The role of negative affect and message credibility in perceived effectiveness of smokeless tobacco health warning labels in Navi Mumbai, India and Dhaka, Bangladesh: A moderated-mediation analysis

The Role of Harm Visibility for Pictorial Health Warning Labels on Cigars

INTRODUCTION

Pictorial health warning labels (HWLs) can communicate the harms of tobacco product use, yet little research exists for cigars. We sought to identify the most effective types of images to pair with newly developed cigar HWLs.

AIMS AND METHODS

In September 2021, we conducted an online survey experiment with US adults who reported using little cigars, cigarillos, or large cigars in the past 30 days (n = 753). After developing nine statements about health effects of cigar use, we randomized participants to view one of three levels of harm visibility paired with each statement, either: (1) an image depicting internal harm not visible outside the body, (2) an image depicting external harm visible outside of the body, or (3) two images depicting both internal and external harm. After viewing each image, participants answered questions on perceived message effectiveness (PME), negative affect, and visual-verbal redundancy (VVR). We used linear mixed models to examine the effect of harm visibility on each outcome, controlling for warning statement.

RESULTS

Warnings with both and external harm depictions performed significantly better than the internal harm depictions across all outcomes, including PME (B = 0.21 and B = 0.17), negative affect (B = 0.26 and B = 0.25), and VVR (B = 0.24 and B = 0.17), respectively (all p < .001). Compared to both, the external depiction of harm did not significantly change PME or negative affect but did significantly lower VVR (B = -0.07, p = .01).

CONCLUSIONS

Future cigar pictorial HWLs may benefit from including images depicting both or external harm depictions. Future research should examine harm visibility's effect for other tobacco pictorial HWLs.

IMPLICATIONS

The cigar health warning labels (HWLs) proposed by the US Food and Drug Administration are text-only. We conducted an online survey experiment among people who use cigars to examine the effectiveness of warnings with images depicting different levels of harm visibility. We found HWLs with images depicting both an internal and external depiction of cigar harm, or an external depiction of harm alone, performed better overall than images portraying internal depictions of harm. These findings provide important regulatory evidence regarding what type of images may increase warning effectiveness and offer a promising route for future cigar HWL development.

Non-compliant packaging and illicit smokeless tobacco in Bangladesh, India and Pakistan: findings of a pack analysis

INTRODUCTION

Illicit smokeless tobacco (ST) trade has seldom been documented despite ST use in at least 127 countries across the world. Based on non-compliance with packaging regulations, we report the proportion of illicit ST products from samples on sale in Bangladesh, India and Pakistan where 85% of global ST users reside.

METHODS

We purchased unique ST products from tobacco sellers in two purposively selected administrative areas (division/district) in each of the three countries. The criteria to determine illicit ST products were based on country-specific legal requirements for ST packaging and labelling. These requirements included: 'market retail price disclosure', 'sale statement disclosure', 'pictorial health warning (PHW) pertinence', 'appropriate textual health warning' and 'using misleading descriptors (MDs)'. Non-compliance with even one of the legal requirements was considered to render the ST product illicit.

RESULTS

Almost all ST products bought in Bangladesh and India were non-compliant with the local packaging requirements and hence potentially illicit, all products in Pakistan lacked desirable features. The most common feature missing was health warnings: 84% packs in Bangladesh, 93% in India, and 100% in Pakistan either did not have PHW or their sizes were too small. In Bangladesh, 61% packs carried MDs. In India and Pakistan, the proportions of such packs were 32% and 42%, respectively.

CONCLUSIONS

Weak and poorly enforced ST control policies may be slowing the progress of tobacco control in South Asia. Standardised regulations are required for packaging and labelling ST. Improving compliance and reducing sale of cheap illicit products may require business licensing and market surveillance.

Association between textual and pictorial warnings on tumbac (waterpipe tobacco) boxes and motivation to quit waterpipe smoking among Lebanese and Iraqi adolescents

BACKGROUND

Waterpipe tobacco smoking has increased tremendously at a global level among all age groups, particularly young people. Previous studies have examined the impact of waterpipe tobacco pictorial health warnings on adults but scarce studies were done on adolescents. The aim of this study was to assess the association of textual versus pictorial warnings on tumbac boxes and the motivation to quit waterpipe smoking among adolescents located in two Eastern Mediterranean countries Lebanon and Iraq.

