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Mostafa A, Mohammed HT. Graphic health warnings and their best position on waterpipes: A cross-sectional survey of expert and public opinion. Tob Prev Cessat 2017; 3:116. [PMID: 32432191 PMCID: PMC7232823 DOI: 10.18332/tpc/70873] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 04/26/2017] [Accepted: 05/02/2017] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Our aim was to assess the visibility and efficiency of graphic health warnings (GHWs) on waterpipe tobacco packs (WTPs) and to explore other more effective places to display them for better impact. We also evaluated the visibility of GHWs when placed on the waterpipe device. METHODS We conducted 3 cross-sectional study phases using face-to-face survey questionnaires in 2014-2015. Phase I surveyed 31 tobacco control experts, while Phase II surveyed 700 participants and Phase III surveyed 348 from the public in Cairo, Egypt. RESULTS Approximately half of the experts and participants in Phases II and III thought that GHWs on WTPs are not adequately visible, and 68.9% and 79.6% in Phases II and III, respectively, suggested posting warnings also in other places. About one-third of experts and 69.1% of Phase II participants suggested posting GHWs inside cafés or in public places, while 46.9% of Phase III participants favored placing them on waterpipes. After viewing our suggested positions on a waterpipe, all experts, 80.6% of participants in Phase II, and 81.6% in Phase III acknowledged that GHWs would be more visible there. The mouthpiece was the location selected most often across all phases (31.1% in Phase I, 35.6% in Phase II and 36.3% in Phase III). Lung and throat cancers were similarly effective in raising participants’ concern about waterpipe smoking health risks (24.7%). CONCLUSIONS This is the first population-based study to explore the best location to place GHWs on waterpipes. Policymakers should consider enacting a regulatory framework for placing GHWs on waterpipe devices.
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Affiliation(s)
- Aya Mostafa
- Ain Shams University, Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Cairo, Egypt
| | - Heba Tallah Mohammed
- Ain Shams University, Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Cairo, Egypt.,School of Pharmacy, University of Waterloo, Ontario, Canada
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Owens MM, MacKillop J, Gray JC, Hawkshead BE, Murphy CM, Sweet LH. Neural correlates of graphic cigarette warning labels predict smoking cessation relapse. Psychiatry Res 2017; 262:63-70. [PMID: 28236714 PMCID: PMC5404379 DOI: 10.1016/j.pscychresns.2017.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 02/14/2017] [Indexed: 01/12/2023]
Abstract
Exposure to graphic warning labels (GWLs) on cigarette packaging has been found to produce heightened activity in brain regions central to emotional processing and higher-order cognitive processes. The current study extends this literature by using functional magnetic resonance imaging (fMRI) to investigate neural activation in response to GWLs and use it to predict relapse in an evidence-based smoking cessation treatment program. Participants were 48 treatment-seeking nicotine-dependent smokers who completed an fMRI paradigm in which they were exposed to GWLs, text-only warning labels (TOLs), and matched control stimuli. Subsequently, they enrolled in smoking cessation treatment and their smoking behavior was monitored. Activation in bilateral amygdala, right dorsolateral prefrontal cortex, right inferior frontal gyrus, left medial temporal gyrus, bilateral occipital lobe, and bilateral fusiform gyrus was greater during GWLs than TOLs. Neural response in the ventromedial prefrontal cortex (vmPFC) during exposure to GWLs (relative to a visual control image) predicted relapse during treatment beyond baseline demographic and dependence severity, but response in the amygdala to GWLs did not. These findings suggest that neurocognitive processes in the vmPFC may be critical to understanding how GWL's induce behavior change and may be useful as a predictor of smoking cessation treatment prognosis.
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Affiliation(s)
- Max M Owens
- Department of Psychology, The University of Georgia, Athens, GA, USA.
| | - James MacKillop
- Department of Psychology, The University of Georgia, Athens, GA, USA; Peter Boris Centre for Addictions Research and Department of Psychiatry and Behavioural Neurosciences, McMaster University/St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada; Department of Psychiatry, Brown University, Providence, RI, USA
| | - Joshua C Gray
- Department of Psychology, The University of Georgia, Athens, GA, USA; Department of Psychiatry, Brown University, Providence, RI, USA
| | | | - Cara M Murphy
- Peter Boris Centre for Addictions Research and Department of Psychiatry and Behavioural Neurosciences, McMaster University/St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Lawrence H Sweet
- Department of Psychology, The University of Georgia, Athens, GA, USA; Department of Psychiatry, Brown University, Providence, RI, USA
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Mansour AY, Bakhsh Z. Factors Affecting the Perceived Effectiveness of Pictorial Health Warnings on Cigarette Packages in Gulf Countries: A Cross-sectional Study. Tob Use Insights 2017; 10:1179173X17698462. [PMID: 28579845 PMCID: PMC5428085 DOI: 10.1177/1179173x17698462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 02/06/2017] [Indexed: 11/30/2022] Open
Abstract
Objectives: To explore the perceived effectiveness of pictorial health warning (PHW) labels required by the Gulf Cooperation Council, to compare them with the Food and Drug Administration–approved PHW labels, and to determine factors affecting their perceived effectiveness. Methods: A cross-sectional study using a convenience sample of adult smokers and nonsmokers was conducted. The data were collected through a self-administered online questionnaire. The perceived effectiveness scores of PHW labels were calculated and compared among different subgroups using the Kruskal-Wallis test and the Dunn multiple comparison test at a .05 significance level. Results: Of the 90 people invited to participate in the survey, 77 (86%) completed it, with 39 (50%) nonsmokers, 22 (29%) smokers, and 16 (21%) former smokers. Overall, labels having graphic images of illness or pathology are perceived to be most effective. Smokers generally perceived labels significantly less effective compared with former smokers and nonsmokers. Also, 55 respondents (71%) suggested that the presence of a telephone quit-line would be effective. Conclusions: Smoking status and image type had the most effect on the perceived effectiveness of the PHW labels on cigarette packs. Pictorial health warning labels with graphic images of pathology and a telephone quit-line are perceived to be most effective.
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Affiliation(s)
- Ameerah Y Mansour
- Department of Dental Public Health, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Zuhair Bakhsh
- Department of Orthodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
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Kollath-Cattano C, Osman A, Thrasher JF. Evaluating the perceived effectiveness of pregnancy-related cigarette package health warning labels among different gender/age groups. Addict Behav 2017; 66:33-40. [PMID: 27871043 PMCID: PMC5177510 DOI: 10.1016/j.addbeh.2016.11.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 11/08/2016] [Accepted: 11/09/2016] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The impact of pregnancy-related health warning labels (HWLs) appearing on cigarette packages on women of reproductive age and other socio-demographic groups is not well understood. The current study analyzes how different age/gender groups respond to pregnancy-related HWLs as compared to non-pregnancy HWLs. METHODS Data were analyzed from four waves of an online longitudinal study with adult smokers aged 18-64 in Australia, Canada, Mexico, and the US. Participants were classified into four age\gender groups: women 40 and under; men 40 and under; women over 40; men over 40. Participants rated one pregnancy-related and several non-pregnancy related labels on worry, believability, and motivation to quit. Country-specific adjusted linear GEE were estimated regressing ratings for each of the three key outcomes for 1) pregnancy-related HWLs and 2) a rating difference score that subtracted the average ratings of the non-pregnancy warning from the rating of the pregnancy warning. All models adjusted for socio-demographics and smoking related variables. RESULTS In Mexico and Australia, where graphic pregnancy-related HWL imagery is used (i.e., premature infant), women of reproductive age reported stronger believability, worry, and quit motivation than all other groups. Results were similar in the US, where text only HWLs are used. In contrast in Canada, where the pregnancy-related HWL imagery features a pregnant woman, ratings were unassociated with gender/age groups. Stronger effects among women of reproductive age were limited to pregnancy HWLs in each country, except Canada. CONCLUSIONS HWLs that depict graphic effects to illustrate smoking-related pregnancy risks appear to be perceived as particularly effective among women of reproductive age.
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Affiliation(s)
- Christy Kollath-Cattano
- Department of Health Prevention, Education, and Behavior, University of South Carolina, 915 Greene St., Columbia, SC 29208, USA.
| | - Amira Osman
- Department of Health Prevention, Education, and Behavior, University of South Carolina, 915 Greene St., Columbia, SC 29208, USA
| | - James F Thrasher
- Department of Health Prevention, Education, and Behavior, University of South Carolina, 915 Greene St., Columbia, SC 29208, USA
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Guydish J, Tajima B, Le T, Henderson C, Yip D, Gruber V, Garcia W, Delucchi KL. Do cigarette graphic warnings encourage smokers to attend a smoking cessation programme: a quasi-experimental study. Tob Control 2016; 27:43-49. [PMID: 27913790 DOI: 10.1136/tobaccocontrol-2016-053207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 11/03/2016] [Accepted: 11/14/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE This study assessed whether exposure to cigarette graphic warning labels (GWLs) increased attendance to a smoking cessation programme. METHOD From 2014 to 2016, alternating cohorts of smokers in 3 residential drug treatment programmes received either GWLs (experimental) or transparent (control) labels placed on their cigarette packs for 30 days. The primary outcome was the proportion of participants who chose to attend a smoking cessation group after the labelling period. RESULTS The sample (N=601) was 72.6% male, with a mean age of 41.9 (SD=11.16) and included African-American (37%), White (29.4%) and Hispanic (19.6%) participants. While similar on most measures, controls were more likely to be married, had been in the treatment programme longer and registered higher on expired carbon monoxide (CO). After labelling, the proportion attending at least one cessation group was 26% in the experimental condition and 18.8% among controls. In an intent-to-treat analysis adjusting for group differences at baseline, and for 2 levels of nesting, those who received GWLs were more likely than controls to attend the smoking cessation group (OR=1.58, 95% CI 1.02 to 2.44). CONCLUSIONS Smokers who received GWLs on their cigarette packs were more likely to attend a cessation programme. Thus, this study is one of the first to document a change in a directly observed behavioural outcome as a function of month-long exposure to cigarette pack GWLs.
