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Skurka C, Kemp D, Davydova J, Thrasher JF, Byrne S, Safi AG, Avery RJ, Dorf MC, Mathios AD, Scolere L, Niederdeppe J. Effects of 30% and 50% Cigarette Pack Graphic Warning Labels on Visual Attention, Negative Affect, Quit Intentions, and Smoking Susceptibility among Disadvantaged Populations in the United States. Nicotine Tob Res 2019; 20:859-866. [PMID: 29126207 DOI: 10.1093/ntr/ntx244] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 11/01/2017] [Indexed: 11/14/2022]
Abstract
Introduction Though the WHO Framework Convention for Tobacco Control (FCTC) calls for the implementation of large graphic warning labels (GWLs) on cigarette boxes, the courts have blocked the implementation of 50% labels in the United States. We conducted an experiment to explore whether changing the size of GWLs is associated with changes in visual attention, negative affect, risk beliefs, and behavioral intentions. Method We recruited adult smokers (N = 238) and middle-school youth (N = 237) throughout the state of New York in May 2016. We randomly assigned participants to one of three between-subject conditions (no GWL [control], 30% GWL, 50% GWL). Results Adult and youth participants looked at the GWLs longer when the GWL covered 50% versus 30% of the pack's front. Increasing GWL size from 30% to 50% did not influence negative affect or risk beliefs, though both GWL sizes increased negative affect relative to the no-GWL control group. Exposure to 50% GWLs increased adult smokers' intentions to quit compared to no-GWL, but smokers exposed to 30% GWLs did not differ from control. There were no differences between 50% GWLs, 30% GWLs, and control on youth smoking susceptibility. Conclusions Findings provide some evidence of the benefits of a 50% versus 30% GWL covering the front of the pack for adult smokers and at-risk youth from socioeconomically disadvantaged backgrounds-though not on all outcomes. Implications This research shows that 30% GWLs on cigarette packages increase negative affect relative to packages without front-of-package GWLs. Larger GWLs on cigarette packages (50% vs. 30%) increase visual attention to the warning and its pictorial content among low-SES smokers and at-risk youth but do not further increase negative affect. A 50% GWL increased adults' quit intention compared to no GWL at all, but we were underpowered to detect modest differences in quit intentions between a 50% and 30% GWL. Future work should thus continue to explore the boundary conditions under which relatively larger GWLs influence cognitive, affective, and behavioral outcomes.
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Affiliation(s)
- Chris Skurka
- Department of Communication, Cornell University, NY
| | - Deena Kemp
- Department of Communication, Cornell University, NY
| | | | - James F Thrasher
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, SC
| | - Sahara Byrne
- Department of Communication, Cornell University, NY
| | - Amelia Greiner Safi
- Department of Communication and Department of Population Medicine and Diagnostic Sciences, Cornell University, NY
| | - Rosemary J Avery
- Department of Policy Analysis and Management, Cornell University, NY
| | | | | | - Leah Scolere
- Department of Design and Merchandising, College of Health and Human Sciences, Colorado State University, CO
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Sontag JM, Wackowski OA, Hammond D. Baseline assessment of noticing e-cigarette health warnings among youth and young adults in the United States, Canada and England, and associations with harm perceptions, nicotine awareness and warning recall. Prev Med Rep 2019; 16:100966. [PMID: 31453077 PMCID: PMC6704048 DOI: 10.1016/j.pmedr.2019.100966] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/24/2019] [Accepted: 08/06/2019] [Indexed: 11/25/2022] Open
Abstract
Health warnings on tobacco products can inform users of potential risks. However, little is known about young people's exposure to health warnings on e-cigarette products. This baseline assessment of young people's noticing e-cigarette warnings uses nationally representative data from three countries. Data were collected under Wave 1 of the ITC Youth Tobacco and E-cigarette Survey, conducted in Canada, England, and the US. Online surveys were completed by 16–19-year-olds in July/August 2017 (n = 12,064), when warnings were either newly required (England) or voluntarily carried by some manufacturers (US, Canada). Analyses examined prevalence and correlates of noticing warnings and associations between noticing warnings and product perceptions, adjusting for country, sex, age, race/ethnicity, and cigarette/e-cigarette use status. About 12% reported noticing warnings on e-cigarette packaging in the past 30 days. Noticing warnings was significantly more likely among youth in England (AOR = 1.3, p < .01) and the US (AOR = 1.3, p < .01) versus Canada, and was most likely among dual e-cigarette/cigarette users (AOR = 4.69, p < .001) versus nonusers. Unaided recall of the keyword “nicotine” was low among those who noticed warnings (7.5%). However, ever e-cigarette users who noticed warnings had higher odds of knowing whether e-cigarettes contained nicotine (AOR = 2.26, p < .001). Noticing warnings was significantly associated with higher odds of believing e-cigarettes cause at least some harm to users (AOR = 1.19), are as harmful as cigarettes (AOR = 1.45), and can be addictive (AOR = 1.43). Baseline assessment reveals that youth's noticing of e-cigarette warnings and recall of nicotine-addiction messages was low. Research should track exposure over time as warning requirements are implemented across different countries. Noticing warnings on e-cig products is low in the US, England and Canada. Ever users: noticing warnings had higher odds of not knowing e-cigs have nicotine. Noticing warnings associated with higher odds of believing e-cigs can be addictive Exposure should be tracked over time as warnings are implemented across countries. Exposure to e-cig warnings may influence harm perceptions and use intentions.
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Affiliation(s)
- Jennah M. Sontag
- Center for Tobacco Studies, Rutgers School of Public Health, New Brunswick, NJ 08901, USA
- Corresponding author.
| | - Olivia A. Wackowski
- Center for Tobacco Studies, Rutgers School of Public Health, New Brunswick, NJ 08901, USA
| | - David Hammond
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
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Francis DB, Mason N, Ross JC, Noar SM. Impact of tobacco-pack pictorial warnings on youth and young adults: A systematic review of experimental studies. Tob Induc Dis 2019; 17:41. [PMID: 31516484 PMCID: PMC6662785 DOI: 10.18332/tid/108614] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 04/17/2019] [Accepted: 04/17/2019] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION We conducted a systematic review of the experimental literature on the impact of tobacco-pack pictorial warning labels (PWLs) on youth and young adults. METHODS We systematically searched computerized databases and the reference lists of relevant articles. We included studies that used an experimental protocol to assess PWLs. Studies had to report findings for youth or young adult samples (aged <30 years). Thirty-one studies met the inclusion criteria, with a total sample size of 27506. Two coders independently coded all study characteristics and outcomes. RESULTS Twenty-eight studies experimentally evaluated PWLs for cigarette packs while three studies evaluated PWLs for smokeless tobacco packs. Generally, PWLs led to higher attention, stronger cognitive and affective reactions, more negative pack attitudes and smoking attitudes, and increased intentions not to use tobacco products compared to text warnings. PWLs were perceived to be more effective than text warnings for both cigarette packs and smokeless tobacco packs. CONCLUSIONS The systematic review showed that PWLs on tobacco products are effective across a wide range of tobacco-related outcomes among young people. Gaps in the literature include a lack of research on tobacco initiation and cessation and a dearth of literature on non-cigarette tobacco products.
