Evaluating the perceived effectiveness of pregnancy-related cigarette package health warning labels among different gender/age groups

Gender-Specific Pictorial Health Warnings: Moderation Effects of the Threat Level and Gender

This study examined the effects of gender-specific pictorial health warning labels contingent on their intended gender and threat levels (for females) in forming anti-smoking intentions. We conducted a within-subject design experiment with smokers and nonsmokers in Singapore (N = 100, 50% men). Each participant viewed 10 warning labels-four female-specific (high and low threat), four gender-neutral (high and low threat), and two male-specific (only low threat)-in a random order, evaluating each label on personal relevance, attention, cognitive elaboration, reactance, and intentions to purchase or avoid smoking. The findings showed that females reported greater relevance, attention, elaboration, and intentions to avoid smoking for low threat female-specific warning labels than male-specific or gender-neutral counterparts. Males reported less attention, elaboration, and relevance for low threat male-specific warning labels than female-specific or gender-neutral counterparts. Under high threat conditions, female-specific and gender-neutral warning labels were equally effective for both genders. No differences were observed by smoking status. Overall, gender-specific warning labels are potentially more effective than gender-neutral ones for deterring smoking in women contingent on low threat levels. By providing a deeper understanding of persuasive mechanisms and boundary conditions for the effects of gender specificity, findings can aid health policymakers in developing better gender-responsive interventions.

Designing more effective cigar warnings: an experiment among adult cigar smokers

INTRODUCTION

Little systematic evidence exists about the effectiveness of cigar warnings. This study examined the perceived message effectiveness (PME) of warning statements about different health consequences caused by cigars. PME is a validated self-report scale of how effectively a health message discourages smoking.

METHODS

We conducted an online study from April-May 2020 with adults in the United States who used cigars in the past 30 days (n=777). Participants were randomly assigned to view and rate PME (3 items, range 1 to 5) for 7 out of 37 text warning statements about different health consequences from cigar use. Linear mixed effects models evaluated the most effective warning characteristics (e.g., type of health consequence), controlling for repeated measures and participant demographics.

RESULTS

Analyses showed that health consequences about the cardiovascular system (B=0.38), mouth (B=0.40), other digestive (B=0.45), respiratory system (B=0.36), and early death (B=0.36) were associated with higher PME scores than reproductive health consequences (all p-values <0.001). Similar results were found for these health consequences compared to addiction (all p-values p<0.001). We also observed that awareness of the health consequence was associated with higher PME scores (B=0.19, p<0.001) and length of the warning message (number of characters) was associated with lower PME scores (B=-0.007, p=0.03). No differences were observed between cancer and non-cancer health consequences (p=0.27) or health consequences that used plain language vs. medical jargon (p=0.94).

CONCLUSIONS

Our study provides new evidence about the perceived effectiveness of different cigar health warning statements and identifies features that may strengthen statements.

IMPLICATIONS

Our study with cigar smokers from across the United States provides much-needed evidence concerning the perceived effectiveness of different cigar health warning statements and features that may strengthen such statements. Mandated cigar warnings in the United States could be strengthened by including health consequences that were perceived as more effective in our study (e.g., early death), using health consequences that participants were aware of, and using short warning statements.

Association of health warning labels and motivation to quit waterpipe tobacco smoking among university students in the Eastern Mediterranean Region

INTRODUCTION

This study aimed to determine associations between health warning label content and motivation to quit waterpipe smoking by gender and smoking location.

METHODS

Convenience samples of university students in three Eastern Mediterranean countries – Egypt (n=442), Jordan (n=535) and Palestine (n=487) – completed an online survey assessing health warning labels. Multinomial logit regression models were conducted to determine the association between different variables, particularly gender and smoking location, with motivation to quit.