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Affiliation(s)
- Joseph Guydish
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Barbara Tajima
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Thao Le
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Catherine Henderson
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Deborah Yip
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Valerie Gruber
- Department of Psychiatry, University of California San Francisco, San Francisco, California, USA
| | | | - Kevin L Delucchi
- Department of Psychiatry, University of California San Francisco, San Francisco, California, USA
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Cappella JN. Advancing the evidentiary base for tobacco warning labels: A commentary. Soc Sci Med 2016; 164:130-132. [PMID: 27492576 PMCID: PMC5413201 DOI: 10.1016/j.socscimed.2016.07.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 07/21/2016] [Accepted: 07/22/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Joseph N Cappella
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA 19104-6220, USA.
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Abstract
Waterpipe smoking has been dramatically increasing among youth worldwide and in the United States. Despite its general association with misperceptions of reduced harm, evidence suggests this is a harmful and dependence-inducing tobacco use method that represents a threat to public health. Waterpipe products continue to be generally unregulated, which likely has contributed to their spread. The Family Smoking Prevention and Tobacco Control Act of 2009 granted the US Food and Drug Administration (FDA) the authority to regulate waterpipe products, and the FDA finalized a rule extending its authority over waterpipe products in May 2016. This critical step in addressing the alarming increase in waterpipe smoking in the United States has created urgency for research to provide the evidence needed for effective regulatory initiatives for waterpipe products. We aim to stimulate such research by providing a framework that addresses the scope of waterpipe products and their unique context and use patterns. The proposed framework identifies regulatory targets for waterpipe product components (i.e., tobacco, charcoal, and device), the waterpipe café setting, and its marketing environment dominated by Internet promotion.
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Affiliation(s)
- Ramzi G Salloum
- Ramzi G. Salloum is with the Department of Health Outcomes and Policy and the Institute for Child Health Policy, University of Florida College of Medicine, Gainesville. Taghrid Asfar is with the Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL. Wasim Maziak is with the Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami
| | - Taghrid Asfar
- Ramzi G. Salloum is with the Department of Health Outcomes and Policy and the Institute for Child Health Policy, University of Florida College of Medicine, Gainesville. Taghrid Asfar is with the Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL. Wasim Maziak is with the Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami
| | - Wasim Maziak
- Ramzi G. Salloum is with the Department of Health Outcomes and Policy and the Institute for Child Health Policy, University of Florida College of Medicine, Gainesville. Taghrid Asfar is with the Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL. Wasim Maziak is with the Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami
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McQueen A, Waters EA, Kaphingst KA, Caburnay CA, Thompson VS, Boyum S, Kreuter MW. Examining Interpretations of Graphic Cigarette Warning Labels Among U.S. Youth and Adults. JOURNAL OF HEALTH COMMUNICATION 2016; 21:855-67. [PMID: 27410753 PMCID: PMC8193916 DOI: 10.1080/10810730.2016.1177142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
- Amy McQueen
- Division of General Medical Sciences, Washington University, School of Medicine, St. Louis MO
- Health Communication Research Laboratory, Washington University, School of Social Work, St. Louis MO
| | - Erika A. Waters
- Division of Public Health Sciences, Washington University, School of Medicine, St. Louis MO
| | - Kimberly A. Kaphingst
- Department of Communication, University of Utah, Salt Lake City UT
- Huntsman Cancer Institute, Salt Lake City UT
| | - Charlene A. Caburnay
- Health Communication Research Laboratory, Washington University, School of Social Work, St. Louis MO
| | - Vetta S. Thompson
- Health Communication Research Laboratory, Washington University, School of Social Work, St. Louis MO
| | - Sonia Boyum
- Health Communication Research Laboratory, Washington University, School of Social Work, St. Louis MO
| | - Matthew W. Kreuter
- Health Communication Research Laboratory, Washington University, School of Social Work, St. Louis MO
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Bigman CA, Nagler RH, Viswanath K. Representation, Exemplification, and Risk: Resonance of Tobacco Graphic Health Warnings Across Diverse Populations. HEALTH COMMUNICATION 2016; 31:974-87. [PMID: 26757354 DOI: 10.1080/10410236.2015.1026430] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
As countries implement Article 11 of the World Health Organization (WHO) Framework Convention on Tobacco Control, graphic warning labels that use images of people and their body parts to illustrate the consequences of smoking are being added to cigarette packs. According to exemplification theory, these case examples-exemplars-can shape perceptions about risk and may resonate differently among demographic subpopulations. Drawing on data from eight focus groups (N = 63) with smokers and nonsmokers from vulnerable populations, this qualitative study explores whether people considered exemplars in their reactions to and evaluations of U.S. graphic health warning labels initially proposed by the Food and Drug Administration. Participants made reference to prior and concurrent mass media messages and exemplars during the focus groups and used demographic cues in making sense of the images on the warning labels. Participants were particularly sensitive to age of the exemplars and how it might affect label effectiveness and beliefs about smoking. Race and socioeconomic status also were salient for some participants. We recommend that exemplars and exemplification be considered when selecting and evaluating graphic health warnings for tobacco labels and associated media campaigns.
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Affiliation(s)
- Cabral A Bigman
- a Department of Communication , University of Illinois at Urbana-Champaign
| | - Rebekah H Nagler
- b School of Journalism & Mass Communication , University of Minnesota
| | - K Viswanath
- c Department of Social and Behavioral Sciences , Harvard T. H. Chan School of Public Health; Center for Community-Based Research and Dana-Farber Cancer Institute
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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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Riddle PJ, Newman-Norlund RD, Baer J, Thrasher JF. Neural response to pictorial health warning labels can predict smoking behavioral change. Soc Cogn Affect Neurosci 2016; 11:1802-1811. [PMID: 27405615 PMCID: PMC5091679 DOI: 10.1093/scan/nsw087] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 06/20/2016] [Indexed: 11/19/2022] Open
Abstract
In order to improve our understanding of how pictorial health warning labels (HWLs) influence smoking behavior, we examined whether brain activity helps to explain smoking behavior above and beyond self-reported effectiveness of HWLs. We measured the neural response in the ventromedial prefrontal cortex (vmPFC) and the amygdala while adult smokers viewed HWLs. Two weeks later, participants’ self-reported smoking behavior and biomarkers of smoking behavior were reassessed. We compared multiple models predicting change in self-reported smoking behavior (cigarettes per day [CPD]) and change in a biomarkers of smoke exposure (expired carbon monoxide [CO]). Brain activity in the vmPFC and amygdala not only predicted changes in CO, but also accounted for outcome variance above and beyond self-report data. Neural data were most useful in predicting behavioral change as quantified by the objective biomarker (CO). This pattern of activity was significantly modulated by individuals’ intention to quit. The finding that both cognitive (vmPFC) and affective (amygdala) brain areas contributed to these models supports the idea that smokers respond to HWLs in a cognitive-affective manner. Based on our findings, researchers may wish to consider using neural data from both cognitive and affective networks when attempting to predict behavioral change in certain populations (e.g. cigarette smokers).
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Affiliation(s)
- Philip J Riddle
- Department of Health Promotion Education and Behavior, University of South Carolina, Columbia, SC, USA
| | - Roger D Newman-Norlund
- Department of Exercise Science, University of South Carolina, USC Brain Stimulation Lab, Columbia, SC, USA
| | - Jessica Baer
- Department of Exercise Science, University of South Carolina, USC Brain Stimulation Lab, Columbia, SC, USA
| | - James F Thrasher
- Department of Health Promotion Education and Behavior, University of South Carolina, Columbia, SC, USA
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Brewer NT, Hall MG, Noar SM, Parada H, Stein-Seroussi A, Bach LE, Hanley S, Ribisl KM. Effect of Pictorial Cigarette Pack Warnings on Changes in Smoking Behavior: A Randomized Clinical Trial. JAMA Intern Med 2016; 176:905-12. [PMID: 27273839 PMCID: PMC5458743 DOI: 10.1001/jamainternmed.2016.2621] [Citation(s) in RCA: 187] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Pictorial warnings on cigarette packs draw attention and increase quit intentions, but their effect on smoking behavior remains uncertain. OBJECTIVE To assess the effect of adding pictorial warnings to the front and back of cigarette packs. DESIGN, SETTING, AND PARTICIPANTS This 4-week between-participant randomized clinical trial was carried out in California and North Carolina. We recruited a convenience sample of adult cigarette smokers from the general population beginning September 2014 through August 2015. Of 2149 smokers who enrolled, 88% completed the trial. No participants withdrew owing to adverse events. INTERVENTIONS We randomly assigned participants to receive on their cigarette packs for 4 weeks either text-only warnings (one of the Surgeon General's warnings currently in use in the United States on the side of the cigarette packs) or pictorial warnings (one of the Family Smoking Prevention and Tobacco Control Act's required text warnings and pictures that showed harms of smoking on the top half of the front and back of the cigarette packs). MAIN OUTCOMES AND MEASURES The primary trial outcome was attempting to quit smoking during the study. We hypothesized that smokers randomized to receive pictorial warnings would be more likely to report a quit attempt during the study than smokers randomized to receive a text-only Surgeon General's warning. RESULTS Of the 2149 participants who began the trial (1039 men, 1060 women, and 34 transgender people; mean [SD] age, 39.7 [13.4] years for text-only warning, 39.8 [13.7] for pictorial warnings), 1901 completed it. In intent-to-treat analyses (n = 2149), smokers whose packs had pictorial warnings were more likely than those whose packs had text-only warnings to attempt to quit smoking during the 4-week trial (40% vs 34%; odds ratio [OR], 1.29; 95% CI, 1.09-1.54). The findings did not differ across any demographic groups. Having quit smoking for at least the 7 days prior to the end of the trial was more common among smokers who received pictorial than those who received text-only warnings (5.7% vs 3.8%; OR, 1.53; 95% CI, 1.02-2.29). Pictorial warnings also increased forgoing a cigarette, intentions to quit smoking, negative emotional reactions, thinking about the harms of smoking, and conversations about quitting. CONCLUSIONS AND RELEVANCE Pictorial warnings effectively increased intentions to quit, forgoing cigarettes, quit attempts, and successfully quitting smoking over 4 weeks. Our trial findings suggest that implementing pictorial warnings on cigarette packs in the United States would discourage smoking. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02247908.