METHODS

A cross-sectional study was conducted between May and November 2022, involving 294 adolescents waterpipe smokers from Lebanon and Iraq. The questionnaire included the Lebanese Waterpipe Dependence Smoking-11, the Depression, Anxiety and Stress Scale, the Waterpipe Harm Perception Scale, Waterpipe Knowledge Scale, Waterpipe Attitude Scale, the Fagerstrom Test for Nicotine Dependence, and the Motivation to Stop Scale.

RESULTS

When adjusting the results over confounding variables, the results showed that compared to finding the warnings to stop smoking not efficacious at all, adolescents who find the warnings moderately (aOR = 2.83) and very (aOR = 6.64) efficacious had higher motivation to quit. Compared to finding the warnings not increasing their curiosity for information about how to stop waterpipe smoking at all, participants who confessed that warnings increased their curiosity a little (aOR = 2.59), moderately (aOR = 3.34) and very (aOR = 3.58) had higher motivation to quit. Compared to not considering changing the tumbac brand if the company uses pictorial warnings, adolescents who would consider changing the tumbac brand (aOR = 2.15) had higher motivation to quit.

CONCLUSION

Pictorial and textual warnings on waterpipe packs were associated with higher motivation to stop waterpipe smoking. Public health education programs for this purpose seem warranted.

Willingness to reduce alcohol consumption predicted by short-form video exposure, media involvement, psychological bias, and cognitive factor

Introduction

Through previous studies, Chinese college students are known to be prone to alcohol consumption, which can lead to health-risk behaviors such as high blood pressure, heart disease, stroke, liver disease, and digestive problems. However, little is known about how popular social media platforms (e.g., short-form video applications) can positively impact their willingness to reduce alcohol consumption. This study was guided by the theory of optimistic bias; we investigated the direct, mediated, and moderating effects of exposure to anti-alcohol consumption short-form videos and short-form video involvement on Chinese college students' willingness to reduce their alcohol consumption.

Methods

The current study has an empirical cross-sectional design and employed an online survey from September 1st, 2022, to November 1st, 2022. The survey specifically targeted Chinese college students, who are the most common users of short-form video applications. The accumulated data underwent rigorous examination, including hierarchical regression, mediation, and moderation analyses, all conducted using the PROCESS macro 4.0 within SPSS version 22.

Results

A total of 434 participants, aged 18-24 years, were included in this study. There were mediating effects regarding Chinese college students' exposure to anti-alcohol consumption short-form videos (β = 0.35, p < 0.01, 95% CI [0.17, 0.63]) and short-form video involvement (β = 0.44, p < 0.001, 95% CI [0.20, 0.65]) on their willingness to reduce alcohol consumption via reversed optimistic bias. Moreover, perceived prevention of heavy drinking control (β = 0.05, p < 0.001, 95% CI [0.01, 0.09]) played mediating roles in the relationship between exposure to anti-alcohol consumption short-form videos and willingness to reduce alcohol consumption.

Conclusion

This study is one of the earliest studies to examine the intricate effects of exposure to anti-alcohol consumption short-form videos and short-form video involvement on the willingness to reduce alcohol consumption among Chinese college students. In addition, this study confirms that regardless of whether Chinese college students are conscientious, exposure to anti-alcohol consumption short-form videos did not increase their level of reversed optimistic bias. The empirical findings of this study are critical and can provide practical insights for Chinese health departments that encourage Chinese college students to minimize alcohol consumption.

Impact of pictorial health warning labels on smoking beliefs and perceptions among waterpipe smokers: an online randomised cross-over experimental study

PURPOSE

Waterpipe tobacco smoking (WTS) has substantially increased among young people in Lebanon, who perceive WTS as safer than cigarettes. Health warning labels (HWLs) can inform the adverse effects associated with smoking. Thus, their application to waterpipe offers a favourable policy to limit WTS epidemic. This study assessed the effectiveness of pictorial HWLs and their placements on waterpipe parts (device, tobacco and charcoal package) on several communication outcomes.

METHODS

We conducted a randomised cross-over experimental study among 276 waterpipe smokers (aged 18-34) between 13 and 26 August 2021. Participants observed three conditions: pictorial HWLs on tobacco packages, pictorial HWLs on three parts of the waterpipe (device, tobacco and charcoal package) and text only on tobacco package in random order. Participants completed baseline and postexposure assessments evaluating HWL effectiveness on attention, reaction, attitudes and beliefs, perceived effectiveness of HWLs and intention to quit WTS. Planned comparisons using Friedman test followed by pairwise Wilcoxon signed-rank test for multiple comparisons were conducted.