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Affiliation(s)
- Diane B Francis
- Department of Communication, University of Kentucky, Lexington, United States
| | - Nia Mason
- Manship School of Mass Communication, Louisiana State University, Baton Rouge, United States
| | - Jennifer Cornacchione Ross
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston Salem, United States
| | - Seth M Noar
- School of Media & Journalism, University of North Carolina at Chapel Hill, Chapel Hill, United States.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, United States
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Tangcharoensathien V, Chandrasiri O, Kunpeuk W, Markchang K, Pangkariya N. Addressing NCDs: Challenges From Industry Market Promotion and Interferences. Int J Health Policy Manag 2019; 8:256-260. [PMID: 31204441 PMCID: PMC6571489 DOI: 10.15171/ijhpm.2019.02] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 01/16/2019] [Indexed: 11/13/2022] Open
Abstract
Addressing the determinants of non-communicable diseases (NCDs) is challenged by aggressive market promotion by tobacco, alcohol and unhealthy food industries in emerging countries with fast economic development; and interference by these industries in government policies aimed at containing consumption of unhealthy products. This editorial reviews market promotion and industry interference and classifies them into four groups of tactics: (a) interfering with the legislative process; (b) using front groups to act on their behalf; (c) questioning the evidence of tobacco harm and the effectiveness of harm-reduction interventions; and (d) appearing responsible in the eyes of the public, journalists and policy-makers. Despite active implementation of the Framework Convention on Tobacco Control (FCTC), the tobacco, alcohol and unhealthy food industries use similar tactics to aggressively interfere in policies, with the tobacco industry being the most aggressive. Policy interference by industries are effective in the context of poor governance, rampant corruption, conflict of interest among political and government actors, and regulatory capture in all levels of countries from low- to high-income. In addressing these interferences, government requires the practice of good governance, effective mechanisms to counteract conflict of interests among political and policy actors, and prevention of regulatory capture. The World Health Organization (WHO) Framework of Engagement with non-State Actors can be applied to the country context when engaging private entities in the prevention and control of NCDs.
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Noar SM, Rohde JA, Horvitz C, Lazard AJ, Cornacchione Ross J, Sutfin EL. Adolescents' receptivity to E-cigarette harms messages delivered using text messaging. Addict Behav 2019; 91:201-207. [PMID: 29960716 DOI: 10.1016/j.addbeh.2018.05.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 05/24/2018] [Accepted: 05/27/2018] [Indexed: 11/16/2022]
Abstract
INTRODUCTION E-cigarette use among adolescents has dramatically risen since 2011, yet little research has tested e-cigarette harms messages among adolescents. We conducted a pretest-posttest pilot study to examine adolescents' receptivity to e-cigarette health harms messages delivered using text messaging. METHODS N = 69 adolescents were enrolled in an 8-day pretest-posttest text messaging study. Participants completed a pretest survey on day one, were texted one of three e-cigarette health harms messages per day on days two through seven, and completed a posttest survey on day eight (88% retention). We assessed message ratings at posttest and knowledge, thoughts, and beliefs about e-cigarette harms at pretest and posttest. RESULTS Adolescents rated the three messages favorably, with both the chemical and brain messages scoring higher than the nicotine message on fear arousal and perceived message effectiveness. More than one-third of adolescents showed the messages to others and talked to others about the messages. At posttest, knowledge about the harms of e-cigarettes, thinking about the risks of e-cigarettes, and perceived risks of e-cigarettes were all significantly higher compared to pretest (p < .05). Participants largely adhered to the text messaging protocol and found the study highly acceptable. CONCLUSIONS This pilot study suggests that adolescents are receptive to e-cigarette health harms messages and that delivering such messages using text messaging is feasible and acceptable. Future research should systematically develop and test a broad set of e-cigarette health harms messages and examine their impact in a randomized controlled trial.
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Affiliation(s)
- Seth M Noar
- University of North Carolina at Chapel Hill, United States; Lineberger Comprehensive Cancer Center, United States.
| | - Jacob A Rohde
- University of North Carolina at Chapel Hill, United States
| | - Casey Horvitz
- Lineberger Comprehensive Cancer Center, United States
| | - Allison J Lazard
- University of North Carolina at Chapel Hill, United States; Lineberger Comprehensive Cancer Center, United States
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Abstract
Communication regulatory science is an emerging field that uses validated techniques, tools, and models to inform regulatory actions that promote optimal communication outcomes and benefit the public. In the opening article to this special issue on communication and tobacco regulatory science, we 1) describe Food and Drug Administration (FDA) regulation of tobacco products in the US; 2) introduce communication regulatory science and provide examples in the tobacco regulatory science realm; and 3) describe the special issue process and final set of articles. Communication research on tobacco regulatory science is a burgeoning area of inquiry, and this work advances communication science, informs and potentially guides the FDA, and may help to withstand legal challenges brought by the tobacco industry. This research has the potential to have a major impact on the tobacco epidemic and population health by helping implement the most effective communications to prevent tobacco initiation and increase cessation. This special issue provides an example of 10 studies that exemplify tobacco regulatory science and demonstrate how the health communication field can affect regulation and benefit public health.
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Affiliation(s)
- Seth M. Noar
- School of Media and Journalism, University of North Carolina at Chapel Hill
- Center for Regulatory Research on Tobacco Communication, University of North Carolina at Chapel Hill
| | - Joseph N. Cappella
- Annenberg School for Communication, University of Pennsylvania
- Penn Tobacco Center of Regulatory Science, University of Pennsylvania
| | - Simani Price
- Coordinating Center for Tobacco Centers of Regulatory Science, Rockville, Maryland
- Westat, Rockville, Maryland
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Byrne S, Greiner Safi A, Kemp D, Skurka C, Davydova J, Scolere L, Mathios AD, Avery RJ, Dorf MC, Steinhardt J, Niederdeppe J. Effects of Varying Color, Imagery, and Text of Cigarette Package Warning Labels among Socioeconomically Disadvantaged Middle School Youth and Adult Smokers. HEALTH COMMUNICATION 2019; 34:306-316. [PMID: 29236526 PMCID: PMC5999539 DOI: 10.1080/10410236.2017.1407228] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
The U.S. Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) of 2009 paved the way for the Food and Drug Administration (FDA) to propose nine different graphic warning labels (GWLs) intended for prominent placement on the front and back of cigarette packs and on cigarette advertisements. Those GWLs were adjudicated as unconstitutional on the ground that they unnecessarily infringed tobacco companies' free speech without sufficiently advancing the government's public health interests. This study examines whether less extensive alternatives to the original full-color GWLs, including black-and-white GWLs and text-only options, have similar or divergent effects on visual attention, negative affect, and health risk beliefs. We used a mobile media research lab to conduct a randomized experiment with two populations residing in socioeconomically disadvantaged communities: biochemically confirmed adult smokers (N = 313) and middle school youth (N = 340). Results indicate that full-color GWLs capture attention for longer than black-and-white GWLs among both youth and adult smokers. Among adults, packages with GWLs (in either color or black-and-white) engendered more negative affect than those with text-only labels, while text-only produced greater negative affect than the packages with brand imagery only. Among youth, GWLs and text-only labels produced comparable levels of negative affect, albeit more so than brand imagery. We thus offer mixed findings related to the claim that a less extensive alternative could satisfy the government's compelling public health interest to reduce cigarette smoking rates.
