Cigarette warning label policy alternatives and smoking-related health disparities

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.

Youth Exposure and Response to the FDA Health Warning Label on Electronic Cigarettes Packaging: Policy Implications

INTRODUCTION

Youth represent a high-priority group for e-cigarette health communication. This study examined youth exposure to the Food and Drug Administration (FDA) e-cigarette warning label over 4 years and its association with change in youth harm perception and intention.

AIMS AND METHODS

We pooled data from the 2018-2021 National Youth Tobacco Survey (age 10-17; n = 67 159). Participants were divided into four groups: never users (58.5%), susceptible nonusers (16.3%), former users (12.7%), and current users (12.5%). We examined the prevalence, time-trend, correlates, and association of youth exposure to the warning with addictiveness and harm perception, intention to use e-cigarettes, and intention to quit all tobacco products.

RESULTS

Only 24.5% of youth were exposed to the warning. Exposure increased from 14.9% in 2018 to 30.8% in 2019, then declined to 25.2% in 2021. Hispanic (adjusted odds ratio (aOR) = 0.76 [95% CI = 0.641 to 0.89]) and non-Hispanic black current users (0.53 [0.40 to 0.69]) were less likely to be exposed to the warning than white current users. Youth exposure was positively associated with a higher perception of e-cigarette addictiveness (1.12 [1.04 to 1.19]) and intention to quit all tobacco products (1.28 [1.13 to 1.46]). However, exposure was negatively associated with harm perception (0.91 [0.85 to 0.96]) and the intention to use e-cigarettes among e-cigarette nonusers (2.38 [1.99 to 2.84]).

CONCLUSIONS

The decline in youth exposure to the warning indicates wear-out effects. Strengthening the label by using compelling designs, adding themes on e-cigarette harm to youth, periodically rotating warning content, and using culturally tailored messaging may improve its impact on youth and address racial/ethnic disparities.

IMPLICATIONS

The FDA e-cigarette label reached only 24.5% of youth, and exposure to the warning declined to indicate wear-out effects. Exposure was significantly lower among minorities. Exposure was associated with a higher perception of e-cigarette addictiveness and intention to quit all tobacco products. Still, it did not increase harm perception or reduce intention to use e-cigarettes among nonusers. Strengthening the label by using more compelling designs, including diverse themes focusing on e-cigarette harm relevant to youth, and periodically rotating warning content may improve its impact on youth. Continued surveillance of the implementation of e-cigarette policies is needed to ensure that they equally affect youth across racial/ethnic subpopulations.

Combining Inserts With Warning Labels on Cigarette Packs to Promote Smoking Cessation: A 2-Week Randomized Trial

BACKGROUND

Cigarette pack inserts with messages on cessation benefits and advice are a promising labeling policy that may help promote smoking cessation.

PURPOSE

To assess insert effects, with and without accompanying pictorial health warning labels(HWLs), on hypothesized psychosocial and behavioral outcomes.

METHODS

We conducted a 2 × 2 between-subject randomized trial (inserts with efficacy messages vs. no inserts; large pictorial HWLs vs. small text HWLs), with 367 adults who smoked at least 10 cigarettes a day. Participants received a 14-day supply of their preferred cigarettes with packs modified to reflect their experimental condition. Over 2 weeks, we surveyed participants approximately 4-5 times a day during their smoking sessions, querying feelings about smoking, level of worry about harms from smoking, self-efficacy to cut down on cigarettes, self-efficacy to quit, hopefulness about quitting, and motivation to quit. Each evening, participants reported their perceived susceptibility to smoking harms and, for the last 24 hr, their frequency of thinking about smoking harms and cessation benefits, conversations about smoking cessation or harms, and foregoing or stubbing out cigarettes before they finished smoking. Mixed-effects ordinal and logistic models were estimated to evaluate differences between groups.

RESULTS

Participants whose packs included inserts were more likely than those whose packs did not include inserts to report foregoing or stubbing out of cigarettes (OR = 2.39, 95% CI = 1.36, 4.20). Otherwise, no statistically significant associations were found between labeling conditions and outcomes.

CONCLUSIONS

This study provides some evidence, albeit limited, that pack inserts with efficacy messages can promote behaviors that predict smoking cessation attempts.

A mixed-method study of perceptions of cigarette pack inserts among adult smokers from New York and South Carolina exposed as part of a randomized controlled trial

While many countries require prominent pictorial health warning labels (PHWLs) on the outside of cigarette packs to communicate the harms of smoking, there is evidence that cigarette pack inserts that contain efficacy messages may enhance the effectiveness of PHWLs. The US Food and Drug Administration (FDA) has regulatory authority to communicate with smokers through inserts. While current labeling regulations do not require inclusion of inserts, the FDA could implement them in the future. This study assesses US smokers' perceptions of cigarette package inserts at the conclusion of a two-week randomized trial on cigarette labeling where half of participants were exposed to insert messages (two response-efficacy messages and two self-efficacy messages) in their packs. Participants (n = 359) completed a 30- to 60-min interview with both quantitative and qualitative assessments, including measures of recall and perceived message effectiveness (PME) for specific inserts. Correlates of recall and PME were estimated using mixed-effects regression models. Qualitative responses to PME items were analyzed using thematic analysis. Response-efficacy messages had higher PME and recall than self-efficacy messages. People had diverse responses to the inserts, including that they were positive, thought-provoking, and helpful. Reactions to and perceptions of the inserts indicate potential benefits of integrating efficacy messages into labeling policies.