RESULTS

In Palestine, female smokers were more motivated to quit waterpipe smoking when seeing textual warning labels related to children (T2) and pregnancy (T6) [T2: 1.8 (95% CI: 1.1–2.8), T6: 2.7 (95% CI: 1.6–4.3)] compared to males. Similar results were found in Jordan [T2: 1.6 (95% CI: 1.0–2.6), T6: 1.8 (95% CI: 1.1–3.0)]. As for the smoking location, home-only smokers in Palestine were more likely to quit in response to the following warnings: waterpipe smoking is addictive T1: 2.3 (95% CI: 1.4–3.7), harmful for children T2: 2.3 (95% CI: 1.4–4.1), harmful for the baby during pregnancy T6: 2.4 (95% CI: 1.3–4.3), and to believe that quitting reduces the health risks T9: 1.8 (95% CI: 1.0–3.1). These results were not found in Jordan nor Egypt. Smokers reported that the most noticeable location of a HWL on a waterpipe device is the mouthpiece.

CONCLUSIONS

A better understanding of motivation to quit and its association with various warnings and smoking location could guide countries on which warnings to require in legislation and where best to require them particularly in relation to location.

Effectiveness of Cessation Messages Targeting Pregnant and Nonpregnant Female Smokers in the United States: A Cross-Sectional Analysis into the Impact of Pregnancy, Self-Efficacy, and Risk Perception

OBJECTIVES

Roughly 10% of pregnant women are current smokers. Improving smoking cessation in this population before and during pregnancy is essential to prevent adverse fetal outcomes. This study aimed to examine cessation messages targeting American women.

METHODS

An obstetrics-gynecological clinic-based sample of female, current smokers of reproductive age (18-44 years old) was recruited (n = 135) from January to May 2019; half (51.2%) were currently pregnant. Participants completed a within-subjects study with a randomized set of gain- and loss-framed text-only pregnancy-related cessation messages (5 each). Each individual message was rated on a validated, 10-point scale for perceived effectiveness; responses to the seven items were averaged. Regression analyses examined differences in effectiveness ratings by message framing.

RESULTS

Study participants (female smokers) rated the gain-framed messages as slightly more effective than loss-framed messages (7.9 versus 7.7, p < 0.01). After adjusting for quit intention and pregnancy, the relationship between gain- and loss-framing and effectiveness ratings was modified by both self-efficacy and risk perceptions. Women who perceived high risks of smoking during pregnancy had higher effectiveness ratings of both gain- and loss-framed cessation messages, compared to women who perceived low risks. Lower cessation self-efficacy was significantly associated with lower effectiveness ratings for gain- and loss-framed messages (1.53 and 1.92, respectively; p < 0.05).

CONCLUSIONS FOR PRACTICE

Women with lower self-efficacy and low risk perception of smoking risks had the lowered effectiveness ratings for both frames of cessation messages. Enhancing self-efficacy and risk perceptions through clinical interventions may improve the effectiveness of targeted messages to promote quitting smoking before or during pregnancy.

Reducing tobacco use among women of childbearing age: Contributions of tobacco regulatory science and tobacco control

Tobacco use has unique, adverse health consequences for reproductive-aged women, particularly should these women become pregnant. Thus, successful efforts to reduce tobacco use among this population have strong potential to improve public health and reduce health disparities. The present review examines contributions to reducing tobacco use among women of childbearing age spanning the domains of tobacco regulatory science and tobacco control from the passage of the Family Smoking Prevention and Tobacco Control Act in 2009 through September 2019. In the domain of tobacco regulatory science, such efforts include research conducted by various National Institutes of Health/Food and Drug Administration (FDA)-supported Tobacco Centers of Regulatory Science, epidemiological surveillance studies, as well as studies examining the potential impact of tobacco regulatory policies currently under consideration by the FDA (e.g., reduced nicotine content cigarettes, health warning labels). Tobacco control efforts within this same 10-year timeframe include developments in pharmacological and psychosocial approaches to promoting tobacco cessation, mHealth interventions, and tobacco control policy. Emerging issues pertinent to ongoing efforts to reduce tobacco use within the domains of both tobacco regulatory science and tobacco control are also reviewed, including e-cigarettes, comorbid health conditions, course of tobacco and other drugs of abuse, and obstacles to the dissemination and implementation of evidence-based treatment and policy. Although the past decade has seen numerous important contributions to reducing tobacco use among reproductive-aged women within both domains, existing obstacles must be surmounted to continue reducing tobacco use and protecting health among this population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Sex-specific initiation rates of tobacco smoking and its determinants among adults from a Middle Eastern population: a cohort study

OBJECTIVES

To assess the initiation rate and determinants of tobacco smoking among adults.