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Affiliation(s)
- Sahara Byrne
- a Department of Communication , Cornell University
| | - Amelia Greiner Safi
- a Department of Communication , Cornell University
- e Department of Population Medicine and Diagnostic Sciences , College of Veterinary Medicine, Cornell University
| | - Deena Kemp
- a Department of Communication , Cornell University
| | | | | | - Leah Scolere
- a Department of Communication , Cornell University
| | | | - Rosemary J Avery
- c Department of Policy Analysis and Management , Cornell University
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Trofor AC, Papadakis S, Lotrean LM, Radu-Loghin C, Eremia M, Mihaltan F, Driezen P, Kyriakos CN, Mons U, Demjén T, Nogueira SO, Fernández E, Tountas Y, Przewoźniak K, McNeill A, Fong GT, Vardavas CI. Knowledge of the health risks of smoking and impact of cigarette warning labels among tobacco users in six European countries: Findings from the EUREST-PLUS ITC Europe Surveys. Tob Induc Dis 2019; 16:A10. [PMID: 31516464 PMCID: PMC6661855 DOI: 10.18332/tid/99542] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/27/2018] [Accepted: 11/02/2018] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The aim of this study was to examine knowledge of health effects of smoking and the impact of cigarette package warnings among tobacco users from six European Union (EU) Member States (MS) immediately prior to the introduction of the EU Tobacco Products Directive (TPD) in 2016 and to explore the interrelationship between these two factors. METHODS Cross-sectional data were collected via face-to-face interviews with adult smokers (n=6011) from six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) between June-September 2016. Sociodemographic variables and knowledge of health risks of smoking (KHR) were assessed. Warning salience, thoughts of harm, thoughts of quitting and foregoing of cigarettes as a result of health warnings were assessed. The Label Impact Index (LII) was used as a composite measure of warning effects. Linear and logistic regression analyses were used to examine sociodemographic predictors of KHR and LII and the inter-relationship between knowledge and LII scores. RESULTS The KHR index was highest in Romania and Greece and lowest in Hungary and Germany. While the majority of smokers knew that smoking increases the risk for heart diseases, lung and throat cancer, there was lower awareness that tobacco use caused mouth cancer, pulmonary diseases, stroke, and there were very low levels of knowledge that it was also associated with impotence and blindness, in all six countries. Knowledge regarding the health risks of passive smoking was moderate in most countries. The LII was highest in Romania and Poland, followed by Spain and Greece, and lowest in Germany and Hungary. In almost all countries, there was a positive association between LII scores and higher KHR scores after controlling for sociodemographic variables. Several sociodemographic factors were associated with KHR and LII, with differences in these associations documented across countries. CONCLUSIONS These data provide evidence to support the need for stronger educational efforts and policies that can enhance the effectiveness of health warnings in communicating health risks and promoting quit attempts. Data will serve as a baseline for examining the impact of the TPD.
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Affiliation(s)
- Antigona C Trofor
- University of Medicine and Pharmacy, 'Grigore T. Popa' Iasi, Iasi, Romania
- Aer Pur România, București, România
| | - Sophia Papadakis
- University of Crete (UoC), Heraklion, Greece
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
| | - Lucia M Lotrean
- Aer Pur România, București, România
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Cornel Radu-Loghin
- European Network for Smoking and Tobacco Prevention (ENSP), Brussels, Belgium
| | | | - Florin Mihaltan
- Aer Pur România, București, România
- University of Medicine and Pharmacy 'Carol Davilla', Bucharest, Romania
| | - Pete Driezen
- Department of Psychology, University of Waterloo (UW), Waterloo, Canada
| | - Christina N Kyriakos
- University of Crete (UoC), Heraklion, Greece
- European Network for Smoking and Tobacco Prevention (ENSP), Brussels, Belgium
| | - Ute Mons
- Cancer Prevention Unit and WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Tibor Demjén
- Smoking or Health Hungarian Foundation (SHHF), Budapest, Hungary
| | - Sarah O Nogueira
- Tobacco Control Unit, Catalan Institute of Oncology (ICO), Barcelona, Spain
- Cancer Control and Prevention Group, Bellvitge Biomedical Research Institute, Barcelona, Spain
| | - Esteve Fernández
- Tobacco Control Unit, Catalan Institute of Oncology (ICO), Barcelona, Spain
- Cancer Control and Prevention Group, Bellvitge Biomedical Research Institute, Barcelona, Spain
| | - Yannis Tountas
- National and Kapodistrian University of Athens (UoA), Athens, Greece
| | - Krzysztof Przewoźniak
- Health Promotion Foundation (HPF), Warsaw, Poland
- Maria Skłodowska-Curie Institute-Oncology Center (MSCI), Warsaw, Poland
| | - Ann McNeill
- National Addiction Centre, Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London (KCL), London, United Kingdom
- UK Centre for Tobacco and Alcohol Studies, London, United Kingdom
| | - Geoffrey T Fong
- Department of Psychology, University of Waterloo (UW), Waterloo, Canada
- School of Public Health and Health Systems, University of Waterloo (UW), Waterloo, Canada
- Ontario Institute for Cancer Research, Toronto, Canada
| | - Constantine I Vardavas
- University of Crete (UoC), Heraklion, Greece
- European Network for Smoking and Tobacco Prevention (ENSP), Brussels, Belgium
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The Impact of E-Cigarette Warnings, Warning Themes and Inclusion of Relative Harm Statements on Young Adults' E-Cigarette Perceptions and Use Intentions. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16020184. [PMID: 30634618 PMCID: PMC6352031 DOI: 10.3390/ijerph16020184] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/21/2018] [Accepted: 01/07/2019] [Indexed: 11/17/2022]
Abstract
Although e-cigarettes in the United States are required to carry one nicotine addiction warning, little is known about the impact of other potential e-cigarette warning themes, nor about pairing warnings with messages that communicate e-cigarettes' reduced-harm potential relative to cigarettes. We randomly assigned 876 young adults (ages 18⁻29) to view e-cigarette ads in a 3 × 2 plus control online experiment that varied by warning theme (i.e., nicotine addiction; nicotine's impact on adolescent brain development; presence of harmful chemicals) and warning type-i.e., the presence ("relative harm warning") or absence ("standard warning") of a relative harm (RH) statement in the warning label ("e-cigarettes may cause harm to health but are less harmful than cigarettes"). Warning believability, informativeness, understandability and support were high across conditions and there were no significant differences by warning theme on e-cigarette harm perceptions or use intentions nor on nicotine (mis)perceptions. Perceived warning effectiveness for discouraging youth initiation was higher for the "brain" and "chemicals" warnings compared to the addiction warning. Warnings with the included RH statement were perceived as less believable and credible and were less frequently correctly recalled. Research should continue to investigate the impact of different e-cigarette warning themes and formats with priority audiences.