Impact of health warning labels and calorie labels on selection and purchasing of alcoholic and non-alcoholic drinks: A randomized controlled trial

AIMS

To estimate the impact on selection and actual purchasing of (a) health warning labels (text-only and image-and-text) on alcoholic drinks and (b) calorie labels on alcoholic and non-alcoholic drinks.

DESIGN

Parallel-groups randomised controlled trial.

SETTING

Drinks were selected in a simulated online supermarket, before being purchased in an actual online supermarket.

PARTICIPANTS

Adults in England and Wales who regularly consumed and purchased beer or wine online (n = 651). Six hundred and eight participants completed the study and were included in the primary analysis.

INTERVENTIONS

Participants were randomized to one of six groups in a between-subjects three [health warning labels (HWLs) (i): image-and-text HWL; (ii) text-only HWL; (iii) no HWL] × 2 (calorie labels: present versus absent) factorial design (n per group 103-113).

MEASUREMENTS

The primary outcome measure was the number of alcohol units selected (with intention to purchase); secondary outcomes included alcohol units purchased and calories selected and purchased. There was no time limit for selection. For purchasing, participants were directed to purchase their drinks immediately (although they were allowed up to 2 weeks to do so).

FINDINGS

There was no evidence of main effects for either (a) HWLs or (b) calorie labels on the number of alcohol units selected (HWLs: F(2,599)  = 0.406, P = 0.666; calorie labels: F(1,599)  = 0.002, P = 0.961). There was also no evidence of an interaction between HWLs and calorie labels, and no evidence of an overall difference on any secondary outcomes. In pre-specified subgroup analyses comparing the 'calorie label only' group (n = 101) with the 'no label' group (n = 104) there was no evidence that calorie labels reduced the number of calories selected (unadjusted means: 1913 calories versus 2203, P = 0.643). Among the 75% of participants who went on to purchase drinks, those in the 'calorie label only' group (n = 74) purchased fewer calories than those in the 'no label' group (n = 79) (unadjusted means: 1532 versus 2090, P = 0.028).

CONCLUSIONS

There was no evidence that health warning labels reduced the number of alcohol units selected or purchased in an online retail context. There was some evidence suggesting that calorie labels on alcoholic and non-alcoholic drinks may reduce calories purchased from both types of drinks.

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.

Effects of cigarette price and packaging on hypothetical quit-smoking behaviour: a discrete choice experiment among Vietnamese adults who smoke

INTRODUCTION

Raising cigarette prices, increasing graphic health warning label (HWL) coverage and requiring plain packaging could reduce cigarette smoking in Vietnam. This discrete choice experiment estimates the potential impact of these policies on smoking behaviour.

METHODS

In February-May 2022, we conducted a phone-based, cross-sectional survey of 1494 Vietnamese adults who smoke. Participants were randomly assigned to view four individual cigarette pack images, varied on price (15 000 (reference group); 20 000; 30 000 or 40 000 Vietnamese dong (VND)) and packaging (branded pack with 50% graphic HWL (reference group); branded pack with 85% graphic HWL; plain pack with 50% graphic HWL or branded pack without HWL). Participants responded if they would quit or continue smoking if they could only purchase the pack shown. We used binomial logistic regressions to estimate the relative risk (RR) of price and packaging on hypothetical quitting.

RESULTS

Participants were more likely to report they would quit when presented with 30 000 VND (RR 1.20, 95% CI 1.07 to 1.35) and 40 000 VND packs (RR 1.40, 95% CI 1.23 to 1.58) vs the 15 000 VND pack. Participants were also more likely to report they would quit when shown the branded pack with 85% HWL (RR 1.30, 95% CI 1.18 to 1.42) and plain pack with 50% HWL (RR 1.34, 95% CI 1.21 to 1.49) vs the branded pack with 50% HWL coverage. Participants had significantly lower quit likelihood (RR 0.41, 95% CI 0.35 to 0.48) when shown the branded pack without a HWL.

CONCLUSIONS

Results suggest raising cigarette prices to at least 30 000 VND, implementing larger graphic HWLs or plain packaging could decrease smoking rates in Vietnam.