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Affiliation(s)
- Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill2Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Marissa G Hall
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill2Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Seth M Noar
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill3School of Media and Journalism, University of North Carolina, Chapel Hill
| | - Humberto Parada
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Al Stein-Seroussi
- Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina
| | - Laura E Bach
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Sean Hanley
- Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina
| | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill2Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
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Which Images and Features in Graphic Cigarette Warnings Predict Their Perceived Effectiveness? Findings from an Online Survey of Residents in the UK. Ann Behav Med 2016; 49:639-49. [PMID: 25697135 DOI: 10.1007/s12160-015-9693-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Many countries are implementing graphic warnings for cigarettes. Which graphic features influence their effectiveness remains unclear. PURPOSE To identify features of graphic warnings predicting their perceived effectiveness in discouraging smoking. METHOD Guided by the Common-Sense Model of responses to health threats, we content-analyzed 42 graphic warnings for attributes of illness risk representations and media features (e.g., photographs, metaphors). Using data from 15,536 survey participants, we conducted stratified logistic regressions testing which attributes predict participant selections of warnings as effective. RESULTS Images of diseased body parts predicted greater perceived effectiveness; OR = 6.53-12.45 across smoking status (smoker, ex-smoker, young non-smoker) groups. Features increasing perceived effectiveness included images of dead or sick persons, children, and medical technology; focus on cancer; and photographs. Attributes decreasing perceived effectiveness included infertility/impotence, addictiveness, cigarette chemicals, cosmetic appearance, quitting self-efficacy, and metaphors. CONCLUSIONS These findings on representational and media attributes predicting perceived effectiveness can inform strategies for generating graphic warnings.
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Green AE, Mays D, Falk EB, Vallone D, Gallagher N, Richardson A, Tercyak KP, Abrams DB, Niaura RS. Young Adult Smokers' Neural Response to Graphic Cigarette Warning Labels. Addict Behav Rep 2016; 3:28-32. [PMID: 27019865 PMCID: PMC4804345 DOI: 10.1016/j.abrep.2016.02.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction The study examined young adult smokers' neural response to graphic warning labels (GWLs) on cigarette packs using functional magnetic resonance imaging (fMRI). Methods Nineteen young adult smokers (M age 22.9, 52.6% male, 68.4% non-white, M 4.3 cigarettes/day) completed pre-scan, self-report measures of demographics, cigarette smoking behavior, and nicotine dependence, and an fMRI scanning session. During the scanning session participants viewed cigarette pack images (total 64 stimuli, viewed 4 s each) that varied based on the warning label (graphic or visually occluded control) and pack branding (branded or plain packaging) in an event-related experimental design. Participants reported motivation to quit (MTQ) in response to each image using a push-button control. Whole-brain blood oxygenation level-dependent (BOLD) functional images were acquired during the task. Results GWLs produced significantly greater self-reported MTQ than control warnings (p < .001). Imaging data indicate stronger neural activation in response to GWLs than the control warnings at a cluster-corrected threshold p < .001 in medial prefrontal cortex, amygdala, medial temporal lobe, and occipital cortex. There were no significant differences in response to warnings on branded versus plain cigarette packages. Conclusions In this sample of young adult smokers, GWLs promoted neural activation in brain regions involved in cognitive and affective decision-making and memory formation and the effects of GWLs did not differ on branded or plain cigarette packaging. These findings complement other recent neuroimaging GWL studies conducted with older adult smokers and with adolescents by demonstrating similar patterns of neural activation in response to GWLs among young adult smokers. Novel data on the neurobiological effect of graphic cigarette warning labels (GWLs) GWLs produced activation indicating emotional and cognitive decision-making. Activation in response to GWLs also indicates memory formation. No differences in neural activity for GWLs on branded or plain cigarette packages
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Affiliation(s)
- Adam E. Green
- Department of Psychology, Georgetown University, Washington, DC, USA
| | - Darren Mays
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
- Corresponding author at: Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC 20007, USA.Department of OncologyGeorgetown University Medical CenterLombardi Comprehensive Cancer Center3300 Whitehaven Street, NW, Suite 4100WashingtonDC20007USA
| | - Emily B. Falk
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA, USA
| | - Donna Vallone
- Truth Initiative, Washington, DC, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Global Institute of Public Health, New York University, New York, NY
| | - Natalie Gallagher
- Department of Psychology, Georgetown University, Washington, DC, USA
| | - Amanda Richardson
- University of North Carolina Gillings School of Public Health, Chapel Hill, NC, USA
| | - Kenneth P. Tercyak
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - David B. Abrams
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
- Truth Initiative, Washington, DC, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Raymond S. Niaura
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
- Truth Initiative, Washington, DC, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Huang LL, Thrasher JF, Reid JL, Hammond D. Predictive and External Validity of a Pre-Market Study to Determine the Most Effective Pictorial Health Warning Label Content for Cigarette Packages. Nicotine Tob Res 2016; 18:1376-81. [PMID: 26377516 PMCID: PMC5942614 DOI: 10.1093/ntr/ntv184] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 08/18/2015] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Studies examining cigarette package pictorial health warning label (HWL) content have primarily used designs that do not allow determination of effectiveness after repeated, naturalistic exposure. This research aimed to determine the predictive and external validity of a pre-market evaluation study of pictorial HWLs. METHODS Data were analyzed from: (1) a pre-market convenience sample of 544 adult smokers who participated in field experiments in Mexico City before pictorial HWL implementation (September 2010); and (2) a post-market population-based representative sample of 1765 adult smokers in the Mexican administration of the International Tobacco Control Policy Evaluation Survey after pictorial HWL implementation. Participants in both samples rated six HWLs that appeared on cigarette packs, and also ranked HWLs with four different themes. Mixed effects models were estimated for each sample to assess ratings of relative effectiveness for the six HWLs, and to assess which HWL themes were ranked as the most effective. RESULTS Pre- and post-market data showed similar relative ratings across the six HWLs, with the least and most effective HWLs consistently differentiated from other HWLs. Models predicting rankings of HWL themes in post-market sample indicated: (1) pictorial HWLs were ranked as more effective than text-only HWLs; (2) HWLs with both graphic and "lived experience" content outperformed symbolic content; and, (3) testimonial content significantly outperformed didactic content. Pre-market data showed a similar pattern of results, but with fewer statistically significant findings. CONCLUSIONS The study suggests well-designed pre-market studies can have predictive and external validity, helping regulators select HWL content.
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Affiliation(s)
- Li-Ling Huang
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, SC; Center for Regulatory Research on Tobacco Communication, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC;
| | - James F Thrasher
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, SC; Department of Tobacco Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Jessica L Reid
- Propel Centre for Population Health Impact, University of Waterloo, Waterloo, ON, Canada
| | - David Hammond
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
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Gantiva C, Guerrero L, Rico A, Ramírez N, Díaz M, González M, Romo-González T. Influence of Cigarette Package Brand on the Emotional Impact of Tobacco-Warning Images That Cover 30% of Cigarette Packs in Smokers and Nonsmokers. Nicotine Tob Res 2016; 18:1324-30. [PMID: 26574553 DOI: 10.1093/ntr/ntv257] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 11/04/2015] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Research on the emotional impact of tobacco-warning images (TWIs) has not evaluated the role of context (ie, cigarette packs) as a modulator of the emotional response to TWIs. The objective of the present study was to identify the influence of the cigarette package brand on the emotional impact of TWIs that cover 30% of cigarette packs in smokers and nonsmokers using a specific methodology for the study of emotion. METHODS The participants included 95 smokers and 111 nonsmokers who observed three TWIs under two conditions: TWIs that covered 30% of cigarette packs and TWIs alone, without brands. Additionally, 18 pictures from the International Affective Picture System were presented as comparison stimuli and to reduce the effect of habituation. The Self-Assessment Manikin was used to assess valence, arousal, and dominance dimensions. RESULTS TWIs that covered 30% of cigarette packs were evaluated as least aversive, with lower ratings of arousal and higher ratings of dominance in both groups. Differences in the valence, arousal, and dominance dimensions were found between groups. Smokers rated TWIs that covered 30% of cigarette packs as less aversive and more arousing and gave them lower dominance scores compared with nonsmokers. CONCLUSION The results suggest that cigarette packages modulate the emotional impact of TWIs, especially in smokers, and the minimum size of TWIs (ie, 30% of the front and back of the package) is not sufficiently large to generate an emotional impact associated with avoidance behavior. IMPLICATIONS Cigarette packages modulate the emotional impact of TWIs, especially in smokers. The cigarette package itself is an appetitive context that captures the attention of the observer and decreases the aversive emotional response to the TWIs. The minimum size of TWIs (ie, 30% of the front and back of the package) is not sufficiently large to generate an emotional impact associated with avoidance behavior.
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Affiliation(s)
- Carlos Gantiva
- Department of Psychology, University of San Buenaventura, Bogotá, Bogotá, Colombia;
| | - Lorena Guerrero
- Department of Psychology, University of San Buenaventura, Bogotá, Bogotá, Colombia
| | - Andrea Rico
- Department of Psychology, University of San Buenaventura, Bogotá, Bogotá, Colombia
| | - Natalia Ramírez
- Department of Psychology, University of San Buenaventura, Bogotá, Bogotá, Colombia
| | - Maite Díaz
- Department of Psychology, University of San Buenaventura, Bogotá, Bogotá, Colombia
| | - Miyer González
- Department of Psychology, University of San Buenaventura, Bogotá, Bogotá, Colombia
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Nagelhout GE, Willemsen MC, de Vries H, Mons U, Hitchman SC, Kunst AE, Guignard R, Siahpush M, Yong HH, van den Putte B, Fong GT, Thrasher JF. Educational differences in the impact of pictorial cigarette warning labels on smokers: findings from the International Tobacco Control (ITC) Europe surveys. Tob Control 2016; 25:325-32. [PMID: 25873647 PMCID: PMC6295173 DOI: 10.1136/tobaccocontrol-2014-051971] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 03/25/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine (1) the impact of pictorial cigarette warning labels on changes in self-reported warning label responses: warning salience, cognitive responses, forgoing cigarettes and avoiding warnings, and (2) whether these changes differed by smokers' educational level. METHODS Longitudinal data of smokers from two survey waves of the International Tobacco Control (ITC) Europe Surveys were used. In France and the UK, pictorial warning labels were implemented on the back of cigarette packages between the two survey waves. In Germany and the Netherlands, the text warning labels did not change. FINDINGS Warning salience decreased between the surveys in France (OR=0.81, p=0.046) and showed a non-significant increase in the UK (OR=1.30, p=0.058), cognitive responses increased in the UK (OR=1.34, p<0.001) and decreased in France (OR=0.70, p=0.002), forgoing cigarettes increased in the UK (OR=1.65, p<0.001) and decreased in France (OR=0.83, p=0.047), and avoiding warnings increased in France (OR=2.93, p<0.001) and the UK (OR=2.19, p<0.001). Warning salience and cognitive responses decreased in Germany and the Netherlands, forgoing did not change in these countries and avoidance increased in Germany. In general, these changes in warning label responses did not differ by education. However, in the UK, avoidance increased especially among low (OR=2.25, p=0.001) and moderate educated smokers (OR=3.21, p<0.001). CONCLUSIONS The warning labels implemented in France in 2010 and in the UK in 2008 with pictures on one side of the cigarette package did not succeed in increasing warning salience, but did increase avoidance. The labels did not increase educational inequalities among continuing smokers.