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Campbell BK, Le T, Yip D, Griffin KB, Gubner NR, Guydish JR. Sex Differences in Graphic Warning Label Ratings by Addictions Clients. TOB REGUL SCI 2019; 5:3-14. [PMID: 31236435 PMCID: PMC6590904 DOI: 10.18001/trs.5.1.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Research on sex differences in responses to cigarette graphic warning labels (GWLs) has been limited despite tobacco-related, health disparities for women. We examined whether women had stronger responses to certain labels than to others, whether this pattern differed from men's, and whether there were overall sex ratings differences. METHODS Smokers (N = 881) in 24, addictions treatment programs rated 3 of 9 Food and Drug Administration-developed labels on credibility, message reactance, quit motivation, and negative emotions. Participants rated one label depicting a woman and/or baby, and 2 depicting tobacco-related disease or male images. RESULTS Women's (n = 432) ratings of labels depicting women/babies versus other labels did not differ from men's (n = 449) ratings. Women had higher ratings than men across all labels combined on credibility (p < .001), quit motivation (p = .007), and negative emotions (p < .001). Individual labels were analyzed for sex differences. Women's ratings were higher on credibility for 3 of 9 labels, and on negative emotions for 7 of 9 labels. CONCLUSIONS Female smokers in addictions treatment had generally stronger responses to GWLs than men, supporting GWL implementation in the United States to help close the sex gap in smoking cessation.
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Affiliation(s)
- Barbara K. Campbell
- OHSU/PSU School of Public Health, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098, USA
| | - Thao Le
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118, USA
| | - Deborah Yip
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118, USA
| | - Kayla B. Griffin
- Morgan State University, 1700 E. Cold Springs Lane, Baltimore, MD 21251, USA
| | - Noah R. Gubner
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118, USA
| | - Joseph R. Guydish
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118, USA
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Mantzari E, Vasiljevic M, Turney I, Pilling M, Marteau T. Impact of warning labels on sugar-sweetened beverages on parental selection: An online experimental study. Prev Med Rep 2018; 12:259-267. [PMID: 30406003 PMCID: PMC6215029 DOI: 10.1016/j.pmedr.2018.10.016] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 10/12/2018] [Accepted: 10/21/2018] [Indexed: 12/12/2022] Open
Abstract
Sugar-sweetened beverages (SSBs) are one of the largest added sugar sources to diets in the UK and USA, particularly among young people. Warning labels, including calorie information labels, could reduce SSB consumption but uncertainty surrounds the labels that are most effective. This study assessed the impact of labels containing (a) each of two image-based warnings and (b) calorie information, singly and together, on SSB selection by parents of 11-16-year-olds living in the UK. Using a 3 (disease image, sugar content image, no image) × 2 (calorie information, no calorie information) between-subjects experimental design, 2002 participants were randomised to see beverages with one of six labels and selected one for their child to consume. The primary outcome was the proportion of participants selecting an SSB. Data were collected in December 2017. Logistic regressions showed SSB selection was lower when labels contained an image-based warning (35%), compared to not having any label (49%) or just calorie information (43.5%). The disease image lowered selection more than the sugar image (32% vs 40.5%). Providing calorie information with the disease image had no additional impact on selection (33%) but enhanced the impact of the sugar image (36%). Image-based warning labels discourage SSB selection by parents for their children. Images depicting health consequences of excess sugar consumption have larger effects than those depicting sugar content. Calorie information does not add to the effect of the former but does to that of the latter. Field studies are needed to assess the impact of SSB warning labels in real-life settings.
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Affiliation(s)
- Eleni Mantzari
- Behaviour and Health Research Unit, University of Cambridge, UK
| | | | | | - Mark Pilling
- Behaviour and Health Research Unit, University of Cambridge, UK
| | - Theresa Marteau
- Behaviour and Health Research Unit, University of Cambridge, UK
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Morgan JC, Golden SD, Noar SM, Ribisl KM, Southwell BG, Jeong M, Hall MG, Brewer NT. Conversations about pictorial cigarette pack warnings: Theoretical mechanisms of influence. Soc Sci Med 2018; 218:45-51. [PMID: 30340152 DOI: 10.1016/j.socscimed.2018.09.063] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 09/19/2018] [Accepted: 09/30/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Social interactions are a key mechanism through which health communication campaigns influence behavior. Little research has examined how conversations about pictorial warnings motivate behavior. PURPOSE We sought to establish whether and how smokers' conversations explain the effect of pictorial warnings on quit attempts. METHODS US adult smokers (n = 2149) participated in a controlled trial that randomly assigned them to have their cigarette packs labeled with pictorial or text-only warnings for four weeks. Surveys assessed the number of conversations sparked by pictorial warnings and the theoretical mechanisms cognitive elaboration and social norms at each visit. Analyses used structural equation modeling to test our theorized mediation models. RESULTS The number of conversations about the warnings mediated the relationship between exposure to pictorial warnings and quit attempts (p < .001). In serial mediation analysis examining possible theoretical mechanisms, the number of conversations was associated with greater cognitive elaboration, which in turn was associated with being more likely to make a quit attempt (p < .05). Social norms did not explain the influence of conversations on quit attempts. CONCLUSIONS Pictorial warnings increased conversations about the warnings, which led to greater cognitive elaboration, which led to greater quit attempts. Our findings suggest designing warnings that increase conversations in order to better inform and motivate smokers. Furthermore, these findings improve our understanding of why conversations matter in health communication.
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Affiliation(s)
- Jennifer C Morgan
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, NC, USA; Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA, USA.
| | - Shelley D Golden
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, NC, USA
| | - Seth M Noar
- School of Media and Journalism, University of North Carolina at Chapel Hill, North Carolina, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, North Carolina, NC, USA
| | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, North Carolina, NC, USA
| | - Brian G Southwell
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, NC, USA; School of Media and Journalism, University of North Carolina at Chapel Hill, North Carolina, NC, USA; RTI International, Research Triangle Park, North Carolina, NC, USA
| | - Michelle Jeong
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, North Carolina, NC, USA; Center for Tobacco Studies, Rutgers School of Public Health, New Brunswick, NJ, USA
| | - Marissa G Hall
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, North Carolina, NC, USA
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, North Carolina, NC, USA
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63
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Leas EC, Pierce JP, Dimofte CV, Trinidad DR, Strong DR. Standardised cigarette packaging may reduce the implied safety of Natural American Spirit cigarettes. Tob Control 2018; 27:e118-e123. [PMID: 29255011 PMCID: PMC7392163 DOI: 10.1136/tobaccocontrol-2017-053940] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 10/30/2017] [Accepted: 11/14/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Over two-thirds of Natural American Spirit (NAS) smokers believe their cigarettes might be 'less harmful', but toxicological evidence does not support this belief. We assessed whether standardised packaging could reduce the possibility of erroneous inferences of 'safety' drawn from NAS cigarette packaging. METHODS US adult smokers (n=909) were recruited to a between-subject survey experiment (3 brands×3 packaging/labelling styles) through Amazon Mechanical Turk and rated their perception of whether a randomly assigned cigarette package conveyed that the brand was 'safer' on a three-item scale (Cronbach's α=0.92). We assessed whether NAS packs were rated higher on the 'implied safety' scale than two other brands and estimated the effect that plain packaging (ie, all branding replaced with a drab dark brown colour) and Australian-like packaging (ie, all branding replaced with a drab dark brown colour and a graphic image and text on 75% of the pack surface) had on perceptions of the NAS cigarette package. RESULTS Smokers' ratings of the standard NAS pack on the implied safety scale (mean=4.6; SD=2.9) were 1.9 times (P <0.001) higher than smokers' ratings of a Marlboro Red pack (mean=2.4; SD=2.3) and 1.7 times (P <0.001) higher than smokers' ratings of a Newport Menthol pack (mean=2.7; SD=2.4). These perceptions of implied safety were lower when plain packaging was used (Cohen's d=0.66; P <0.001) and much lower when Australian-like packaging was used (Cohen's d=1.56; P <0.001). CONCLUSION The results suggest that NAS cigarette packaging conveys that its cigarettes are 'safer' and that such perceptions are lower with standardised packaging, both with and without warning images.
