses including acts of disparaging the warnings. Whether warning disparagement undermines HWL effectiveness remains unclear. We assessed correlates of one type of HWL disparagement and its association with subsequent cessation attempts. Longitudinal data (2012-14) on adult smokers from Australia, Canada, Mexico and the United States (US) were analyzed. HWL disparagement was assessed as the frequency of making fun of HWLs in the past month. Using Generalized Estimating Equation models we estimated correlates of HWL disparagement and whether HWL disparagement predicted subsequent cessation attempts. In each country, across all waves, 24-31% of smokers reported making fun of the warnings at least once in the past month. More frequent disparagement was found among males, younger participants, those with higher education and greater addiction, and those who recently attempted to quit. Attention to, avoidance of and talking to others about HWLs were all positively associated with HWL disparagement. In all countries, except the US, this type of HWL disparagement was an independent predictor of subsequent cessation attempts. HWL disparagement among smokers may indicate greater warning relevance and processing and does not result in counterproductive effects on cessation efforts.
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Affiliation(s)
- Amira Osman
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Dr, Chapel Hill, NC 27599, USA
- Correspondence to: A. Osman. E-mail:
| | - James F Thrasher
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 921 Assembly St, Columbia, SC 29208, USA
| | - Hua-Hie Yong
- The Cancer Council Victoria, 615 St Kilda Rd, Melbourne VIC 3004, Australia
| | - Edna Arillo-Santill�n
- Department of Tobacco Research, Mexican National Institute of Public Health, Avenida Universidad 655, Santa Mar��a Ahuacatitl��n, 62100 Cuernavaca, Mor., Mexico
| | - David Hammond
- School of Public Health and Health Systems, University of Waterloo, 200 University Ave W, Waterloo, ON N2L 3G1, Canada
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Cho YJ, Thrasher JF, Yong HH, Szklo AS, O'Connor RJ, Bansal-Travers M, Hammond D, Fong GT, Hardin J, Borland R. Path analysis of warning label effects on negative emotions and quit attempts: A longitudinal study of smokers in Australia, Canada, Mexico, and the US. Soc Sci Med 2017; 197:226-234. [PMID: 29096946 DOI: 10.1016/j.socscimed.2017.10.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 09/26/2017] [Accepted: 10/05/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cigarette pack health warning labels can elicit negative emotions among smokers, yet little is known about how these negative emotions influence behavior change. OBJECTIVE Guided by psychological theories emphasizing the role of emotions on risk concern and behavior change, we investigated whether smokers who reported stronger negative emotional responses when viewing warnings reported stronger responses to warnings in daily life and were more likely to try to quit at follow-up. METHODS We analyzed data from 5439 adult smokers from Australia, Canada, Mexico, and the US, who were surveyed every four months from September 2012 to September 2014. Participants were shown warnings already implemented on packs in their country and reported negative emotional responses (i.e., fear, disgust, worry), which were averaged (range = 1 to 9). Country-stratified logistic and linear generalized estimating equations were used to analyze the effect of negative emotional responses on self-reported responses to warnings in daily life (i.e., attention, risk concern, avoidance of warnings, forgoing planned cigarettes) and quit attempts at follow-up. Models were adjusted for socio-demographic and smoking-related characteristics, survey wave, and the number of prior surveys answered. RESULTS Smokers who reported stronger negative emotions were more likely to make quit attempts at follow-up (Adjusted ORs ranged from 1.09 [95% CI 1.04 to 1.14] to 1.17 [95% CI 1.12 to 1.23]; p < .001) than those who reported lower negative emotions. This relationship was mediated through attention to warnings and behavioral responses to warnings. There was no significant interaction of negative emotions with self-efficacy or nicotine dependence. CONCLUSION Negative emotions elicited by warnings encourage behavior change, promoting attention to warnings and behavioral responses that positively predict quit attempts.