RESULTS

Compared with text only, pictorial HWLs elicited greater attention (p=0.011), higher cognitive elaboration (p=0.021), perceived message effectiveness (p=0.007), negative affect reactions (p<0.01) and greater psychological reactance (p=0.01). No significant differences were found for most communication outcomes between pictorial HWLs on three parts of the waterpipe compared with tobacco package only.

CONCLUSIONS

Pictorial HWLs on tobacco package were superior to text only for several communication outcomes. These findings provide strong evidence for potential implementation of pictorial HWLs on waterpipe tobacco packages to increase smokers' awareness of the health effects of WTS and correct false safety perceptions.

Optimising messages and images for e-cigarette warnings

BACKGROUND

The US Food and Drug Administration (FDA) requires electronic cigarettes (e-cigarettes) to have a single addiction warning, but many other health harms are associated with vaping and warnings grow stale over time. We aimed to develop new warning messages and images to discourage e-cigarette use.

METHODS

Participants were 1629 US adults who vaped or smoked. We randomised each participant to evaluate 7 of 28 messages on newly developed warning themes (metals exposure, DNA mutation, cardiovascular problems, chemical exposure, lung damage, impaired immunity, addiction), and the current FDA-required warning (total of 8 messages). Then, participants evaluated images of hazards (eg, metal), internal harms (eg, organ damage) or people experiencing harms.

RESULTS

Regarding intended effects, new warning themes all discouraged vaping more than the current FDA-required warning (all p<0.001), led to greater negative affect (all p<0.001) and led to more anticipated social interactions (all p<0.001). The most discouraging warnings were about toxic metals exposure. Regarding unintended effects, the new themes led to more stigma against people who vape (6 of 7 themes, p<0.001) and led to a greater likelihood of thinking vaping is more harmful than smoking (all 7 themes, p<0.001), although unintended effects were smaller than intended effects. Images of harms (internal or people experiencing) discouraged vaping more than images of hazards (all p<0.001).

DISCUSSION

Vaping warning policies should communicate a broader range of hazards and harms, beyond addiction, to potentially increase awareness of health harms. Images of internal harm or people experiencing harms may be particularly effective at discouraging vaping.

The global impact of tobacco control policies on smokeless tobacco use: a systematic review

BACKGROUND

Smokeless tobacco, used by more than 300 million people globally, results in substantial morbidity and mortality. For smokeless tobacco control, many countries have adopted policies beyond the WHO Framework Convention on Tobacco Control, which has been instrumental in reducing smoking prevalence. The impact of these policies (within and outside the Framework Convention on Tobacco Control) on smokeless tobacco use remains unclear. We aimed to systematically review policies that are relevant to smokeless tobacco and its context and investigate their impact on smokeless tobacco use.

METHODS

In this systematic review, we searched 11 electronic databases and grey literature between Jan 1, 2005, and Sept 20, 2021, in English and key south Asian languages, to summarise smokeless tobacco policies and their impact. Inclusion criteria were all types of studies on smokeless tobacco users that mentioned any smokeless tobacco relevant policies since 2005, except systematic reviews. Policies issued by organisations or private institutions were excluded as well as studies on e-cigarettes and Electronic Nicotine Delivery System except where harm reduction or switching were evaluated as a tobacco cessation strategy. Two reviewers independently screened articles, and data were extracted after standardisation. Quality of studies was appraised using the Effective Public Health Practice Project's Quality Assessment Tool. Outcomes for impact assessment included smokeless tobacco prevalence, uptake, cessation, and health effects. Due to substantial heterogeneity in the descriptions of policies and outcomes, data were descriptively and narratively synthesised. This systematic review was registered in PROSPERO (CRD42020191946).