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Affiliation(s)
- Eric Craig Leas
- Department of Family Medicine and Public Health, University of California: San Diego, La Jolla, California, USA
- UC San Diego Moores Cancer Center, University of California: San Diego, La Jolla, California, USA
- Stanford Prevention Research Center, Stanford University School of Medicine, Palo Alto, California, USA
| | - John P Pierce
- Department of Family Medicine and Public Health, University of California: San Diego, La Jolla, California, USA
- UC San Diego Moores Cancer Center, University of California: San Diego, La Jolla, California, USA
| | - Claudiu V Dimofte
- Department of Marketing, San Diego State University, San Diego, California, USA
| | - Dennis R Trinidad
- Department of Family Medicine and Public Health, University of California: San Diego, La Jolla, California, USA
- UC San Diego Moores Cancer Center, University of California: San Diego, La Jolla, California, USA
| | - David R Strong
- Department of Family Medicine and Public Health, University of California: San Diego, La Jolla, California, USA
- UC San Diego Moores Cancer Center, University of California: San Diego, La Jolla, California, USA
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Hwang JE, Yang YS, Oh YM, Lee SY, Lee JE, Cho SI. Differences in visual fixation duration according to the position of graphic health warning labels: An eye-tracking approach. Tob Induc Dis 2018; 16:39. [PMID: 31516438 PMCID: PMC6659495 DOI: 10.18332/tid/94327] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/15/2018] [Accepted: 08/15/2018] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The Framework Convention on Tobacco Control (FCTC) recommends that graphic health warning labels (GHWLs) be positioned at the top of the principal area of cigarette packs, rather than at the bottom, to increase visibility. However, during the legislative process of introducing GHWLs in South Korea, the position of GHWLs has become a contested issue. The pro-tobacco industry group argued that the warnings should be placed at the bottom of cigarette packs because evidence for the effectiveness of the upper position was insufficient. Therefore, this study investigated whether the position of the GHWL affects eye movement. METHODS Participants (30 daily smokers and 24 non-smokers) were shown six cigarette packs in random order with different position combinations (top, middle, bottom) and image concepts (skin aging, toxic constituents). Participants’ eye movements were recorded using eye-tracking equipment to measure visual fixation duration in milliseconds (ms) RESULTS Participants visually fixated longer on the health warning area than on the tobacco branding area (p<0.05). Mean fixation duration on the health warning area was significantly longer at the top or middle positions compared to the bottom, by 28% (mean difference=340 ms, p=0.006) and by 30% (mean difference=368 ms, p=0.002), respectively. By contrast, mean fixation duration on the branding area was longer with the warning at the bottom compared to top or middle positions by 25% and 33%, with mean differences of 157 ms (p=0.100) and 212 ms (p=0.026), respectively. No significant difference in fixation time was observed between the top and middle positions (p>0.05) CONCLUSIONS The duration of visual fixation on GHWLs was longer when they were displayed at the top and middle, rather than at the bottom. Therefore, GHWLs should be positioned from the top to the middle of the tobacco package.
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Affiliation(s)
- Ji-Eun Hwang
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Yu-Seon Yang
- Korea Health Promotion Institute, Seoul, Republic of Korea
| | - Yu-Mi Oh
- Korea Health Promotion Institute, Seoul, Republic of Korea
| | - Seon-Young Lee
- Gyeonggi Infectious Disease Control Center, Seongnam, Republic of Korea
| | - Joung-Eun Lee
- Korea Health Promotion Institute, Seoul, Republic of Korea
| | - Sung-Il Cho
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea.,Institute of Health and Environment, Seoul National University, Seoul, Republic of Korea
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Hall MG, Mendel JR, Noar SM, Brewer NT. Why smokers avoid cigarette pack risk messages: Two randomized clinical trials in the United States. Soc Sci Med 2018; 213:165-172. [PMID: 30096636 DOI: 10.1016/j.socscimed.2018.07.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 07/10/2018] [Accepted: 07/29/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Message avoidance (e.g., trying not to look at the message) may be motivated by reactance, a maladaptive rejection of the message. An alternative view is that avoidance indicates that a message is eliciting fear and other negative affect, thereby increasing the likelihood of behavioral change. We sought to identify which psychological mechanism-reactance or fear and other negative affect-explains message avoidance. We also examined whether avoidance was associated with more forgoing or butting out of cigarettes. METHOD Trial 1 randomly assigned 2149 adult U.S. smokers to receive either pictorial warnings (intervention) or text-only warnings (control) on their cigarette packs for four weeks in 2014 and 2015. Trial 2 randomly assigned 719 adult U.S. smokers to receive either messages about toxic chemicals in cigarette smoke (intervention) or messages about not littering cigarette butts (control) for three weeks in 2016 and 2017. Negative affect included fear, anxiety, disgust, sadness, and guilt. Reactance included perceived threat to freedom, anger, and counterarguing. RESULTS Intervention messages led to greater message avoidance in both trials (both p < .001). In Trial 1, intervention messages elicited greater negative affect, which in turn was associated with greater avoidance (mediated effect = 0.21, p < .001). In contrast, reactance explained only a small part of the effect in Trial 1 (mediated effect = 0.03, p < .001). Similarly, in Trial 2, intervention messages elicited greater negative affect, which was associated with more avoidance (mediated effect = 0.12, p < .001); reactance did not explain any of the effect. In both trials, avoidance was associated with more forgoing or butting out of cigarettes (ps < .001). CONCLUSIONS Smokers may avoid cigarette pack risk messages because they evoke aversive types of emotion. These studies add to a growing body of evidence that, in the context of cigarette pack messages, avoidance is not a form of defensive processing but instead a sign of deeper processing.