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Affiliation(s)
- Yoo Jin Cho
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC, USA.
| | - James F Thrasher
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC, USA; Department of Tobacco Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Hua-Hie Yong
- The Cancer Council Victoria, Carlton, Victoria, Australia
| | - André Salem Szklo
- Division of Epidemiology, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
| | - Richard J O'Connor
- Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, NY, USA
| | | | - David Hammond
- School of Public Health & Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Geoffrey T Fong
- School of Public Health & Health Systems, University of Waterloo, Waterloo, Ontario, Canada; Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada; Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - James Hardin
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA
| | - Ron Borland
- The Cancer Council Victoria, Carlton, Victoria, Australia
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Hajian S, Imani F, Riazi H, Salmani F. Prediction of Adequate Prenatal Care Utilization Based on the Extended Parallel Process Model. INTERNATIONAL JOURNAL OF COMMUNITY BASED NURSING AND MIDWIFERY 2017; 5:342-354. [PMID: 29043280 PMCID: PMC5635554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background: Pregnancy complications are one of the major public health concerns. One of the main causes of preventable complications is the absence of or inadequate provision of prenatal care. The present study was conducted to investigate whether Extended Parallel Process Model’s constructs can predict the utilization of prenatal care services.
Methods: The present longitudinal prospective study was conducted on 192 pregnant women selected through the multi-stage sampling of health facilities in Qeshm, Hormozgan province, from April to June 2015. Participants were followed up from the first half of pregnancy until their childbirth to assess adequate or inadequate/non-utilization of prenatal care services. Data were collected using the structured Risk Behavior Diagnosis Scale. The analysis of the data was carried out in SPSS-22 using one-way ANOVA, linear regression and logistic regression analysis. The level of significance was set at 0.05.
Results: Totally, 178 pregnant women with a mean age of 25.31±5.42 completed the study. Perceived self-efficacy (OR=25.23; P<0.001) and perceived susceptibility (OR=0.048; P<0.001) were two predictors of the intention to utilize prenatal care. Husband’s occupation in the labor market (OR=0.43; P=0.02), unwanted pregnancy (OR=0.352; P<0.001), and the need to care for the minors or elderly at home (OR=0.35; P=0.045) were associated with lower odds of receiving prenatal care.
Conclusion: The model showed that when perceived efficacy of the prenatal care services overcame the perceived threat, the likelihood of prenatal care usage will increase. This study identified some modifiable factors associated with prenatal care usage by women, providing key targets for appropriate clinical interventions.
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Affiliation(s)
- Sepideh Hajian
- Department of Midwifery & Reproductive Health, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Imani
- Department of Midwifery & Reproductive Health, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hedyeh Riazi
- Department of Midwifery & Reproductive Health, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Salmani
- Department of Biostatistics, School of Paramedicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Wirtz PW, Rohrbeck CA. Efficacy for Dealing With Terrorism Precautionary Behavior: Laying the Groundwork for Communication Effectiveness. JOURNAL OF HEALTH COMMUNICATION 2017; 22:829-838. [PMID: 28956713 DOI: 10.1080/10810730.2017.1363323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In order to formulate effective communication and intervention strategies to respond to the widespread lack of preparedness for public health crises resulting from natural and human-made disasters, researchers have developed models describing the interrelationships between factors associated with emergency preparedness decisions. Empirical research has generally assumed that two key elements of most health behavior theories-self-efficacy and response efficacy-additively influence the decision to prepare, despite compelling theoretical rationale for an interactive relationship. The few studies that have investigated interactions in preparedness outcomes have not tested the Social Cognitive Theory prediction that non-zero levels of both efficacy types are required before individuals will engage in any preparedness behavior. Based on the responses of 3,101 participants in the National Survey of Disaster Experiences and Preparedness, this study tested additive, interactive, and conditional main effect hypotheses about the influence of self-efficacy and response efficacy for dealing with terrorism on preparedness due to terrorism six years after the September 11, 2001, terrorist attacks. A significant self-efficacy × response efficacy interaction effect on preparedness was found, in addition to a significant response efficacy effect when perceived self-efficacy was zero, contrary to the expectation from Social Cognitive Theory. These results offer insights into the cognitive processes underlying individuals' decisions to prepare for disasters such as terrorist attacks, and highlight the importance of considering more complex theory-based cognitive interaction models in designing effective communication strategies to facilitate individual emergency preparedness.