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Affiliation(s)
- Gera E Nagelhout
- Department of Health Promotion, Maastricht University (CAPHRI), Maastricht, The Netherlands Dutch Alliance for a Smokefree Society, The Hague, The Netherlands
| | - Marc C Willemsen
- Department of Health Promotion, Maastricht University (CAPHRI), Maastricht, The Netherlands Dutch Alliance for a Smokefree Society, The Hague, The Netherlands
| | - Hein de Vries
- Department of Health Promotion, Maastricht University (CAPHRI), Maastricht, The Netherlands
| | - Ute Mons
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany Unit Cancer Prevention, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sara C Hitchman
- UK Centre for Tobacco and Alcohol Studies (UKCTAS), London, UK Department of Addictions, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Anton E Kunst
- Department of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Romain Guignard
- French Institute for Health Promotion and Health Education (INPES), Saint-Denis, France
| | - Mohammad Siahpush
- Department of Health Promotion, Social and Behavioral Health, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Hua-Hie Yong
- VicHealth Centre for Tobacco Control, The Cancer Council Victoria, Carlton, Victoria, Australia
| | - Bas van den Putte
- Department of Communication, University of Amsterdam (ASCoR), Amsterdam, The Netherlands Trimbos Institute, Netherlands Institute for Mental Health and Addiction, Utrecht, The Netherlands
| | - Geoffrey T Fong
- Department of Psychology, School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - James F Thrasher
- Department of Health Promotion, Education and Behaviour, University of South Carolina, Columbia, South Carolina, USA Department of Tobacco Research, Mexican National Institute of Public Health, Cuernavaca, Mexico
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Noar SM, Hall MG, Francis DB, Ribisl KM, Pepper JK, Brewer NT. Pictorial cigarette pack warnings: a meta-analysis of experimental studies. Tob Control 2016. [PMID: 25948713 DOI: 10.1136/tobaccocontrol-] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
OBJECTIVE To inform international research and policy, we conducted a meta-analysis of the experimental literature on pictorial cigarette pack warnings. DATA SOURCES We systematically searched 7 computerised databases in April 2013 using several search terms. We also searched reference lists of relevant articles. STUDY SELECTION We included studies that used an experimental protocol to test cigarette pack warnings and reported data on both pictorial and text-only conditions. 37 studies with data on 48 independent samples (N=33,613) met criteria. DATA EXTRACTION AND SYNTHESIS Two independent coders coded all study characteristics. Effect sizes were computed from data extracted from study reports and were combined using random effects meta-analytic procedures. RESULTS Pictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes (all p<0.05). Relative to text-only warnings, pictorial warnings (1) attracted and held attention better; (2) garnered stronger cognitive and emotional reactions; (3) elicited more negative pack attitudes and negative smoking attitudes and (4) more effectively increased intentions to not start smoking and to quit smoking. Participants also perceived pictorial warnings as being more effective than text-only warnings across all 8 perceived effectiveness outcomes. CONCLUSIONS The evidence from this international body of literature supports pictorial cigarette pack warnings as more effective than text-only warnings. Gaps in the literature include a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects.
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Affiliation(s)
- Seth M Noar
- School of Journalism and Mass Communication, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Marissa G Hall
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Diane B Francis
- School of Journalism and Mass Communication, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kurt M Ribisl
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jessica K Pepper
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Noel T Brewer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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O'Connor RJ, Bansal-Travers M, Cummings KM, Hammond D, Thrasher JF, Tworek C. Filter presence and tipping paper color influence consumer perceptions of cigarettes. BMC Public Health 2015; 15:1279. [PMID: 26695774 PMCID: PMC4688990 DOI: 10.1186/s12889-015-2643-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 12/17/2015] [Indexed: 11/10/2022] Open
Abstract
Background Cigarettes are marketed in a wide array of packaging and product configurations, and these may impact consumers’ perceptions of product health effects and attractiveness. Filtered cigarettes are typically perceived as less hazardous and white tipping paper (as opposed to cork) often conveys ‘lightness’. Methods This study examined cigarette-related perceptions among 1220 young adult (age 18-35) current, ever, and never smokers recruited from three eastern U.S. cities (Buffalo NY, Columbia SC, Morgantown WV). Participants rated three cigarette sticks: two filtered cigarettes 85 mm in length, differing only in tipping paper color (cork versus white), and an unfiltered 70 mm cigarette. Results Overall, the cork-tipped cigarette was most commonly selected on taste and attractiveness, the white-tipped on least dangerous, and the unfiltered on most dangerous. Current smokers were more likely to select white-tipped (OR = 1.98) and cork-tipped (OR = 3.42) cigarettes, while ever smokers more commonly selected the cork-tipped (OR = 1.96), as most willing to try over the other products. Those willing to try the filtered white-tipped cigarette were more likely to have rated that cigarette as best tasting (OR = 11.10), attracting attention (OR = 17.91), and lowest health risk (OR = 1.94). Similarly, those willing to try cork tipped or unfiltered cigarettes rated those as best testing, attracting attention, and lowest health risk, respectively. Conclusions Findings from this study demonstrate that consumer product perceptions can be influenced by elements of cigarette design, such as the presence and color of the filter tip.
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Affiliation(s)
- Richard J O'Connor
- Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, NY, 14263, USA.
| | - Maansi Bansal-Travers
- Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, NY, 14263, USA.
| | - K Michael Cummings
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | - David Hammond
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada.
| | - James F Thrasher
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
| | - Cindy Tworek
- Department of Pharmaceutical Systems and Policy, West Virginia University, Morgantown, WV, USA.
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Evans AT, Peters E, Strasser AA, Emery LF, Sheerin KM, Romer D. Graphic Warning Labels Elicit Affective and Thoughtful Responses from Smokers: Results of a Randomized Clinical Trial. PLoS One 2015; 10:e0142879. [PMID: 26672982 PMCID: PMC4684406 DOI: 10.1371/journal.pone.0142879] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/26/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Observational research suggests that placing graphic images on cigarette warning labels can reduce smoking rates, but field studies lack experimental control. Our primary objective was to determine the psychological processes set in motion by naturalistic exposure to graphic vs. text-only warnings in a randomized clinical trial involving exposure to modified cigarette packs over a 4-week period. Theories of graphic-warning impact were tested by examining affect toward smoking, credibility of warning information, risk perceptions, quit intentions, warning label memory, and smoking risk knowledge. METHODS Adults who smoked between 5 and 40 cigarettes daily (N = 293; mean age = 33.7), did not have a contra-indicated medical condition, and did not intend to quit were recruited from Philadelphia, PA and Columbus, OH. Smokers were randomly assigned to receive their own brand of cigarettes for four weeks in one of three warning conditions: text only, graphic images plus text, or graphic images with elaborated text. RESULTS Data from 244 participants who completed the trial were analyzed in structural-equation models. The presence of graphic images (compared to text-only) caused more negative affect toward smoking, a process that indirectly influenced risk perceptions and quit intentions (e.g., image->negative affect->risk perception->quit intention). Negative affect from graphic images also enhanced warning credibility including through increased scrutiny of the warnings, a process that also indirectly affected risk perceptions and quit intentions (e.g., image->negative affect->risk scrutiny->warning credibility->risk perception->quit intention). Unexpectedly, elaborated text reduced warning credibility. Finally, graphic warnings increased warning-information recall and indirectly increased smoking-risk knowledge at the end of the trial and one month later. CONCLUSIONS In the first naturalistic clinical trial conducted, graphic warning labels are more effective than text-only warnings in encouraging smokers to consider quitting and in educating them about smoking's risks. Negative affective reactions to smoking, thinking about risks, and perceptions of credibility are mediators of their impact. TRIAL REGISTRATION Clinicaltrials.gov NCT01782053.
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Affiliation(s)
- Abigail T. Evans
- Department of Psychology, Ohio State University, Columbus, Ohio, United States of America
| | - Ellen Peters
- Department of Psychology, Ohio State University, Columbus, Ohio, United States of America
| | - Andrew A. Strasser
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Lydia F. Emery
- Department of Psychology, Northwestern University, Evanston, Illinois, United States of America
| | - Kaitlin M. Sheerin
- Department of Psychological Sciences, University of Missouri, Columbia, Missouri, United States of America
| | - Daniel Romer
- Annenberg Public Policy Center, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Baskerville NB, Hayward L, Brown KS, Hammond D, Kennedy RD, Campbell HS. Impact of Canadian tobacco packaging policy on quitline reach and reach equity. Prev Med 2015; 81:243-50. [PMID: 26400639 DOI: 10.1016/j.ypmed.2015.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 09/09/2015] [Accepted: 09/12/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To examine the impact of the new Canadian tobacco package warning labels with a quitline toll-free phone number for seven provincial quitlines, focusing on treatment reach and reach equity in selected vulnerable groups. METHODS A quasi-experimental design assessed changes in new incoming caller characteristics, treatment reach for selected vulnerable sub-populations and the extent to which this reach is equitable, before and after the introduction of the labels in June, 2012. Administrative call data on smokers were collected at intake. Pre- and post-label treatment reach and reach equity differences were analysed by comparing the natural logarithms of the reach and reach equity statistics. RESULTS During the six months following the introduction of the new warning labels, 86.4% of incoming new callers indicated seeing the quitline number on the labels. Treatment reach for the six-month period significantly improved compared to the same six-month period the year before from .042% to .114% (p<.0001) and reach equity significantly improved for young males (p<.0001) and those with high school education or less (p=.004). CONCLUSIONS The introduction of the new tobacco warning labels with a quitline toll-free number in Canada was associated with an increase in treatment reach. The toll-free number on tobacco warning labels aided in reducing tobacco related inequalities, such as improved reach equity for young males and those with high school or less education.