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Affiliation(s)
- Marissa G Hall
- Lineberger Comprehensive Cancer Center, University of North Carolina, USA; Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, USA.
| | - Jennifer R Mendel
- Lineberger Comprehensive Cancer Center, University of North Carolina, USA
| | - Seth M Noar
- School of Media and Journalism, University of North Carolina, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, USA
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, USA
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66
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Morgan JC, Moracco KE, Mendel JR, Kelley DE, Noar SM, Brewer NT. Increasing Effectiveness of Messages about Chemicals in Cigarette Smoke. TOB REGUL SCI 2018; 4:50-62. [PMID: 34141828 PMCID: PMC8208641 DOI: 10.18001/trs.4.4.6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Federal law requires informing the public on toxic chemicals in cigarette smoke. We sought the public's advice about communicating information about these chemicals. METHODS Adolescents, young adults, and adults (N = 59), including smokers and non-smokers, participated in 9 focus groups that discussed inclusion of messages about toxic chemicals on cigarette packs, in media campaigns, and on a website. We transcribed, coded, and analyzed focus group audio-recordings. RESULTS Participants had 3 suggestions for message content to increase the impact of messages about cigarette smoke chemicals. First, they wanted to see messages rotated more frequently to increase message novelty. Second, they recommended using stories and pictures to help connect people to the abstract idea of chemicals in smoke. Third, they cautioned against making messages that might seem overblown and could appeal to the rebellious nature of adolescents. Some participants mentioned that chemical information on a website might discourage people from smoking; others mentioned that people might use it to choose which brand to smoke. CONCLUSIONS Legislation provides the impetus to design new chemical disclosure messages for cigarette packs and other media. Our findings can help increase the impact of these messages.
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Affiliation(s)
- Jennifer C Morgan
- Health Communication, Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA
| | - Kathryn E Moracco
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, NC
| | - Jennifer R Mendel
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, North Carolina, NC
| | | | - Seth M Noar
- School of Media and Journalism, University of North Carolina at Chapel Hill, North Carolina, NC
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, NC
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67
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Skurka C, Byrne S, Davydova J, Kemp D, Safi AG, Avery RJ, Dorf MC, Mathios AD, Niederdeppe J. Testing competing explanations for graphic warning label effects among adult smokers and non-smoking youth. Soc Sci Med 2018; 211:294-303. [PMID: 29980116 DOI: 10.1016/j.socscimed.2018.06.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 06/16/2018] [Accepted: 06/24/2018] [Indexed: 11/17/2022]
Abstract
RATIONALE The United States courts have blocked the implementation of graphic warning labels on cigarette packages (GWLs). This decision was based, in part, on the premise that GWLs are unnecessarily emotional and are meant to scare rather than inform consumers about smoking's health effects. However, research in judgment and decision-making suggests these relationships are more complex. OBJECTIVE In this article, we draw on several theoretical frameworks that lead to competing hypotheses about the relationships between negative affect, health risk beliefs, and quit intentions (among adult smokers) or susceptibility to start smoking (among non-smoking youth). METHOD We tested these competing mediation models using data from two experiments with two populations each-adult smokers (Ns = 313 and 238) and primarily non-smoking middle-school youth (Ns = 340 and 237). Using mobile recruitment methods, we focused specifically on individuals from socioeconomically disadvantaged communities in rural and urban areas of the Northeastern United States. RESULTS The best fitting model across all four datasets was one in which label-induced negative affect (a) directly predicted intentions/susceptibility but also (b) indirectly predicted intentions/susceptibility via risk beliefs. Although mediation analyses did not demonstrate significant serial mediation effects of label exposure on intentions/susceptibility through negative affect then risk beliefs, there was some evidence that label exposure indirectly promoted adults' quit intentions through negative affect. Additionally, negative affect consistently mediated the indirect effect of label exposure on strengthened risk beliefs among adults and youth. CONCLUSIONS These results speak to the importance of negative affect in directly motivating adult smokers' quit intentions but also serving an informational function, directing adult smokers and non-smoking youth to accept the health risks of smoking.
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Affiliation(s)
- Chris Skurka
- Department of Communication, Cornell University, 450B Mann Library Building, Ithaca, NY, 14853, USA.
| | - Sahara Byrne
- Department of Communication, Cornell University, 450B Mann Library Building, Ithaca, NY, 14853, USA
| | - Julie Davydova
- Department of Communication, Cornell University, 450B Mann Library Building, Ithaca, NY, 14853, USA
| | - Deena Kemp
- Department of Communication, Cornell University, 450B Mann Library Building, Ithaca, NY, 14853, USA
| | - Amelia Greiner Safi
- Department of Communication and Department of Population Medicine and Diagnostic Sciences, Cornell University, 450B Mann Library Building, Ithaca, NY, 14853, USA
| | - Rosemary J Avery
- Department of Policy Analysis and Management, Cornell University, 2301G Martha Van Rensselaer Hall, Ithaca, NY, 14853, USA
| | - Michael C Dorf
- Cornell University Law School, 247 Hughes Hall, Ithaca, NY, 14853, USA
| | - Alan D Mathios
- College of Human Ecology, Cornell University, 1300 Martha Van Rensselaer Hall, Ithaca, NY, 14853, USA
| | - Jeff Niederdeppe
- Department of Communication, Cornell University, 450B Mann Library Building, Ithaca, NY, 14853, USA
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68
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Donnelly GE, Zatz LY, Svirsky D, John LK. The Effect of Graphic Warnings on Sugary-Drink Purchasing. Psychol Sci 2018; 29:1321-1333. [PMID: 29912624 DOI: 10.1177/0956797618766361] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Governments have proposed text warning labels to decrease consumption of sugary drinks-a contributor to chronic diseases such as diabetes. However, they may be less effective than more evocative, graphic warning labels. We field-tested the effectiveness of graphic warning labels (vs. text warning labels, calorie labels, and no labels), provided insight into psychological mechanisms driving effectiveness, and assessed consumer sentiment. Study 1 indicated that graphic warning labels reduced the share of sugary drinks purchased in a cafeteria from 21.4% at baseline to 18.2%-an effect driven by substitution of water for sugary drinks. Study 2 showed that graphic warning labels heighten negative affect and prompt consideration of health consequences. Study 3 indicated that public support for graphic warning labels can be increased by conveying effectiveness information. These findings could spur more effective labeling policies that facilitate healthier choices, do not decrease overall beverage purchases, and are publicly accepted.
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Affiliation(s)
| | - Laura Y Zatz
- 2 Department of Nutrition, Harvard T. H. Chan School of Public Health.,3 Department of Social & Behavioral Sciences, Harvard T. H. Chan School of Public Health
| | - Dan Svirsky
- 4 Negotiation, Organizations & Markets Unit, Harvard Business School
| | - Leslie K John
- 4 Negotiation, Organizations & Markets Unit, Harvard Business School
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Affiliation(s)
- Noel T. Brewer
- Department of Health Behavior, Gillings School of Global Public
Health, University of North Carolina
- Lineberger Comprehensive Cancer Center, University of North
Carolina
| | - Marissa G. Hall
- Department of Health Behavior, Gillings School of Global Public
Health, University of North Carolina
- Lineberger Comprehensive Cancer Center, University of North
Carolina
| | - Seth M. Noar
- Lineberger Comprehensive Cancer Center, University of North
Carolina
- School of Media and Journalism, University of North Carolina
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Hall MG, Marteau TM, Sunstein CR, Ribisl KM, Noar SM, Orlan EN, Brewer NT. Public support for pictorial warnings on cigarette packs: an experimental study of US smokers. J Behav Med 2018; 41:398-405. [PMID: 29411272 PMCID: PMC5924634 DOI: 10.1007/s10865-018-9910-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 01/06/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Understanding factors that influence public support for "nudging" policies, like pictorial cigarette pack warnings, may offer insight about how to increase such support. We sought to examine factors that influence smokers' support for requiring pictorial warnings on cigarette packs. METHODS In 2014 and 2015, we randomly assigned 2149 adult US smokers to receive either pictorial warnings or text-only warnings on their cigarette packs for 4 weeks. The outcome examined in the current study was support for a policy requiring pictorial warnings on cigarette packs in the US. RESULTS Support for pictorial warnings was high at baseline (mean: 3.2 out of 4). Exposure to pictorial warnings increased policy support at week 4 (β = .05, p = .03). This effect was explained by increases in perceived message effectiveness (p < .001) and reported conversations about policy support (p < .001). Message reactance (i.e., an oppositional reaction to the warning) partially diminished the impact of pictorial warnings on policy support (p < .001). CONCLUSIONS Exposing people to a new policy through implementation could increase public support for that policy by increasing perceived effectiveness and by prompting conversations about the policy. Reactance may partially weaken the effect of policy exposure on public support.