FINDINGS

14 317 records were identified, of which 252 eligible studies were included as describing smokeless tobacco policies. 57 countries had policies targeting smokeless tobacco, of which 17 had policies outside the Framework Convention on Tobacco Control for smokeless tobacco (eg, spitting bans). 18 studies evaluated the impact, which were of variable quality (six strong, seven moderate, and five weak) and reported mainly on prevalence of smokeless tobacco use. The body of work evaluating policy initiatives based on the Framework Convention on Tobacco Control found that these initiatives were associated with reductions in smokeless tobacco prevalence of between 4·4% and 30·3% for taxation and 22·2% and 70·9% for multifaceted policies. Two studies evaluating the non-Framework policy of sales bans reported significant reductions in smokeless tobacco sale (6·4%) and use (combined sex 17·6%); one study, however, reported an increased trend in smokeless tobacco use in the youth after a total sales ban, likely due to cross-border smuggling. The one study reporting on cessation found a 13·3% increase in quit attempts in individuals exposed (47·5%) to Framework Convention on Tobacco Control policy: education, communication, training, and public awareness, compared with non-exposed (34·2%).

INTERPRETATION

Many countries have implemented smokeless tobacco control policies, including those that extend beyond the Framework Convention on Tobacco Control. The available evidence suggests that taxation and multifaceted policy initiatives are associated with meaningful reductions in smokeless tobacco use.

FUNDING

UK National Institute for Health Research.

Does the Graphic Health Warning on Tobacco Products Have an Influence on Tobacco Consumers in India? A Scoping Review

It is now a legal requirement in India that all tobacco products carry graphic health warnings on their packaging. The Government of India has taken steps to reduce the number of people using tobacco products by introducing the Cigarettes and Other Tobacco Products Act. This law states that all tobacco products must display health warnings on their packaging. Despite this, many people in India still use tobacco products. Graphic health warnings on tobacco packaging and labeling can be an effective way to spread awareness about the risks associated with smoking. Pictures or pictograms should be included on all products, as this can be particularly helpful for those with limited literacy skills. This way, everyone can understand the dangers of tobacco use, even if they cannot read. This review examines the effectiveness of pictures on cigarette and other tobacco product packages as health warnings in India. To assess the impact of these graphic warnings, research from India was reviewed, along with information from the Ministry of Health and Family Welfare websites and the World Health Organization. The results indicate that the images on packages have some positive effects. However, they need to be made more visible and easier to comprehend to have a more significant influence on discouraging people from taking up smoking.

Promoting Social Distancing and COVID-19 Vaccine Intentions to Mothers: Randomized Comparison of Information Sources in Social Media Messages

Background

Social media disseminated information and spread misinformation during the COVID-19 pandemic that affected prevention measures, including social distancing and vaccine acceptance.

Objective

In this study, we aimed to test the effect of a series of social media posts promoting COVID-19 nonpharmaceutical interventions (NPIs) and vaccine intentions and compare effects among 3 common types of information sources: government agency, near-peer parents, and news media.

Methods

A sample of mothers of teen daughters (N=303) recruited from a prior trial were enrolled in a 3 (information source) × 4 (assessment period) randomized factorial trial from January to March 2021 to evaluate the effects of information sources in a social media campaign addressing NPIs (ie, social distancing), COVID-19 vaccinations, media literacy, and mother–daughter communication about COVID-19. Mothers received 1 social media post per day in 3 randomly assigned Facebook private groups, Monday-Friday, covering all 4 topics each week, plus 1 additional post on a positive nonpandemic topic to promote engagement. Posts in the 3 groups had the same messages but differed by links to information from government agencies, near-peer parents, or news media in the post. Mothers reported on social distancing behavior and COVID-19 vaccine intentions for self and daughter, theoretic mediators, and covariates in baseline and 3-, 6-, and 9-week postrandomization assessments. Views, reactions, and comments related to each post were counted to measure engagement with the messages.

Results

Nearly all mothers (n=298, 98.3%) remained in the Facebook private groups throughout the 9-week trial period, and follow-up rates were high (n=276, 91.1%, completed the 3-week posttest; n=273, 90.1%, completed the 6-week posttest; n=275, 90.8%, completed the 9-week posttest; and n=244, 80.5%, completed all assessments). In intent-to-treat analyses, social distancing behavior by mothers (b=–0.10, 95% CI –0.12 to –0.08, P<.001) and daughters (b=–0.10, 95% CI –0.18 to –0.03, P<.001) decreased over time but vaccine intentions increased (mothers: b=0.34, 95% CI 0.19-0.49, P<.001; daughters: b=0.17, 95% CI 0.04-0.29, P=.01). Decrease in social distancing by daughters was greater in the near-peer source group (b=–0.04, 95% CI –0.07 to 0.00, P=.03) and lesser in the government agency group (b=0.05, 95% CI 0.02-0.09, P=.003). The higher perceived credibility of the assigned information source increased social distancing (mothers: b=0.29, 95% CI 0.09-0.49, P<.01; daughters: b=0.31, 95% CI 0.11-0.51, P<.01) and vaccine intentions (mothers: b=4.18, 95% CI 1.83-6.53, P<.001; daughters: b=3.36, 95% CI 1.67-5.04, P<.001). Mothers’ intentions to vaccinate self may have increased when they considered the near-peer source to be not credible (b=–0.50, 95% CI –0.99 to –0.01, P=.05).