METHODS

In the Tehran Lipid and Glucose Study, a population-based cohort from Iran, 6101 participants ≥ 18 years old who had never smoked tobacco at baseline (phase II: 2002-2006) were followed until phase VI (2015-2018). Sex-specific initiation rates per 1000 person-years for self-reported tobacco smoking and hazard ratios (HR) for its potential determinants (using Cox proportional hazards models) were calculated.

RESULTS

The age- and sex-adjusted smoking initiation rate was 13.77 [95% confidence interval (CI) 12.59-14.94] per 1000 person-years, of which 78% was attributed to water pipe use. Initiation rate was remarkably higher among men [19.1 (16.9-21.2)] than women [8.3 (7.4-9.2)] and declined in older age-groups. Among both genders, being married was protective [men: HR 0.67 (CI 95% 0.48-0.92); women: 0.58 (0.45-0.74)], while intermediate-level education (compared with high level) [men: 1.61 (1.14-2.26); women: 1.33 (0.95-1.84, p value = 0.092)] and passive smoking [men: 1.76 (1.36-2.28); women: 1.82 (1.42-2.33)] increased the risk. Educational intervention decreased the risk among women [0.74 (0.58-0.94)].

CONCLUSIONS

The majority of adult smoking initiators started smoking with water pipe. The initiation rate was remarkably higher in men and younger age-groups. Passive smoking, being single and lower education were risk factors. Educational intervention was protective among women.

Responses to cigarette health warning labels, harm perceptions and knowledge in a national sample of pregnant and non-pregnant women of reproductive age

INTRODUCTION

Little is known about the effectiveness of cigarette health warning labels (HWLs) among U.S. pregnant and non-pregnant women of reproductive age. Our intent was to examine HWL responses by pregnancy status and their associations with knowledge and perceived harm.

METHODS

We conducted cross-sectional analyses of first (2013-2014) and second (2014-2015) Population Assessment of Tobacco and Health waves. The sample (N = 19,095) was representative of U.S. women of reproductive age (18-45 years). We examined three HWL responses (seeing HWLs, forgoing cigarettes because of HWLs, likely-to-quit because of HWLs), perceived harm from smoking, and knowledge of health effects to fetuses and others. Weighted logistic regression compared HWL responses by pregnancy status and their associations with perceived harm and knowledge, adjusting for demographics and tobacco use. Results were presented as marginal predicted probabilities.

RESULTS

Pregnant smokers were less likely than never-pregnant smokers to report likelihood of quitting (57% vs 67%, p = 0.020). Forgoing cigarettes and likely-to-quit due to HWLs-but not seeing HWLs-were positively associated with perceived harm and knowledge. Pregnant smokers were less likely to have knowledge of fetal harm (83%) than ever-pregnant (91%, p = 0.006) and never-pregnant (92%, p = 0.003) smokers. However, pregnant smokers who reported likelihood of quitting were much more likely to have knowledge of fetal harm than those who did not (93% vs. 67%, p = 0.028).

CONCLUSIONS

Implementation of HWLs that elicit stronger reactions-such as pictorial HWLs-and increase knowledge of fetal risks is one action to help reduce tobacco use in pregnant and non-pregnant U.S. women of reproductive age.

Sex Differences in Graphic Warning Label Ratings by Addictions Clients

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.