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Affiliation(s)
- N Bruce Baskerville
- Propel Centre for Population Health Impact, University of Waterloo, Canada; School of Public Health and Health Systems, University of Waterloo, Canada.
| | - Lynda Hayward
- Propel Centre for Population Health Impact, University of Waterloo, Canada
| | - K Stephen Brown
- Statistics and Actuarial Sciences, University of Waterloo, Canada
| | - David Hammond
- School of Public Health and Health Systems, University of Waterloo, Canada
| | - Ryan David Kennedy
- Propel Centre for Population Health Impact, University of Waterloo, Canada; Institute for Global Tobacco Control, Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, United States
| | - H Sharon Campbell
- Propel Centre for Population Health Impact, University of Waterloo, Canada; School of Public Health and Health Systems, University of Waterloo, Canada
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Macy JT, Chassin L, Presson CC, Yeung E. Exposure to graphic warning labels on cigarette packages: Effects on implicit and explicit attitudes towards smoking among young adults. Psychol Health 2015; 31:349-63. [PMID: 26442992 PMCID: PMC4767655 DOI: 10.1080/08870446.2015.1104309] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To test the effect of exposure to the US Food and Drug Administration's proposed graphic images with text warning statements for cigarette packages on implicit and explicit attitudes towards smoking. DESIGN AND METHODS A two-session web-based study was conducted with 2192 young adults 18-25-years-old. During session one, demographics, smoking behaviour, and baseline implicit and explicit attitudes were assessed. Session two, completed on average 18 days later, contained random assignment to viewing one of three sets of cigarette packages, graphic images with text warnings, text warnings only, or current US Surgeon General's text warnings. Participants then completed post-exposure measures of implicit and explicit attitudes. ANCOVAs tested the effect of condition on the outcomes, controlling for baseline attitudes. RESULTS Smokers who viewed packages with graphic images plus text warnings demonstrated more negative implicit attitudes compared to smokers in the other conditions (p = .004). For the entire sample, explicit attitudes were more negative for those who viewed graphic images plus text warnings compared to those who viewed current US Surgeon General's text warnings (p = .014), but there was no difference compared to those who viewed text-only warnings. CONCLUSION Graphic health warnings on cigarette packages can influence young adult smokers' implicit attitudes towards smoking.
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Affiliation(s)
- Jonathan T. Macy
- Department of Applied Health Science, Indiana University School of Public Health, Bloomington, Indiana, USA
| | - Laurie Chassin
- Department of Psychology, Arizona State University, Tempe, Arizona, USA
| | - Clark C. Presson
- Department of Psychology, Arizona State University, Tempe, Arizona, USA
| | - Ellen Yeung
- Department of Psychology, Arizona State University, Tempe, Arizona, USA
- Institute for Interdisciplinary Salivary Bioscience Research, Arizona State University, Tempe, Arizona, USA
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Do KT, Galván A. FDA cigarette warning labels lower craving and elicit frontoinsular activation in adolescent smokers. Soc Cogn Affect Neurosci 2015; 10:1484-96. [PMID: 25887154 PMCID: PMC4631145 DOI: 10.1093/scan/nsv038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 03/27/2015] [Accepted: 04/07/2015] [Indexed: 01/25/2023] Open
Abstract
Cigarette smoking is an economically and epidemiologically expensive public health concern. Most adult smokers become addicted during adolescence, rendering it a crucial period for prevention and intervention. Although litigation claims have delayed implementation, graphic warning labels proposed by the U.S. Food and Drug Administration (FDA) may be a promising way to achieve this goal. We aimed to determine the efficacy of the labels in reducing in-scanner craving and to characterize the neurobiological responses in adolescent and adult smokers and non-smokers. While undergoing functional magnetic resonance imaging, thirty-nine 13- to 18-year-old adolescent and forty-one 25- to 30-year-old adult smokers and non-smokers rated their desire to smoke when presented with emotionally graphic warning labels and comparison non-graphic labels. Compared with adult smokers, adolescent smokers exhibited greater craving reduction in response to the warning labels. Although smokers evinced overall blunted recruitment of insula and dorsolateral prefrontal cortex (DLPFC) relative to non-smokers, an effect that was stronger in adolescent smokers, parametrically increasing activation of these regions was associated with greater craving reduction. Functional connectivity analyses suggest that greater DLPFC regulation of limbic regions predicted cigarette craving. These data underscore a prominent role of frontoinsular circuitry in predicting the efficacy of FDA graphic warning labels in craving reduction in adult and adolescent smokers.
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Affiliation(s)
- Kathy T Do
- Department of Psychology, University of California, LA, USA
| | - Adriana Galván
- Department of Psychology, University of California, LA, USA
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Gibson L, Brennan E, Momjian A, Shapiro-Luft D, Seitz H, Cappella JN. Assessing the Consequences of Implementing Graphic Warning Labels on Cigarette Packs for Tobacco-Related Health Disparities. Nicotine Tob Res 2015; 17:898-907. [PMID: 26180214 PMCID: PMC4580548 DOI: 10.1093/ntr/ntv082] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 04/02/2015] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Population-level communication interventions, such as graphic warning labels (GWLs) on cigarette packs, have the potential to reduce or exacerbate tobacco-related health disparities depending on their effectiveness among disadvantaged sub-populations. This study evaluated the likely impact of nine GWLs proposed by the US Food and Drug Administration on (1) African American and (2) Hispanic smokers, who disproportionately bear the burden of tobacco-related illness, and (3) low education smokers, who have higher smoking rates. METHODS Data were collected online from current smokers randomly assigned to see GWLs (treatment) or the current text-only warning labels (control). Participants were stratified by age (18-25; 26+) in each of four groups: general population (n = 1246), African Americans (n = 1200), Hispanics (n = 1200), and low education (n = 1790). We tested the effectiveness of GWLs compared to text-only warning labels using eight outcomes that are predictive of quitting intentions or behaviors including negative emotion, intentions to hold back from smoking, intentions to engage in avoidance behaviors, and intentions to quit. RESULTS Across all outcomes, GWLs were significantly more effective than text-only warning labels more often than expected by chance. Results suggested that African Americans, Hispanics and smokers with low education did not differ from the general population of smokers in their reactions to any of the nine individual GWLs. CONCLUSIONS The nine GWLs were similarly effective for disadvantaged sub-populations and the general population of smokers. Implementation of GWLs is therefore unlikely to reduce or exacerbate existing tobacco-related health disparities, but will most likely uniformly increase intentions and behaviors predictive of smoking cessation.
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Affiliation(s)
- Laura Gibson
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA;
| | - Emily Brennan
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Australia
| | - Ani Momjian
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA
| | - Dina Shapiro-Luft
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA
| | - Holli Seitz
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA
| | - Joseph N Cappella
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA
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McQueen A, Kreuter MW, Boyum S, Thompson VS, Caburnay CA, Waters EA, Kaphingst KA, Rath S, Fu Q. Reactions to FDA-Proposed Graphic Warning Labels Affixed to U.S. Smokers' Cigarette Packs. Nicotine Tob Res 2015; 17:784-95. [PMID: 25589676 PMCID: PMC4542680 DOI: 10.1093/ntr/ntu339] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 12/15/2014] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Graphic warning labels have been shown to be more effective than text-only labels in increasing attention and perceived health risks, but most U.S. studies have involved single exposures in laboratory or Internet settings. METHODS We recruited a convenience sample (N = 202) of U.S. adult smokers from population subgroups with higher rates of smoking and smoking-related deaths who had participated in a larger survey about graphic warning labels. Participants were randomized to get 1 of 9 graphic + text labels or a text-only label. Research staff affixed a warning label sticker to participants' cigarette pack(s) at enrollment. Color graphic labels covered slightly more than the lower half of packs. Black and white labels of current U.S. text-only warnings covered the existing side warning to prompt attention to the label (i.e., attention control). Participants received extra stickers of the same label for subsequent packs, and completed 3 telephone interviews in 1 week. RESULTS Participants reported low avoidance (<34%) and consistent use of the stickers (91%). Smokers consistently paid more attention to graphic than text-only labels. Only 5 of the 9 graphic warning labels were significantly associated with greater thoughts of health risks. Thinking about quitting and stopping smoking did not differ by label. Qualitative data illustrated differences in the "stickiness," self-referencing, and counterarguments of graphic warning labels. CONCLUSIONS U.S. smokers' reactions to graphic warning labels on their own packs were similar to other, more controlled studies. Qualitative findings underscore the need for warning labels that encourage self-referential processing without increasing defensive reactions.
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Affiliation(s)
- Amy McQueen
- Health Communication Research Laboratory, Washington University in St. Louis, St. Louis, MO;
| | - Matthew W Kreuter
- Health Communication Research Laboratory, Washington University in St. Louis, St. Louis, MO
| | - Sonia Boyum
- Health Communication Research Laboratory, Washington University in St. Louis, St. Louis, MO
| | - Vetta S Thompson
- Health Communication Research Laboratory, Washington University in St. Louis, St. Louis, MO
| | - Charlene A Caburnay
- Health Communication Research Laboratory, Washington University in St. Louis, St. Louis, MO
| | - Erika A Waters
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO
| | | | | | - Qiang Fu
- Department of Biostatistics, Saint Louis University, College for Public Health and Social Justice, Salus Center, St. Louis, MO
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Noar SM, Hall MG, Francis DB, Ribisl KM, Pepper JK, Brewer NT. Pictorial cigarette pack warnings: a meta-analysis of experimental studies. Tob Control 2015; 25:341-54. [PMID: 25948713 PMCID: PMC4636492 DOI: 10.1136/tobaccocontrol-2014-051978] [Citation(s) in RCA: 408] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 03/31/2015] [Indexed: 11/30/2022]
Abstract
Objective To inform international research and policy, we conducted a meta-analysis of the experimental literature on pictorial cigarette pack warnings. Data sources We systematically searched 7 computerised databases in April 2013 using several search terms. We also searched reference lists of relevant articles. Study selection We included studies that used an experimental protocol to test cigarette pack warnings and reported data on both pictorial and text-only conditions. 37 studies with data on 48 independent samples (N=33 613) met criteria. Data extraction and synthesis Two independent coders coded all study characteristics. Effect sizes were computed from data extracted from study reports and were combined using random effects meta-analytic procedures. Results Pictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes (all p<0.05). Relative to text-only warnings, pictorial warnings (1) attracted and held attention better; (2) garnered stronger cognitive and emotional reactions; (3) elicited more negative pack attitudes and negative smoking attitudes and (4) more effectively increased intentions to not start smoking and to quit smoking. Participants also perceived pictorial warnings as being more effective than text-only warnings across all 8 perceived effectiveness outcomes. Conclusions The evidence from this international body of literature supports pictorial cigarette pack warnings as more effective than text-only warnings. Gaps in the literature include a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects.