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Affiliation(s)
- Philip W Wirtz
- a Department of Decision Sciences , The George Washington University , Washington , District of Columbia , USA
| | - Cynthia A Rohrbeck
- b Department of Psychology , The George Washington University , Washington , District of Columbia , USA
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The role of negative affect and message credibility in perceived effectiveness of smokeless tobacco health warning labels in Navi Mumbai, India and Dhaka, Bangladesh: A moderated-mediation analysis. Addict Behav 2017; 73:22-29. [PMID: 28441573 DOI: 10.1016/j.addbeh.2017.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 03/29/2017] [Accepted: 04/01/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE There is strong evidence showing that pictorial health warnings are more effective than text-only warnings. However, much of this evidence comes from high-income countries and is limited to cigarette packaging. Moreover, few studies have identified mechanisms that might explain the impact of warnings. METHODS The current study examined the potential mediating role of negative affect and the moderating influence of message credibility in perceived effectiveness of smokeless tobacco warnings in two low- and middle-income countries (LMICs). Field interviews were conducted in India and Bangladesh, with adult (19+ years) smokeless tobacco users (n=1053), and youth (16-18years) users (n=304) and non-users (n=687). Respondents were randomly assigned to view warnings in one of four conditions: (1) Text-only, (2) pictorial with symbolic imagery, (3) pictorial with graphic images of health effects, or (4) pictorial with personalized graphic images plus a personal testimonial. RESULTS The findings provide support for the mediating influence of negative affect in perceived effectiveness, for adult and youth smokeless tobacco users who viewed pictorial warnings (vs. text-only), and graphic health warnings (vs. personal testimonials). Among adults, message credibility moderated the indirect effect; the association was stronger when credibility was high and weaker when it was low. Among youth users and non-users, message credibility did not moderate the indirect effect. CONCLUSIONS Consistent with research from high-income countries, these findings highlight the importance of selecting imagery that will elicit negative emotional reactions and be perceived as credible. Differential effects among adults and youth highlight the importance of pre-testing images.
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Yost AB, Finney SJ. Assessing the Unidimensionality of Trait Reactance Using a Multifaceted Model Assessment Approach. J Pers Assess 2017. [PMID: 28631975 DOI: 10.1080/00223891.2017.1280044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This study employed a multifaceted model assessment approach to investigate the dimensionality and nomological network of a popular measure of trait reactance, the Hong Psychological Reactance Scale (HPRS; Hong & Page, 1989 ). To address confusion regarding the scoring and modeling of the HPRS as well as its limited external validity evidence, we tested competing factor models, diagnosed model-data misfit, examined relationships between competing factor models and key personality traits, and cross-validated the results. Confirmatory factor analytic results supported modeling the HPRS via a bifactor model and, when this model was applied, trait reactance was negatively related to agreeableness, conscientiousness, and conformity, and positively related to entitlement, as expected. However, we also demonstrated the consequences of championing a 1-factor model by highlighting differences in relationships with external variables. Specifically, although modeling the HPRS scores with the bifactor model resulted in greater model-data fit than the 1-factor model, relationships with external variables based on the 2 models differed negligibly. Moreover, bifactor statistical indexes indicted that scores were essentially unidimensional, providing some support that HPRS scores can be treated as unidimensional in structure. Implications for using and scoring the HPRS are discussed.
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Affiliation(s)
| | - Sara J Finney
- a Center for Assessment and Research Studies, James Madison University
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The influence of graphic warning labels on efficacy beliefs and risk perceptions: a qualitative study with low-income, urban smokers. Tob Induc Dis 2016; 14:25. [PMID: 27471440 PMCID: PMC4964038 DOI: 10.1186/s12971-016-0088-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 07/01/2016] [Indexed: 11/22/2022] Open
Abstract
Background Health communication theories indicate that messages depicting efficacy and threat might promote behavior change by enhancing individuals’ efficacy beliefs and risk perceptions, but this has received little attention in graphic warning label research. We explored low socioeconomic status (SES) smokers’ perceptions of theory-based graphic warning labels to inform the development of labels to promote smoking cessation. Methods Twelve graphic warning labels were developed with self-efficacy and response efficacy messages paired with messages portraying high, low, or no threat from smoking. Self-efficacy messages were designed to promote confidence in ability to quit, while response efficacy messages were designed to promote confidence in the ability of the Quitline to aid cessation. From January – February 2014, we conducted in-depth interviews with 25 low SES adult men and women smokers in Baltimore, Maryland, U.S. Participants discussed the labels’ role in their self-efficacy beliefs, response efficacy beliefs about the Quitline, and risk perceptions (including perceived severity of and susceptibility to disease). Data were analyzed through framework analysis, a type of thematic analysis. Results Efficacy messages in which participants vicariously experienced the characters’ quit successes were reported as most influential to self-efficacy beliefs. Labels portraying a high threat were reported as most influential to participants’ perceived severity of and susceptibility to smoking risks. Self-efficacy messages alone and paired with high threat were seen as most influential on self-efficacy beliefs. Labels portraying the threat from smoking were most motivational for calling the Quitline, followed by labels showing healthy role models who had successfully quit using the Quitline. Conclusions Role model-based efficacy messages might enhance the effectiveness of labels by making smokers’ self-efficacy beliefs about quitting most salient and enhancing the perceived efficacy of the Quitline. Threatening messages play an important role in enhancing risk perceptions, but findings suggest that efficacy messages are also important in the impact of labels on beliefs and motivation. Our findings could aid in the development of labels to address smoking disparities among low SES populations in the U.S.