Examining the relationship between pregnancy and quitting use of tobacco products in a U.S. national sample of women of reproductive age

This study examined quit rates longitudinally for cigarettes, e-cigarettes, hookah, cigars, and all tobacco products in a U.S. national sample of women aged 18-44 who completed both Wave 1 (W1) and Wave 2 (W2) of the Population Assessment of Tobacco and Health (PATH, 2013-2014, 2014-2015) study (N = 7814). Quit rates were examined among women who transitioned into pregnancy across survey waves, and among a comparable sample of non-pregnant women to provide contextual information about quitting among the broader population of reproductive-aged women. Multiple logistic regression modeling was used to estimate the associations of pregnancy and quitting adjusting for other demographic and psychosocial characteristics. Quit rates among women who were pregnant in W2 were highest for hookah (98.3%), followed by cigars (88.0%), e-cigarettes (81.3%), and lowest for tobacco cigarettes (53.4%). Slightly more than half (58.7%) of women reported quitting use all tobacco products while pregnant. Pregnancy was independently associated with increased odds of quitting hookah (AOR = 52.9, 95%CI = 3.4, 830.2), e-cigarettes (AOR = 21.0, 95%CI = 2.6, 170.3), all tobacco products (AOR = 9.6, 95%CI = 6.4, 14.5), and cigarettes (AOR = 6.5, 95%CI = 4.2, 10.1), although not cigars. Relative to other demographic and psychosocial characteristics, pregnancy was the strongest predictor of quitting use of each tobacco product. While these data indicate that pregnancy has strong, independent associations with quitting a variety of commercially available tobacco products, the comparatively lower quit rates for cigarettes versus other tobacco products underscores the long-standing need for more intensive, multipronged clinical and regulatory interventions to reduce cigarette use among reproductive-aged women.

Perceived Effectiveness of Differing Health Warning Label Messaging Strategies among Adults in the Republic of Georgia: One Size Does Not Fit All

Background: While pictorial health warning labels (HWLs) are evidence-based, the different messaging strategies are understudied. Methods: We analyzed 2014 national survey data from 1163 Georgian adults to examine: (1) perceived effectiveness of pictorial vs. text-only HWLs; (2) pictorial HWL themes; and (3) correlates of perceived effectiveness of different pictorial themes. Participants were randomized to evaluate the effectiveness of either Set A or Set B of HWLs (each contained half pictorial, half text-only). Results: All but 2 pictorial HWLs were perceived as more effective than text-only. Factor analyses identified one factor among Set A (“benign”) and two in Set B pictorial HWLs (“benign”, “gruesome”). Among Set A pictorial HWLs, correlates of greater perceived effectiveness included being female, rural residence, not having children, and nonsmoker status. Among smokers, correlates included being female and unmarried, fewer smoking friends, and higher quitting importance. Among Set B, 43.8% rated gruesome pictorial HWLs more effective, 12.9% benign more effective, and 43.4% equally effective. Correlates of perceiving benign more effective included fewer smoking friends and higher income. Among smokers, lower income predicted gruesome being perceived as more effective; fewer smoking friends and higher quitting importance predicted perceiving benign as more effective. Conclusion: A variety of pictorial HWL strategies should be used.

Does Segmentation Really Work? Effectiveness of Matched Graphic Health Warnings on Cigarette Packaging by Race, Gender and Chronic Disease Conditions on Cognitive Outcomes among Vulnerable Populations

We examined the differential impact of exposure to smoking-related graphic health warnings (GHWs) on risk perceptions and intentions to quit among different audience segments characterized by gender, race/ethnic group, and presence of chronic disease condition. Specifically, we sought to test whether GHWs that portray specific groups (in terms of gender, race, and chronic disease conditions) are associated with differences in risk perception and intention to quit among smokers who match the portrayed group. We used data from Project CLEAR, which oversampled lower SES groups as well as race/ethnic minority groups living in the Greater Boston area (n = 565). We fitted multiple linear regression models to examine the impact of exposure to different GHWs on risk perceptions and quit intentions. After controlling for age, gender, education and household income, we found that women who viewed GHWs portraying females reported increased risk perception as compared to women who viewed GHWs portraying men. However, no other interactions were found between the groups depicted in GHWs and audience characteristics. The findings suggest that audience segmentation of GHWs may have limited impact on risk perceptions and intention to quit smoking among adult smokers.