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Affiliation(s)
- Seth M Noar
- School of Journalism and Mass Communication, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Marissa G Hall
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Diane B Francis
- School of Journalism and Mass Communication, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kurt M Ribisl
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jessica K Pepper
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Noel T Brewer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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77
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Healey B, Hoek J. Young Adult Smokers’ and Prior-Smokers’ Evaluations of Novel Tobacco Warning Images: Table 1. Nicotine Tob Res 2015; 18:93-7. [DOI: 10.1093/ntr/ntv041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 02/11/2015] [Indexed: 11/14/2022]
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78
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Magnan RE, Cameron LD. Do Young Adults Perceive That Cigarette Graphic Warnings Provide New Knowledge About the Harms of Smoking? Ann Behav Med 2015; 49:594-604. [DOI: 10.1007/s12160-015-9691-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Bosone L, Martinez F, Kalampalikis N. When the model fits the frame: the impact of regulatory fit on efficacy appraisal and persuasion in health communication. PERSONALITY AND SOCIAL PSYCHOLOGY BULLETIN 2015; 41:526-39. [PMID: 25680684 DOI: 10.1177/0146167215571089] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In health-promotional campaigns, positive and negative role models can be deployed to illustrate the benefits or costs of certain behaviors. The main purpose of this article is to investigate why, how, and when exposure to role models strengthens the persuasiveness of a message, according to regulatory fit theory. We argue that exposure to a positive versus a negative model activates individuals' goals toward promotion rather than prevention. By means of two experiments, we demonstrate that high levels of persuasion occur when a message advertising healthy dietary habits offers a regulatory fit between its framing and the described role model. Our data also establish that the effects of such internal regulatory fit by vicarious experience depend on individuals' perceptions of response-efficacy and self-efficacy. Our findings constitute a significant theoretical complement to previous research on regulatory fit and contain valuable practical implications for health-promotional campaigns.
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Affiliation(s)
- Lucia Bosone
- Social Psychology Research Group (EA 4163), Université Lumière Lyon 2, France
| | - Frédéric Martinez
- Social Psychology Research Group (EA 4163), Université Lumière Lyon 2, France
| | - Nikos Kalampalikis
- Social Psychology Research Group (EA 4163), Université Lumière Lyon 2, France
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80
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Nonnemaker JM, Choiniere CJ, Farrelly MC, Kamyab K, Davis KC. Reactions to graphic health warnings in the United States. HEALTH EDUCATION RESEARCH 2015; 30:46-56. [PMID: 24974219 DOI: 10.1093/her/cyu036] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
This study reports consumer reactions to the graphic health warnings selected by the Food and Drug Administration to be placed on cigarette packs in the United States. We recruited three sets of respondents for an experimental study from a national opt-in e-mail list sample: (i) current smokers aged 25 or older, (ii) young adult smokers aged 18-24 and (iii) youth aged 13-17 who are current smokers or who may be susceptible to initiation of smoking. Participants were randomly assigned to be exposed to a pack of cigarettes with one of nine graphic health warnings or with a text-only warning statement. All three age groups had overall strong negative emotional (ß = 4.7, P < 0.001 for adults; ß = 4.6, P < 0.001 for young adults and ß = 4.0, P < 0.001 for youth) and cognitive (ß = 2.4, P < 0.001 for adults; ß = 3.0, P < 0.001 for young adults and ß = 4.6, P < 0.001 for youth) reactions to the proposed labels. The strong negative emotional and cognitive reactions following a single exposure to the graphic health warnings suggest that, with repeated exposures over time, graphic health warnings may influence smokers' beliefs, intentions and behaviors.
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Affiliation(s)
- James M Nonnemaker
- RTI International, Research Triangle Park, NC 27709, USA and Food and Drug Administration, Center for Tobacco Products, Rockville, MD 20850, USA
| | - Conrad J Choiniere
- RTI International, Research Triangle Park, NC 27709, USA and Food and Drug Administration, Center for Tobacco Products, Rockville, MD 20850, USA
| | - Matthew C Farrelly
- RTI International, Research Triangle Park, NC 27709, USA and Food and Drug Administration, Center for Tobacco Products, Rockville, MD 20850, USA
| | - Kian Kamyab
- RTI International, Research Triangle Park, NC 27709, USA and Food and Drug Administration, Center for Tobacco Products, Rockville, MD 20850, USA
| | - Kevin C Davis
- RTI International, Research Triangle Park, NC 27709, USA and Food and Drug Administration, Center for Tobacco Products, Rockville, MD 20850, USA
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81
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Balhara YPS, Gupta R. Revised Size of Pictorial Warning on Cigarette Packages—A Step in Right Direction. Nicotine Tob Res 2015; 17:1401-2. [DOI: 10.1093/ntr/ntv023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/21/2015] [Indexed: 11/12/2022]
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82
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Newman-Norlund RD, Thrasher JF, Fridriksson J, Brixius W, Froeliger B, Hammond D, Cummings MK. Neural biomarkers for assessing different types of imagery in pictorial health warning labels for cigarette packaging: a cross-sectional study. BMJ Open 2014; 4:e006411. [PMID: 25552613 PMCID: PMC4281542 DOI: 10.1136/bmjopen-2014-006411] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Countries around the world have increasingly adopted pictorial health warning labels (HWLs) for tobacco packages to warn consumers about smoking-related risks. Research on how pictorial HWLs work has primarily analysed self-reported responses to HWLs; studies at the neural level comparing the brain's response to different types of HWLs may provide an important complement to prior studies, especially if self-reported responses are systematically biased. In this study we characterise the brain's response to three types of pictorial HWLs for which prior self-report studies indicated different levels of efficacy. METHODS Current smokers rated pictorial HWLs and then observed the same HWLs during functional MRI (fMRI) scanning. Fifty 18-50-year-old current adult smokers who were free from neurological disorders were recruited from the general population and participated in the study. Demographics, smoking-related behaviours and self-reported ratings of pictorial HWL stimuli were obtained prior to scanning. Brain responses to HWLs were assessed using fMRI, focusing on a priori regions of interest. RESULTS Pictorial HWL stimuli elicited activation in a broad network of brain areas associated with visual processing and emotion. Participants who rated the stimuli as more emotionally arousing also showed greater neural responses at these sites. CONCLUSIONS Self-reported ratings of pictorial HWLs are correlated with neural responses in brain areas associated with visual and emotional processing. Study results cross-validate self-reported ratings of pictorial HWLs and provide insights into how pictorial HWLs are processed.
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Affiliation(s)
- Roger D Newman-Norlund
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina, USA
| | - James F Thrasher
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, South Carolina, USA
| | - Johann Fridriksson
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, South Carolina, USA
| | - William Brixius
- Department of Psychology, University of South Carolina, Columbia, South Carolina, USA
| | - Brett Froeliger
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Medical University of South Carolina, Hollings Cancer Center, Charleston, South Carolina, USA
| | - David Hammond
- University of Waterloo, School of Public Health and Health Systems, Waterloo, Ontario, Canada
| | - Michael K Cummings
- Medical University of South Carolina, Hollings Cancer Center, Charleston, South Carolina, USA
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83
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White V, Bariola E, Faulkner A, Coomber K, Wakefield M. Graphic Health Warnings on Cigarette Packs: How Long Before the Effects on Adolescents Wear Out? Nicotine Tob Res 2014; 17:776-83. [PMID: 25239958 DOI: 10.1093/ntr/ntu184] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 08/10/2014] [Indexed: 11/12/2022]
Abstract
INTRODUCTION To examine the long-term impact of graphic health-warning labels (GHWL) on adolescents' cognitive processing of warning labels and cigarette pack perceptions. METHODS Cross-sectional school-based surveys of students aged 13-17 years residing in urban centers, conducted prior to GHWL introduction (2005) and 6 months (2006), 2 years (2008), and 5 years (2011) post-GHWL introduction. Students who had seen a cigarette pack in the previous 6 months or in 2006, who had seen GHWL were included in analyses (2005 n = 2,560; 2006 n = 1,306; 2008 n = 2,303; 2011 n = 2,716). Smoking stage, reported exposure to cigarette packs, cognitive processing of GHWL, and positive and negative perceptions of pack image were assessed. RESULTS While cognitive processing of GHWL in 2006 and 2008 was greater than 2005 (p < .01), by 2011 scores had returned to 2005 levels. This pattern of change was consistent across smoking status groups. Pack image perceptions became more negative over time among all students, irrespective of smoking experience. While positive pack image ratings were lower in all subsequent years than 2005, the 2008 rating was higher than 2006 (p < .01). A significant interaction between survey time and smoking status (p < .01) showed that significant increases in positive pack ratings after 2006 only occurred among current and experimental smokers. CONCLUSIONS When novel, GHWL on cigarette packs increase cognitive processing among adolescents. However, this effect diminishes after 5 years, suggesting more regular message refreshment is needed. Australia's adoption of plain packaging is intended to undermine positive pack appeal and increase warning salience.