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Affiliation(s)
- Marissa G Hall
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
| | - Theresa M Marteau
- Behaviour and Health Research Unit, Institute of Public Health, University of Cambridge, Cambridge, UK
| | | | - Kurt M Ribisl
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 324 Rosenau Hall CB7440, Chapel Hill, NC, 27599, USA
| | - Seth M Noar
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- School of Media and Journalism, University of North Carolina, Chapel Hill, NC, USA
| | - Elizabeth N Orlan
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 324 Rosenau Hall CB7440, Chapel Hill, NC, 27599, USA
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 324 Rosenau Hall CB7440, Chapel Hill, NC, 27599, USA
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Brewer NT, Jeong M, Mendel JR, Hall MG, Zhang D, Parada H, Boynton MH, Noar SM, Baig SA, Morgan JC, Ribisl KM. Cigarette pack messages about toxic chemicals: a randomised clinical trial. Tob Control 2018; 28:74-80. [PMID: 29654122 PMCID: PMC6186198 DOI: 10.1136/tobaccocontrol-2017-054112] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 01/22/2018] [Accepted: 02/20/2018] [Indexed: 11/07/2022]
Abstract
Background The USA can require tobacco companies to disclose information about harmful and potentially harmful chemicals in cigarette smoke, but the impact of these messages is uncertain. We sought to assess the effect of placing messages about toxic chemicals on smokers’ cigarette packs. Methods Participants were 719 adult cigarette smokers from California, USA, recruited from September 2016 through March 2017. We randomly assigned smokers to receive either factual messages about chemicals in cigarette smoke and their health harms (intervention) or messages about not littering cigarette butts (control) on the side of their cigarette packs for 3 weeks. The primary trial outcome was intention to quit smoking. Results In intent-to-treat analyses, smokers whose packs had chemical messages did not have higher intentions to quit smoking at the end of the trial than those whose packs had control messages (P=0.56). Compared with control messages, chemical messages led to higher awareness of the chemicals (28% vs 15%, P<0.001) and health harms (60% vs 52%, P=0.02) featured in the messages. In addition, chemical messages led to greater negative affect, thinking about the chemicals in cigarettes and the harms of smoking, conversations about the messages and forgoing a cigarette (all P<0.05). Discussion Chemical messages on cigarette packs did not lead to higher intentions to quit among smokers in our trial. However, chemical messages informed smokers of chemicals in cigarettes and harms of smoking, which directly supports their implementation and would be critical to defending the messages against cigarette company legal challenges. Trial registration number NCT02785484.
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Affiliation(s)
- Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michelle Jeong
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jennifer R Mendel
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Marissa G Hall
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Dongyu Zhang
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Humberto Parada
- Division of Epidemiology and Biostatistics, Graduate School of Public Health, San Diego State University, San Diego, California, USA
| | - Marcella H Boynton
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Seth M Noar
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA.,School of Media and Journalism, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sabeeh A Baig
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
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Noar SM, Kelley DE, Boynton MH, Morgan JC, Hall MG, Mendel JR, Ribisl KM, Brewer NT. Identifying principles for effective messages about chemicals in cigarette smoke. Prev Med 2018; 106:31-37. [PMID: 28890353 PMCID: PMC5764803 DOI: 10.1016/j.ypmed.2017.09.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/31/2017] [Accepted: 09/04/2017] [Indexed: 10/18/2022]
Abstract
US law requires the Food and Drug Administration (FDA) to disclose information on harmful and potentially harmful chemicals in cigarette smoke (i.e., constituents) to the public. To inform this effort, we sought to identify principles for creating constituent messages that effectively discourage smoking. Participants were an online convenience sample of 1148 US smokers ages 18+. We developed a library of 76 messages about constituents only and constituents plus contextualizing information (i.e., toxic products that also contain the chemical, health effects, or both). We randomized smokers to receive 1 message from each of 7 message panels in a mixed between-/within-subjects experiment. Participants rated each message on perceived message effectiveness. Results indicated that smokers perceived messages about arsenic, formaldehyde, lead, uranium, and ammonia as more effective than messages about nitrosamines. Messages that contained information on toxic products, health effects, or both received higher effectiveness ratings than constituent-only messages. Among constituent-only messages, those that referenced multiple constituents received higher effectiveness ratings than those with fewer constituents. We conclude that chemical messages may have more impact if they pair known constituents with toxic product or health effect information. These message principles can be used to inform studies examining the impact of constituent messages on smoking beliefs and behavior.
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Affiliation(s)
- Seth M Noar
- School of Media and Journalism, University of North Carolina at Chapel Hill, United States; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States.
| | - Dannielle E Kelley
- School of Media and Journalism, University of North Carolina at Chapel Hill, United States
| | - Marcella H Boynton
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States
| | - Jennifer C Morgan
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States
| | - Marissa G Hall
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States
| | - Jennifer R Mendel
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States
| | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States
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Sontag JM, Barnes SR. The visual framing of graphics when used in preventative health digital news packages: exploring the use of a narrative structure as the message infrastructure. J Vis Commun Med 2017; 40:1-11. [PMID: 28946791 DOI: 10.1080/17453054.2017.1366824] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 08/09/2017] [Indexed: 10/18/2022]
Abstract
Visual framing can improve health-message effectiveness. Narrative structure provides a template needed for determining how to frame visuals to maximise message effectiveness. Participants (N = 190) were assigned to a message condition determined by segments (establisher, initial, peak), graphic (static, animated) and cancer (lung, melanoma). ANOVAs revealed that melanoma was more believable than lung cancer with static graphics at the establisher and peak; narratives were more believable with animated graphics at the peak segment; melanoma elicited greater positive attitudes; graphics in the peak influenced greatest intentions. Animated graphics visually framed to emphasise information at the establisher and peak segments suggest maximum effectiveness.