Testing Cessation Messages for Cigarette Package Inserts: Findings from a Best/Worst Discrete Choice Experiment

This study assessed smokers' responses to different smoking cessation topics and imagery for cigarette package inserts. Adult smokers from Canada (n = 1000) participated in three discrete choice experiments (DCEs): DCE 1 assessed five cessation benefit topics and five imagery types; DCE 2 assessed five messages with tips to improve cessation success and five imagery types; DCE 3 assessed four reproductive health benefits of cessation topics and four imagery types. In each DCE, participants evaluated four or five sets of four inserts, selecting the most and least motivating (DCEs 1 & 3) or helpful (DCE 2) for quitting. Linear mixed models regressed choices on insert and smoker characteristics. For DCE 1, the most motivating messages involved novel disease topics and imagery of younger women. For DCE 2, topics of social support, stress reduction and nicotine replacement therapy were selected as most helpful, with no differences by imagery type. For DCE 3, imagery influenced choices more than topic, with imagery of a family or a mom and baby selected as most motivating. Statistically significant interactions for all three experiments indicated that the influence of imagery type on choices depended on the message topic. Messages to promote smoking cessation through cigarette pack inserts should consider specific combinations of message topic and imagery.

Signage as a tool for behavioral change: Direct and indirect routes to understanding the meaning of a sign

Signs, prompts, and symbols are a common means to change behavior in our society. Understanding the psychological mechanisms by which signage influences behavior is a critical first step to achieve the desired outcome. In the current research, we propose a theoretical model of sign-to-behavior process. The model suggests that when one encounters a sign, it is encoded to construct an action representation (comprehension process), which is then acted on unless its enactment is inhibited (decision process). We test the implications of the model in two studies. In support of our hypothesis, for unfamiliar signs, clarity of purpose predicts perceived effectiveness of a sign; however, for familiar signs, clarity of purpose does not matter. Insights gained from the studies will help to design effective signs. Practical implications of the model are discussed, and future research directions are outlined.

Evaluation of strategies to communicate harmful and potentially harmful constituent (HPHC) information through cigarette package inserts: a discrete choice experiment

BACKGROUND

The US Food and Drug Administration (FDA) has regulatory authority to use inserts to communicate with consumers about harmful and potentially harmful constituents (HPHCs) in tobacco products; however, little is known about the most effective manner for presenting HPHC information.

METHODS

In a discrete choice experiment, participants evaluated eight choice sets, each of which showed two cigarette packages from four different brands and tar levels (high vs low), accompanied by an insert that included between-subject manipulations (ie, listing of HPHCs vs grouping by disease outcome and numeric values ascribed to HPHCs vs no numbers) and within-subject manipulations (ie, 1 of 4 warning topics; statement linking an HPHC with disease vs statement with no HPHC link). For each choice set, participants were asked: (1) which package is more harmful and (2) which motivates them to not smoke; each with a 'no difference' option. Alternative-specific logit models regressed choice on attribute levels.

RESULTS

1212 participants were recruited from an online consumer panel (725 18-29-year-old smokers and susceptible non-smokers and 487 30-64-year-old smokers). Participants were more likely to endorse high-tar products as more harmful than low-tar products, with a greater effect when numeric HPHC information was present. Compared with a simple warning statement, the statement linking HPHCs with disease encouraged quit motivation.

CONCLUSIONS

Numeric HPHC information on inserts appears to produce misunderstandings that some cigarettes are less harmful than others. Furthermore, brief narratives that link HPHCs to smoking-related disease may promote cessation versus communications that do not explicitly link HPHCs to disease.

Factors Affecting the Perceived Effectiveness of Pictorial Health Warnings on Cigarette Packages in Gulf Countries: A Cross-sectional Study

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.