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Affiliation(s)
- Victoria White
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Australia
| | - Emily Bariola
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Australia
| | - Agatha Faulkner
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Australia
| | - Kerri Coomber
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Australia
| | - Melanie Wakefield
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Australia
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84
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Levis DM, Stone-Wiggins B, O'Hegarty M, Tong VT, Polen KND, Cassell CH, Council M. Women's perspectives on smoking and pregnancy and graphic warning labels. Am J Health Behav 2014; 38:755-64. [PMID: 24933145 DOI: 10.5993/ajhb.38.5.13] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To explore women's knowledge, attitudes, and beliefs about adverse outcomes associated with smoking during pregnancy and which outcomes might motivate cessation; to explore reactions to graphic warnings depicting 2 adverse outcomes. METHODS Twelve focus groups were conducted with women of childbearing age who were current smokers. RESULTS Participants had low to moderate awareness of many outcomes and believed it was acceptable to smoke in the first trimester before knowledge of pregnancy. Perceived susceptibility to outcomes was low. Motivators included risk-focused information, especially serious risks to the baby (eg, stillbirth, SIDS). Graphic warnings produced strong reactions, especially the warning with a real photo. CONCLUSIONS Despite barriers to reducing rates of smoking during pregnancy, educational information and photos depicting babies' risks could motivate women to quit.
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Affiliation(s)
- Denise M Levis
- Centers for Disease Control and Prevention, Division of Birth Defects and Developmental Disabilities, Atlanta, GA, USA.
| | - Brenda Stone-Wiggins
- RTI International, Public Health Research Division, Research Triangle Park, NC, USA
| | - Michelle O'Hegarty
- Centers for Disease Control and Prevention, Office on Smoking and Health, Atlanta, GA, USA
| | - Van T Tong
- Centers for Disease Control and Prevention, Division of Reproductive Health, Atlanta, GA, USA
| | - Kara N D Polen
- Centers for Disease Control and Prevention, Division of Birth Defects and Developmental Disabilities, Atlanta, GA, USA
| | - Cynthia H Cassell
- Centers for Disease Control and Prevention, Division of Birth Defects and Developmental Disabilities, Atlanta, GA, USA
| | - Mary Council
- RTI International, Public Health Research Division, Research Triangle Park, NC, USA
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85
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Mays D, Turner MM, Zhao X, Evans WD, Luta G, Tercyak KP. Framing Pictorial Cigarette Warning Labels to Motivate Young Smokers to Quit. Nicotine Tob Res 2014; 17:769-75. [PMID: 25143295 DOI: 10.1093/ntr/ntu164] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 08/10/2014] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The Family Smoking Prevention and Tobacco Control Act requires new pictorial warnings for U.S. cigarette packs, but enactment has been delayed by tobacco industry lawsuits. Research can inform implementation of the pictorial warning requirement and identify ways to optimize their public health impact post-implementation. This study investigated the impact of warning label message framing on young smokers' motivation to quit, examining cessation self-efficacy, and perceived risks as moderators of message framing impact. METHODS Smokers ages 18-30 (n = 740) completed baseline measures and were randomized to view 4 images of cigarette packs with pictorial health warnings featuring gain- or loss-framed messages. Motivation to quit was assessed after participants viewed the pack images. Linear models accounting for repeated measures and adjusting for baseline covariates examined the impact of message framing and interactions with baseline self-efficacy to quit and perceived risks of smoking. RESULTS Loss-framed warnings prompted significantly greater motivation to quit among smokers with high self-efficacy compared with smokers with low self-efficacy. Among smokers with low self-efficacy, gain-framed messages were superior to loss-framed messages. Gain-framed warnings generated significantly greater motivation to quit among smokers with high perceived risks compared with smokers with low perceived risks. Among smokers with high perceived risks, gain-framed messages were superior to loss-framed messages. CONCLUSIONS A combination of pictorial warnings featuring risk-based (i.e., loss-framed) and efficacy-enhancing (i.e., gain-framed) information may promote better public health outcomes. Research is needed to investigate how strategically framed warning messages impact smokers' behaviors based on their pre-existing attitudes and beliefs in real-world settings.
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Affiliation(s)
- Darren Mays
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC;
| | - Monique M Turner
- Department of Prevention and Community Health, George Washington University Milken Institute School of Public Health, Washington, DC
| | - Xiaoquan Zhao
- Department of Communication, College of Humanities and Social Sciences, George Mason University, Fairfax, Virginia
| | - W Douglas Evans
- Department of Prevention and Community Health, George Washington University Milken Institute School of Public Health, Washington, DC
| | - George Luta
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Department of Biostatistics, Biomathematics, and Bioinformatics, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC
| | - Kenneth P Tercyak
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC
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Popova L, Neilands TB, Ling PM. Testing messages to reduce smokers' openness to using novel smokeless tobacco products. Tob Control 2014; 23:313-21. [PMID: 23467655 PMCID: PMC3723703 DOI: 10.1136/tobaccocontrol-2012-050723] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Tobacco manufacturers' aggressive promotion of new smokeless tobacco products such as snus warrants a timely and effective public health response. This study tested potential countermarketing messages to discourage current and former smokers from becoming dual users of smokeless tobacco and cigarettes. METHODS In a pretest-post-test experiment, 1836 adult current and recently former smokers from a national sample were randomised to view one of six antismokeless tobacco ads followed by a snus ad, to view a control ad followed by a snus ad; or to view two control ads. Perceived effectiveness of ads and actual changes in attitudes and openness to snus were compared across groups using analyses of variance. RESULTS Some ads that were perceived as most effective did not change attitudes or openness to trying snus, and conversely, some ads not perceived as effective changed attitudes and openness to snus. Ads portraying the negative health effects of smokeless tobacco were perceived as most effective, but ads with antitobacco industry themes significantly decreased favourable attitudes toward snus. Responses to ads were different for smokers who had ever used smokeless tobacco: for this group health effects and humorous/testimonial ads were effective. CONCLUSIONS Measures of perceived effectiveness of antitobacco ads need to be augmented with measures of actual effectiveness to assess countermarketing messages. Some of the developed ads, such as ads with anti-industry themes, were effective for the overall population of smokers whereas humorous/testimonial and health effects ads were particularly effective in changing attitudes of past users of smokeless tobacco.
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Affiliation(s)
- Lucy Popova
- Center for Tobacco Control Research and Education, University of California, San Francisco, California, USA
| | - Torsten B Neilands
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, California, USA
| | - Pamela M Ling
- Division of General Internal Medicine, Department of Medicine, Center for Tobacco Control Research and Education, University of California, San Francisco, California, USA
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Demographic characteristics, nicotine dependence, and motivation to quit as possible determinants of smoking behaviors and acceptability of shocking warnings in Italy. BIOMED RESEARCH INTERNATIONAL 2014; 2014:723035. [PMID: 24900980 PMCID: PMC4037115 DOI: 10.1155/2014/723035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 04/10/2014] [Indexed: 11/23/2022]
Abstract
Introduction. This paper presents the final results of a cross-sectional study started in 2010. It compares the perceived efficacy of different types of tobacco health warning (texts versus shocking pictures) to quit or reduce tobacco use. Methods. The study conducted between 2010 and 2012 in Italy enrolled adults smokers. Administering a questionnaire demographic data, smokers behaviors were collected. Showing text and graphic warnings (the corpse of a smoker, diseased lungs, etc.) the most perceived efficacy to reduce tobacco consumption or to encourage was quit. Results. 666 subjects were interviewed; 6% of responders referred that they stopped smoking at least one month due to the textual warnings. The 81% of the smokers perceived that the warnings with shocking pictures are more effective in reducing/quitting tobacco consumption than text-only warnings. The younger group (<45 years), who are more motivated to quit (Mondor's score ≥ 12), and females showed a higher effectiveness of shocking warnings to reduce tobacco consumption of, 76%, 78%, and 43%, respectively with P < 0.05. Conclusions. This study suggests that pictorial warnings on cigarette packages are more likely to be noticed and rated as effective by Italian smokers. Female and younger smokers appear to be more involved by shock images. The jarring warnings also appear to be supporting those who want to quit smoking. This type of supportive information in Italy may become increasingly important for helping smokers to change their behavior.
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88
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Blanton H, Snyder LB, Strauts E, Larson JG. Effect of graphic cigarette warnings on smoking intentions in young adults. PLoS One 2014; 9:e96315. [PMID: 24806481 PMCID: PMC4012950 DOI: 10.1371/journal.pone.0096315] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 04/04/2014] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Graphic warnings (GWs) on cigarette packs are widely used internationally and perhaps will be in the US but their impact is not well understood. This study tested support for competing hypotheses in different subgroups of young adults defined by their history of cigarette smoking and individual difference variables (e.g., psychological reactance). One hypothesis predicted adaptive responding (GWs would lower smoking-related intentions) and another predicted defensive responding (GWs would raise smoking-related intentions). METHODS Participants were an online sample of 1,169 Americans ages 18-24, who were randomly assigned either to view nine GWs designed by the FDA or to a no-label control. Both the intention to smoke in the future and the intention to quit smoking (among smokers) were assessed before and after message exposure. RESULTS GWs lowered intention to smoke in the future among those with a moderate lifetime smoking history (between 1 and 100 cigarettes), and they increased intention to quit smoking among those with a heavy lifetime smoking history (more than 100 cigarettes). Both effects were limited to individuals who had smoked in some but not all of the prior 30 days (i.e., occasional smokers). No evidence of defensive "boomerang effects" on intention was observed in any subgroup. CONCLUSION Graphic warnings can reduce interest in smoking among occasional smokers, a finding that supports the adaptive-change hypothesis. GWs that target occasional smokers might be more effective at reducing cigarette smoking in young adults.