Conclusions

Decreasing case counts, relaxation of government restrictions, and vaccine distribution during the study may explain the decreased social distancing and increased vaccine intentions. When promoting COVID-19 prevention, campaign planners may be more effective when selecting information sources that audiences consider credible, as no source was more credible in general.

Trial Registration

ClinicalTrials.gov NCT02835807; https://clinicaltrials.gov/ct2/show/NCT02835807

Cognitive and emotional responses to pictorial warning labels and their association with quitting measures after continued exposure

OBJECTIVE

Previous research has highlighted the role of cognitive and affective mediators in facilitating the effectiveness of pictorial warning labels (PWLs). This study examines smokers' responses towards PWLs after 10 days of use and their associations with changes in quitting attitudes, beliefs, and intentions during this period.

METHODS

Non-treatment-seeking, daily smokers completed a randomized, parallel design trial. Participants were randomized to either a PWL or control (i.e., text only or no warning label) group and received their preferred brand cigarettes affixed with their assigned label for 10 days. We assessed quitting attitudes, intentions, and beliefs at the onset and end of the study. At study end, smokers rated their PWL on a 5-point scale for 8 cognitive and emotional attributes: memorable, understandable, shocking, informative, offensive, boring, relevant, and interesting.

RESULTS

Mean ratings of the PWLs were high for memorable, understandable, informative, relevant, and interesting (range = 3.4 to 4.0), moderate for shocking (2.9), and low for offensive (1.7), and boring (1.5). Among the PWLs, quitting-related attitudes, positive beliefs, and intentions increased over the study period (p < .001) and these changes were positively associated with most attributes except offensive and boring (p < .05). For the text-only label group, attitudes and intentions increased significantly but these changes were not associated with any attributes.

CONCLUSION

Smokers generally have favorable evaluations of PWLs following repeated exposures. Further, these evaluations are associated with increased quitting attitudes and intentions, which may facilitate cessation attempts over longer periods of exposure.

Examining the effect of waterpipe specific pictorial health warning labels among young adults in Lebanon and Tunisia: Protocol of a factorial experiment study design

Waterpipe tobacco smoking (WTS) has increased substantially in the Eastern Mediterranean Region (EMR), affecting young adults who perceive waterpipe as safer than cigarette smoking. Applying pictorial health warning labels (HWLs) on tobacco products has been effective in communicating health risks associated with tobacco smoking. However, there are few experimental studies that examined pictorial HWLs specific to WTS. Methods/design: This report describes the design and protocol of the first factorial experimental study that aims to test the effectiveness of pictorial HWLs based on their placement on waterpipe device, tobacco, and charcoal packages among young adult smokers and non-smokers residing in Lebanon and Tunisia. After completing a baseline assessment, participants will be randomly assigned to 3 experimental conditions in a 3 (HWL: pictorial HWL on tobacco package vs. pictorial HWL on 3 placements [device, tobacco, and charcoal packages] vs. text-only HWL on tobacco package) x 4 (pictorial HWLs) x 2 (waterpipe smokers vs. non-smokers) factorial design. We will use a within/between-subject design, where pictorial HWLs and time (pre vs. post-exposure) are the within-subject factors and waterpipe smoking status as the between-subjects factor. Participants will complete post-exposure measures that include attention, perceived harm, intention to quit (smokers) or initiate smoking (non-smokers). Discussion: This is the first international study examining the placements of pictorial HWLs using efficient within/between subject design. Findings will provide additional evidence to convince policymakers to consider three placements of HWLs specific to WTS as a promising regulatory target to curb WTS.