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Cho YJ, Thrasher JF, Swayampakala K, Yong HH, McKeever R, Hammond D, Anshari D, Cummings KM, Borland R. Does Reactance against Cigarette Warning Labels Matter? Warning Label Responses and Downstream Smoking Cessation amongst Adult Smokers in Australia, Canada, Mexico and the United States. PLoS One 2016; 11:e0159245. [PMID: 27411100 PMCID: PMC4943644 DOI: 10.1371/journal.pone.0159245] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 06/29/2016] [Indexed: 11/19/2022] Open
Abstract
Objective Some researchers have raised concerns that pictorial health warning labels (HWLs) on cigarette packages may lead to message rejection and reduced effectiveness of HWL messages. This study aimed to determine how state reactance (i.e., negative affect due to perceived manipulation) in response to both pictorial and text-only HWLs is associated with other types of HWL responses and with subsequent cessation attempts. Methods Survey data were collected every 4 months between September 2013 and 2014 from online panels of adult smokers in Australia, Canada, Mexico, and the US were analyzed. Participants with at least one wave of follow-up were included in the analysis (n = 4,072 smokers; 7,459 observations). Surveys assessed psychological and behavioral responses to HWLs (i.e., attention to HWLs, cognitive elaboration of risks due to HWLs, avoiding HWLs, and forgoing cigarettes because of HWLs) and cessation attempts. Participants then viewed specific HWLs from their countries and were queried about affective state reactance. Logistic and linear Generalized Estimating Equation (GEE) models regressed each of the psychological and behavioral HWL responses on reactance, while controlling for socio-demographic and smoking-related variables. Logistic GEE models also regressed having attempted to quit by the subsequent survey on reactance, each of the psychological and behavioral HWL responses (analyzed separately), adjustment variables. Data from all countries were initially pooled, with interactions between country and reactance assessed; when interactions were statistically significant, country-stratified models were estimated. Results Interactions between country and reactance were found in all models that regressed psychological and behavioral HWL responses on study variables. In the US, stronger reactance was associated with more frequent reading of HWLs and thinking about health risks. Smokers from all four countries with stronger reactance reported greater likelihood of avoiding warnings and forgoing cigarettes due to warnings, although the association appeared stronger in the US. Both stronger HWLs responses and reactance were positively associated with subsequent cessation attempts, with no significant interaction between country and reactance. Conclusions Reactance towards HWLs does not appear to interfere with quitting, which is consistent with its being an indicator of concern, not a systematic effort to avoid HWL message engagement.
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Affiliation(s)
- Yoo Jin Cho
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, United States of America
- * E-mail:
| | - James F. Thrasher
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, United States of America
- Department of Tobacco Research, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Kamala Swayampakala
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, United States of America
| | - Hua-Hie Yong
- Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Robert McKeever
- School of Journalism and Mass Communications, University of South Carolina, Columbia, South Carolina, United States of America
| | - David Hammond
- School of Public Health & Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Dien Anshari
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, United States of America
- Department of Health Education & Behavioral Sciences, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia
| | - K. Michael Cummings
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Ron Borland
- Cancer Council Victoria, Melbourne, Victoria, Australia
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