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Affiliation(s)
- Hart Blanton
- Department of Psychology, University of Connecticut, Storrs, Connecticut, United States of America
| | - Leslie B. Snyder
- Department of Communication Sciences, University of Connecticut, Storrs, Connecticut, United States of America
| | - Erin Strauts
- Department of Psychology, University of Connecticut, Storrs, Connecticut, United States of America
| | - Joy G. Larson
- Center for Health, Intervention, and Prevention, University of Connecticut, Storrs, Connecticut, United States of America
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Brown T, Platt S, Amos A. Equity impact of population-level interventions and policies to reduce smoking in adults: a systematic review. Drug Alcohol Depend 2014; 138:7-16. [PMID: 24674707 DOI: 10.1016/j.drugalcdep.2014.03.001] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 02/21/2014] [Accepted: 03/02/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS There is strong evidence about which tobacco control policies reduce smoking. However, their equity impact is uncertain. The aim was to assess the effectiveness of population-level interventions/policies to reduce socioeconomic inequalities in adult smoking. METHODS Systematic review of studies of population-level interventions/policies reporting smoking-related outcomes in adults of lower compared to higher socioeconomic status (SES). References were screened and independently checked. Studies were quality assessed. Results are presented in a narrative synthesis. Equity impact was assessed as: positive (reduced inequality), neutral (no difference by SES), negative (increased inequality), mixed (equity impact varied) or unclear. RESULTS 117 studies of 130 interventions/policies were included: smokefree (44); price/tax (27); mass media campaigns (30); advertising controls (9); cessation support (9); settings-based interventions (7); multiple policies (4). The distribution of equity effects was: 33 positive, 36 neutral, 38 negative, 6 mixed, 17 unclear. Most neutral equity studies benefited all SES groups. Fourteen price/tax studies were equity positive. Voluntary, regional and partial smokefree policies were more likely to be equity negative than national, comprehensive smokefree policies. Mass media campaigns had inconsistent equity effects. Cigarette marketing controls were equity positive or neutral. Targeted national smoking cessation services can be equity positive by achieving higher reach among low SES, compensating for lower quit rates. CONCLUSIONS Few studies have assessed the equity impact of tobacco control policy/interventions. Price/tax increases had the most consistent positive equity impact. More research is needed to strengthen the evidence-base for reducing smoking inequalities and to develop effective equity-orientated tobacco control strategies.
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Affiliation(s)
- Tamara Brown
- UK Centre for Tobacco Control Studies, Centre for Population Health Sciences, University of Edinburgh, Edinburgh EH8 9AG, UK
| | - Stephen Platt
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh EH8 9AG, UK
| | - Amanda Amos
- UK Centre for Tobacco Control Studies, Centre for Population Health Sciences, University of Edinburgh, Edinburgh EH8 9AG, UK.
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90
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Emery LF, Romer D, Sheerin KM, Jamieson KH, Peters E. Affective and cognitive mediators of the impact of cigarette warning labels. Nicotine Tob Res 2014; 16:263-9. [PMID: 23946325 PMCID: PMC3920332 DOI: 10.1093/ntr/ntt124] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 07/05/2013] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Research conducted by the U.S. Food and Drug Administration to select graphic warning labels for cigarette packs has been challenged as inadequate for demonstrating effects on smokers' beliefs about smoking. The present study tested the prediction that warnings alter risk perceptions and thoughts of quitting indirectly through a cognitive pathway (warning believability) and an affective pathway (worry about health), both of which are important for encouraging smokers to consider quitting. METHODS Using a national Internet panel, individuals who smoke were randomly assigned to view 1 of 3 types of warning labels: basic text only, graphic image with basic text, and graphic image with both basic and additional text elaborating on the reason for the health risk. Analyses were conducted to determine whether cognitive and affective reactions mediated effects on smoking-related outcomes. RESULTS Images influenced perceived risk, immediate desire to smoke, and feelings toward quitting indirectly through affective reactions; elaborated text influenced these outcomes through cognitive believability, with little evidence of direct effects. Believability also enhanced positive feelings toward quitting among smokers who were less worried about health risks due to smoking. CONCLUSIONS The findings indicate that (a) many effects of warnings on smokers' beliefs are mediated rather than direct, (b) both cognitive and affective responses are important mediators, and (c) elaborated text can help to increase effects of images through a cognitive pathway. Warning labels should be designed to maximize effects on these mediators in order to influence smoking outcomes.
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Affiliation(s)
- Lydia F. Emery
- Annenberg Public Policy Center, University of Pennsylvania, Philadelphia, PA
| | - Daniel Romer
- Annenberg Public Policy Center, University of Pennsylvania, Philadelphia, PA
| | - Kaitlin M. Sheerin
- Annenberg Public Policy Center, University of Pennsylvania, Philadelphia, PA
| | | | - Ellen Peters
- Department of Psychology, Ohio State University, Columbus, OH
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91
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Mays D, Niaura RS, Evans WD, Hammond D, Luta G, Tercyak KP. Cigarette packaging and health warnings: the impact of plain packaging and message framing on young smokers. Tob Control 2014; 24:e87-92. [PMID: 24420310 DOI: 10.1136/tobaccocontrol-2013-051234] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE This study examined the impact of pictorial cigarette-warning labels, warning-label message framing and plain cigarette packaging, on young adult smokers' motivation to quit. METHODS Smokers aged 18-30 years (n=740) from a consumer research panel were randomised to one of four experimental conditions where they viewed online images of four cigarette packs with warnings about lung disease, cancer, stroke/heart disease and death, respectively. Packs differed across conditions by warning-message framing (gain vs loss) and packaging (branded vs plain). Measures captured demographics, smoking behaviour, covariates and motivation to quit in response to cigarette packs. RESULTS Pictorial warnings about lung disease and cancer generated the strongest motivation to quit across conditions. Adjusting for pretest motivation and covariates, a message framing by packaging interaction revealed gain-framed warnings on plain packs generated greater motivation to quit for lung disease, cancer and mortality warnings (p<0.05), compared with loss-framed warnings on plain packs. CONCLUSIONS Warnings combining pictorial depictions of smoking-related health risks with text-based messages about how quitting reduces risks, may achieve better outcomes among young adults, especially in countries considering or implementing plain packaging regulations.
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Affiliation(s)
- Darren Mays
- Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Raymond S Niaura
- Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA Schroeder Institute for Tobacco Research and Policy Studies, Legacy, Washington, DC, USA Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - W Douglas Evans
- Department of Prevention & Community Health, School of Public Health and Health Services, George Washington University, Washington, DC, USA
| | - David Hammond
- Department of Health Studies & Gerontology, University of Waterloo, Waterloo, Canada
| | - George Luta
- Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University Medical Center, Washington, DC, USA
| | - Kenneth P Tercyak
- Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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93
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Cameron LD, Pepper JK, Brewer NT. Responses of young adults to graphic warning labels for cigarette packages. Tob Control 2013; 24:e14-22. [PMID: 23624558 DOI: 10.1136/tobaccocontrol-2012-050645] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Linda D Cameron
- Psychological Sciences, School of Social Science, Humanities, and the Arts, University of California, Merced. California, USA
| | - Jessica K Pepper
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Cantrell J, Vallone DM, Thrasher JF, Nagler RH, Feirman SP, Muenz LR, He DY, Viswanath K. Impact of tobacco-related health warning labels across socioeconomic, race and ethnic groups: results from a randomized web-based experiment. PLoS One 2013; 8:e52206. [PMID: 23341895 PMCID: PMC3544861 DOI: 10.1371/journal.pone.0052206] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 11/14/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The U.S. Family Smoking Prevention and Tobacco Control Act of 2009 requires updating of the existing text-only health warning labels on tobacco packaging with nine new warning statements accompanied by pictorial images. Survey and experimental research in the U.S. and other countries supports the effectiveness of pictorial health warning labels compared with text-only warnings for informing smokers about the risks of smoking and encouraging cessation. Yet very little research has examined differences in reactions to warning labels by race/ethnicity, education or income despite evidence that population subgroups may differ in their ability to process health information. The purpose of the present study was to evaluate the potential impact of pictorial warning labels compared with text-only labels among U.S. adult smokers from diverse racial/ethnic and socioeconomic subgroups. METHODS/FINDINGS Participants were adult smokers recruited from two online research panels (n = 3,371) into a web-based experimental study to view either the new pictorial warnings or text-only warnings. Participants viewed the labels and reported their reactions. Adjusted regression models demonstrated significantly stronger reactions for the pictorial condition for each outcome salience (b = 0.62, p<.001); perceived impact (b = 0.44, p<.001); credibility (OR = 1.41, 95% CI = 1.22-1.62), and intention to quit (OR = 1.30, 95% CI = 1.10-1.53). No significant results were found for interactions between condition and race/ethnicity, education, or income. The only exception concerned the intention to quit outcome, where the condition-by-education interaction was nearly significant (p = 0.057). CONCLUSIONS Findings suggest that the greater impact of the pictorial warning label compared to the text-only warning is consistent across diverse racial/ethnic and socioeconomic populations. Given their great reach, pictorial health warning labels may be one of the few tobacco control policies that have the potential to reduce communication inequalities across groups. Policies that establish strong pictorial warning labels on tobacco packaging may be instrumental in reducing the toll of the tobacco epidemic, particularly within vulnerable communities.
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Affiliation(s)
- Jennifer Cantrell
- Department of Research and Evaluation, Legacy Foundation, Washington, DC, USA.
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Thrasher JF, Carpenter MJ, Andrews JO, Gray KM, Alberg AJ, Navarro A, Friedman DB, Cummings KM. Cigarette warning label policy alternatives and smoking-related health disparities. Am J Prev Med 2012; 43:590-600. [PMID: 23159254 PMCID: PMC3504356 DOI: 10.1016/j.amepre.2012.08.025] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 06/12/2012] [Accepted: 08/02/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pictorial health warning labels on cigarette packaging have been proposed for the U.S., but their potential influences among populations that suffer tobacco-related health disparities are unknown. PURPOSE To evaluate pictorial health warning labels, including moderation of their influences by health literacy and race. METHODS From July 2011 to January 2012, field experiments were conducted with 981 adult smokers who were randomized to control (i.e., text-only labels, n=207) and experimental conditions (i.e., pictorial labels, n=774). The experimental condition systematically varied health warning label stimuli by health topic and image type. Linear mixed effects (LME) models estimated the influence of health warning label characteristics and participant characteristics on label ratings. Data were analyzed from January 2012 to April 2012. RESULTS Compared to text-only warning labels, pictorial warning labels were rated as more personally relevant (5.7 vs 6.8, p<0.001) and effective (5.4 vs 6.8, p<0.001), and as more credible, but only among participants with low health literacy (7.6 vs 8.2, p<0.001). Within the experimental condition, pictorial health warning labels with graphic imagery had significantly higher ratings of credibility, personal relevance, and effectiveness than imagery of human suffering and symbolic imagery. Significant interactions indicated that labels with graphic imagery produced minimal differences in ratings across racial groups and levels of health literacy, whereas other imagery produced greater group differences. CONCLUSIONS Pictorial health warning labels with graphic images have the most-pronounced short-term impacts on adult smokers, including smokers from groups that have in the past been hard to reach.
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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 29208, USA.
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