Effectiveness of warning graphic labels on cigarette packs in enhancing late-teenagers' perceived fear of smoking-related harms in Bangkok, Thailand

Background: This study investigated the level of fear of smoking- related harms for teenagers of different gender, different levels of smoking behaviour, and difference in smoking levels of friends and family members, as influenced by warning graphic images on cigarette packs. The study also compared levels of this fear in categories based on participants' perception (e.g., scarier or less scary images). Design and Methods: The sample group was 353 undergraduate students at King Mongkut's University of Technology Thonburi in Bangkok, Thailand. Questionnaires containing 21 warning graphic images, aimed at measuring levels of fear of smoking-related harms, were conducted. Both descriptive statistics and inferential statistics, such as independent and dependent ttest, were used to analyse the data. Results: The results showed that warning graphic images exhibiting patients suffering from cancers (e.g., lung cancer or laryngeal cancer) and images of damaged body parts were perceived as the scariest warning images. In contrast, images that did not illustrate serious disease suffered by smokers were perceived as the least scary images. The scariest images generated a significant higher level of fear of smoking-related harms than the least scary images. In addition, non-smoking participants were more sensitive to scary warning images than smoking participants. It was also found that the level of fear of smoking-related harms was significantly based on individual cognitive judgment, and it was not affected by the influence of social groups such as friends and family members. Conclusions: Developing effective warning graphic images could directly contribute to individuals' perceived health risks and danger associated with smoking.

A Perspective on Age Restrictions and Other Harm Reduction Approaches Targeting Youth Online Gambling, Considering Convergences of Gambling and Videogaming

Internet gambling has become a popular activity among some youth. Vulnerable youth may be particularly at risk due to limited harm reduction and enforcement measures. This article explores age restrictions and other harm reduction measures relating to youth and young adult online gambling. A systematic rapid review was conducted by searching eight databases. Additional articles on online gambling (e.g., from references) were later included. To place this perspective into context, articles on adult gambling, land-based gambling, and substance use and other problematic behaviors were also considered. Several studies show promising findings for legally restricting youth from gambling in that such restrictions may reduce the amount of youth gambling and gambling-related harms. However, simply labeling an activity as "age-restricted" may not deter youth from gambling; in some instances, it may generate increased appeal for gambling. Therefore, advertising and warning labels should be examined in conjunction with age restrictions. Recommendations for age enforcement strategies, advertising, education, and warning labels are made to help multiple stakeholders including policymakers and public health officials internationally. Age restrictions in online gambling should consider multiple populations including youth and young adults. Prevention and harm reduction in gambling should examine how age-restriction strategies may affect problem gambling and how they may be best enforced across gambling platforms. More research is needed to protect youth with respect to online gambling.

Are the Same Health Warnings Effective Across Different Countries? An Experimental Study in Seven Countries

INTRODUCTION

More than 100 countries have implemented pictorial health warnings on cigarette packages. However, few studies have compared how consumers from different geographic and cultural contexts respond to health warning content. The current study compares perceptions of warnings among adult smokers and youth in seven countries, to examine the efficacy of different health warning themes and images.

METHODS

Between 2010 and 2012, online and face-to-face surveys were conducted with ~500 adult smokers and ~500 youth (age 16-18) smokers and nonsmokers in each of Mexico, United States, China, Germany, India, Bangladesh, and Republic of Korea (total N = 8182). Respondents were randomized to view and rate sets of 5-7 health warnings (each set for a different health effect); each set included a text-only warning and various types (ie, themes) of pictorial warnings, including graphic health effects, "lived experience," symbolic images, and personal testimonials. Mixed-effects models were utilized to examine perceived effectiveness of warning themes, and between-country differences in responses.

RESULTS

Overall, pictorial warnings were rated as more effective than text-only warnings (p < .001). Among pictorial themes, "graphic" health effects were rated as more effective than warnings depicting "lived experience" (p < .001) or "symbolic" images (p < .001). Pictorial warnings with personal testimonials were rated as more effective than the same images with didactic text (p < .001). While the magnitude of differences between warning themes varied across countries, the pattern of findings was generally consistent.

CONCLUSIONS

The findings support the efficacy of graphic pictorial warnings across diverse geographic and cultural contexts, and support sharing health warning images across jurisdictions.

IMPLICATIONS

Although over 100 countries have implemented pictorial health warnings on cigarette packages, there is little research on the most effective types of message content across geographic and cultural contexts. The current study examined perceived effectiveness of text and pictorial health warnings featuring different message content-graphic health effects, "lived experience," personal testimonials, and symbolic imagery-among more than 8000 adults and youth in Mexico, United States, China, Germany, India, Bangladesh, and Korea. Across countries, "graphic" pictorial messages were rated as most effective. Consistencies across countries in rating message content suggests there may be "globally effective" themes and styles for designing effective health warnings.