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Affiliation(s)
- Jennah M Sontag
- a School of Media and Journalism , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - Spencer R Barnes
- a School of Media and Journalism , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
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Sontag JM, Noar SM. Assessing the Potential Effectiveness of Pictorial Messages to Deter Young Women from Indoor Tanning: An Experimental Study. JOURNAL OF HEALTH COMMUNICATION 2017; 22:294-303. [PMID: 28266905 DOI: 10.1080/10810730.2017.1281361] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The recent Surgeon General's call-to-action to prevent skin cancer indicates an urgent need for research on messages to deter young women from tanning indoors. Answering this call, the current study assessed differences in the potential effectiveness of pictorial indoor tanning messages. We randomly assigned undergraduate female participants (N = 568) to one of three message conditions visually depicting health effects, appearance damage, or immediate risks, or to a text-only control. All participants viewed three messages within their condition and answered questions after message exposure. Factorial ANOVAs indicated that compared to the text-only condition, pictorial messages produced greater negative emotional reactions and were perceived as more effective than text-only messages. Text-only messages, however, were significantly more believable than pictorial messages. We observed several differences among the pictorial conditions and among the messages within the pictorial conditions. We conclude that messages discouraging indoor tanning should use pictorial messages illustrating the negative health and appearance damaging effects of indoor tanning, focusing on particular health and appearance consequences. Additional research is needed to guide the selection of images that are believable and will most discourage indoor tanning behavior.
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Affiliation(s)
- Jennah M Sontag
- a School of Media and Journalism , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA
| | - Seth M Noar
- a School of Media and Journalism , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA
- b Lineberger Comprehensive Cancer Center , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA
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Kowitt SD, Noar SM, Ranney LM, Goldstein AO. Public attitudes toward larger cigarette pack warnings: Results from a nationally representative U.S. sample. PLoS One 2017; 12:e0171496. [PMID: 28253257 PMCID: PMC5333827 DOI: 10.1371/journal.pone.0171496] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 01/20/2017] [Indexed: 11/18/2022] Open
Abstract
A large body of evidence supports the effectiveness of larger health warnings on cigarette packages. However, there is limited research examining attitudes toward such warning labels, which has potential implications for implementation of larger warning labels. The purpose of the current study was to examine attitudes toward larger warning sizes on cigarette packages and examine variables associated with more favorable attitudes. In a nationally representative survey of U.S. adults (N = 5,014), participants were randomized to different warning size conditions, assessing attitude toward "a health warning that covered (25, 50, 75) % of a cigarette pack." SAS logistic regression survey procedures were used to account for the complex survey design and sampling weights. Across experimental groups, nearly three-quarters (72%) of adults had attitudes supportive of larger warning labels on cigarette packs. Among the full sample and smokers only (N = 1,511), most adults had favorable attitudes toward labels that covered 25% (78.2% and 75.2%, respectively), 50% (70% and 58.4%, respectively), and 75% (67.9% and 61%, respectively) of a cigarette pack. Young adults, females, racial/ethnic minorities, and non-smokers were more likely to have favorable attitudes toward larger warning sizes. Among smokers only, females and those with higher quit intentions held more favorable attitudes toward larger warning sizes. Widespread support exists for larger warning labels on cigarette packages among U.S. adults, including among smokers. Our findings support the implementation of larger health warnings on cigarette packs in the U.S. as required by the 2009 Tobacco Control Act.
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Affiliation(s)
- Sarah D. Kowitt
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Seth M. Noar
- School of Media and Journalism, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Leah M. Ranney
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Adam O. Goldstein
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Huang LL, Lazard AJ, Pepper JK, Noar SM, Ranney LM, Goldstein AO. Impact of The Real Cost Campaign on Adolescents' Recall, Attitudes, and Risk Perceptions about Tobacco Use: A National Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14010042. [PMID: 28054993 PMCID: PMC5295293 DOI: 10.3390/ijerph14010042] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 11/30/2016] [Indexed: 01/19/2023]
Abstract
The Food and Drug Administration’s (FDA) The Real Cost campaign advertisements (ads) have targeted U.S. youth with messages designed to prevent and reduce tobacco use. This study examined exposure to The Real Cost campaign, including ad and slogan recall, and associations with attitudes and risk perceptions among U.S. adolescents. We analyzed data from a nationally representative sample of adolescents aged 13 to 17 years (n = 1125) surveyed by phone from October 2014 to June 2015. We assessed aided recall of and attitudes toward four campaign ads and the one slogan. Logistic regression models assessed whether aided recall of The Real Cost ads or slogan was associated with perceived likelihood of serious health consequences of cigarette smoking. Most (88%) adolescents reported seeing or hearing at least one of four ads for The Real Cost, and 54% recalled The Real Cost slogan. The majority of adolescents reported more negative attitudes toward tobacco products after seeing or hearing the ads. Recall of any The Real Cost ad was significantly associated with greater perceptions of serious health consequences of cigarette smoking (Adjusted Odd Ratios (AOR) = 5.58, 95% Confidence Interval (CI) = 1.20–25.90). The FDA’s The Real Cost campaign has achieved very high reach and is associated with more negative attitudes toward tobacco products and greater risk perceptions of cigarette smoking among U.S. adolescents.
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Affiliation(s)
- Li-Ling Huang
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA.
| | - Allison J Lazard
- School of Media and Journalism, University of North Carolina, Chapel Hill, NC 27599, USA.
| | - Jessica K Pepper
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA.
- RTI International, Research Triangle Park, NC 27709, USA.
| | - Seth M Noar
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA.
- School of Media and Journalism, University of North Carolina, Chapel Hill, NC 27599, USA.
| | - Leah M Ranney
- Department of Family Medicine, University of North Carolina, Chapel Hill, NC 27599, USA.
| | - Adam O Goldstein
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA.
- Department of Family Medicine, University of North Carolina, Chapel Hill, NC 27599, USA.
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Noar SM, Francis DB, Bridges C, Sontag JM, Ribisl KM, Brewer NT. The impact of strengthening cigarette pack warnings: Systematic review of longitudinal observational studies. Soc Sci Med 2016; 164:118-129. [PMID: 27423739 PMCID: PMC5026824 DOI: 10.1016/j.socscimed.2016.06.011] [Citation(s) in RCA: 222] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Cigarette pack warnings are a tobacco control strategy used globally. To understand their impact, we systematically reviewed longitudinal observational studies examining national implementation of strengthened warnings. METHODS We used comprehensive search procedures to identify observational studies examining the impact of strengthening cigarette pack warnings. We report longitudinal changes in knowledge, beliefs, attitudes, intentions, and behavior. RESULTS We identified 32 studies conducted in 20 countries with 812,363 participants. Studies commonly examined changes from text to pictorial warnings (64%); the remainder examined strengthened text or strengthened pictorial warnings. Knowledge increased in all 12 studies that assessed it. Studies of beliefs/attitudes and intentions showed mixed results. Quitline calls increased in four of six studies, while foregoing of cigarettes did not increase. Cigarette consumption decreased in three of eight studies; quit attempts increased in four of seven studies; and short-term cessation increased in two of three studies. Smoking prevalence decreased in six of nine studies. CONCLUSIONS Strengthening warnings was associated with longitudinal increases in knowledge, quitline calls and reductions in smoking behavior. Strengthening warning policies should be a priority for tobacco control globally.
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Affiliation(s)
- Seth M Noar
- School of Media and Journalism, University of North Carolina at Chapel Hill, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, USA.
| | - Diane B Francis
- School of Media and Journalism, University of North Carolina at Chapel Hill, USA
| | - Christy Bridges
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| | - Jennah M Sontag
- School of Media and Journalism, University of North Carolina at Chapel Hill, USA
| | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, USA
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 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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