Perceptions of plain packaging and health warning labels for cannabis among young adults: findings from an experimental study

BACKGROUND

There is strong evidence that plain cigarette packaging and health warning labels (HWLs) reduce brand appeal and increase health knowledge. There is limited evidence examining this population-level public health approach for cannabis packaging. This issue is of particular importance in light of the recent legalization of recreational cannabis in Canada. The current study examined perceptions of plain packaging and HWLs for cannabis packages among young adults.

METHODS

An online experimental study was conducted with a sample of university students in Alberta, Canada (n = 656). Respondents were randomly assigned to view cannabis packages in one of four conditions: Condition 1: branded pack, Condition 2: plain pack (uniform color, brand imagery removed, standardized font), Condition 3: branded pack with a HWL, and Condition 4: plain pack with a HWL. Respondents in Conditions 3 and 4 viewed five text-based HWLs, each corresponding to a health effect associated with cannabis use: (1) brain development, (2) mental health issues, (3) impaired driving, (4) nonlethal overdose, and (5) addiction. After viewing packs, respondents rated packs and health warnings on various measures.

RESULTS

Branded packages without HWLs were rated as most appealing compared to all other packs (p < 0.001 for all contrasts). No differences were found in ratings of appeal when comparing branded and plain packs with HWLs. Warning messages for cognitive development and impaired driving were rated highest on levels of perceived effectiveness, believability, and fear, whereas the addiction warning was rated among the lowest. In general, there were gaps in health knowledge related to cannabis use, however after viewing packs with warnings (compared to viewing packs without warnings) levels of health knowledge increased across all health effects (p < 0.01 for all). Lastly, a significant majority of young adults reported they would purchase the branded pack without a HWL (39.5%), compared to all other pack types (p < 0.05 for all contrasts). The lowest proportion of young adults reported they would purchase a plain pack with a HWL (1.1%).

CONCLUSIONS

Plain packaging and health warnings may reduce brand appeal and increase health knowledge among young adults.

Graphic health warnings on tobacco packets and containers: compliance status in Bangladesh

Objective

This study describes and analyses compliance with tobacco product graphic health warning (GHW) legislation introduced in Bangladesh in March 2016.

Methods

A survey based on a structured questionnaire was conducted in April 2016 (immediately following the law coming into force), and 8 months later in November 2016, in eight divisional cities in Bangladesh. Five stores from three categories of retailers of combustible and smokeless tobacco products were surveyed, providing a total of 120 completed questionnaires. The study investigated a range of measures including the image and text of GHW, their ratio and colour use, and prescribed rotation.

Findings

Warning labels for 3312 tobacco items were assessed. In April 2016, 75% of tobacco products surveyed did not have GHWs. In November 2016, 19% were still found to not have the prescribed warnings. Even among products which did include GHW, there was significant non-compliance with the full range of requirements, in both survey periods. Compliance was highest for cigarette packets and lowest among smokeless tobacco products. In addition, awareness among tobacco retailers about the range of GHW requirements was low.

Conclusion

Effective implementation of GHW labels in low-income and middle-income countries requires awareness-raising among key stakeholders, combined with focused monitoring and compliance strategies. This should take into account different product categories and manufacturers, as well as measures targeted at retailers.

The Importance of 'Likes': The Interplay of Message Framing, Source, and Social Endorsement on Credibility Perceptions of Health Information on Facebook

Online sources not only permeate the information-seeking environment of the younger generation, but also have profound influence in shaping their beliefs and behaviors. In this landscape, examining the factors responsible for credibility perceptions of online information is fundamental, particularly for health-related information. Using a 2 (frames: gain vs. loss) × 2 (source: expert vs. non-expert) × 2 (social endorsement: high vs. low) randomized between-subjects experimental design, this study examines the effect of health message framing and the moderating effects of social endorsement and source type on credibility perceptions of Facebook posts. Testing across two issues--physical activity and alcohol consumption--findings indicate that the gain-framed message was perceived as most credible. Additionally, significant three-way interactions suggest that social endorsement and source type affect the relationship between message framing and credibility perceptions. Specifically, the findings demonstrate that a gain-framed message from an expert source with high number of 'likes' is considered the most credible message. These findings have significant implications for information gathering from social media sources, such as the influence of 'likes' on health information.

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.