The association between viewing cigarette health warning labels and intention to quit smoking among Chinese adult smokers: support for including health outcome content and culturally specific messages

BACKGROUND

Tailored themes of pictorial health warning labels (HWLs) that considers specific cultural dimensions and within a specific policy/historical context can motivate behavior change, such as provoking smokers to think about quitting. Currently in China, the HWLs on cigarettes are text-only. This study designed pictorial HWLs using different themes to explore and examine the association between viewing pictorial HWLs and participants' intention to quit smoking. The themes included: (1) Self-harm from using cigarettes, (2) Harming family or children with secondhand smoke, (3) Complying with existing smoke-free policies, and (4) Cigarette gift giving practices.

METHODS

A cross-sectional randomized experimental survey was conducted among 1,625 smokers in Beijing (n = 545), Shanghai (n = 541), and Shenzhen (n = 539) during 2017. Before and after viewing eight pictorial HWLs of one theme, participants were asked if they had plans to quit smoking within the next month, within the next 6 months, beyond the next 6 months, or not at all. Ordinal logistic regression, Wilcoxon and Chi-square tests were used to analyze the data.

RESULTS

After viewing the HWLs, 434 participants (26.9%) reported an intention to quit smoking sooner, 987 (61.2%) reported the same intention to quit, and 191 (11.8%) reported an intention to quit later. The pre-post change in intention to quit was statistically significant among all participants and participants under each theme (p > 0.05). Participants who rated the effectiveness of the HWL communicating how secondhand smoke harms children had 1.13 (95% CI 1.01-1.27) greater odds of reporting an intention to quit sooner compared to those viewing labels from the other themes, adjusting for covariates. Female participants and participants with annual household income more than 100,000RMB had 1.39 (95% CI 1.14-1.69) and 1.29 (95% CI 1.04-1.60) greater odds of reporting an intention to quit sooner compared to their counterparts across the entire sample.

CONCLUSIONS

Findings of this study provide evidence of an association between all four pictorial HWL themes and smokers' intention to quit smoking. These findings can help inform what HWL themes might be appropriate when China implements pictorial health warning labels.

Role of affective reactivity induced by cigarette packaging including graphic warning labels: the CASA Study

OBJECTIVE

To identify whether three types of cigarette pack designs, including three versions of graphic warning label (GWL) plain packs, one GWL absent and branding absent pack (blank) and the smoker's own GWL absent and branding present pack (US), elicit different valence, type and levels of affect.

DESIGN

US daily smokers (n=324) were asked to handle each of the five pack types and 'think aloud' their reactions. To avoid a muted familiarity response, exposure to their own US pack followed exposure to at least one GWL plain pack. Reactions were scored on a reactivity scale (-3 to +3) and the text was coded for speech polarity (-1 to +1) and emotive word frequency.

RESULTS

Reactivity scores had excellent inter-rater reliability (agreement ≥86%; intraclass correlation coefficient ≥0.89) and were correlated with speech polarity (r=0.21-0.37, p<0.001). When considering their US pack, approximately two-thirds of smokers had a low (31.5%) to medium (34.6%) positive response (reactivity=1.29; polarity=0.14) with expressed feelings of joy and trust. Blank packaging prompted a largely (65.4%) neutral response (reactivity=0.03; polarity=0.00). The gangrenous foot GWL provoked mostly medium (46.9%) to high (48.1%) negative responses (reactivity=-2.44; polarity=-0.20), followed by neonatal baby (reactivity=-1.85; polarity=-0.10) and throat cancer (reactivity=-1.76; polarity=-0.08) warnings. GWLs varied in their elicitation of disgust, anger, fear and sadness.

CONCLUSION

Initial reactions to GWL packs, a blank pack, and smokers' current US pack reflected negative, neutral, and positive affect, respectively. Different versions of the GWL pack elicited different levels and types of immediate negative affect.

Examining the Effectiveness of the 2012 Canadian Graphic Warning Label Policy Change by Sex, Income, and Education

INTRODUCTION

We examined the differential impact of the 2012 Canadian GWL policy changes on key indicators of warning label impact and quit intentions using national cohorts of Canadian and U.S. adults who smoke.

AIMS AND METHODS

We used data from all waves of the International Tobacco Control surveys (2002-2020) in Canada and the United States. Our key measures were quit intentions and an index of warning label effectiveness (salience, cognitive and behavioral reactions). We estimated overall policy impact by comparing Canada (treatment group) with the United States (control group) using controlled interrupted time series (CITS) regression models, with interactions to examine whether policy impact varied by sex, education, and income.

RESULTS

The CITS model showed a statistically significant increase in the warning label effectiveness in Canada post-policy, compared to the United States (β = 0.84, 95% CI 0.35,1.33). Similarly, the odds of quit intentions were relatively higher among adults who smoked in Canada compared to the United States (OR = 1.89, 95% CI 1.51,2.36) post-policy. The three-way interaction model showed that these associations were greater among adults from low socioeconomic status (SES) groups than in high SES groups.

CONCLUSIONS

The 2012 change in the Canadian GWL policy was associated with stronger cognitive and behavioral responses to GWLs and higher odds of quit intentions among adults who smoked in Canada when compared to the United States, specifically among individuals from low SES groups, suggesting a positive equity impact. Our findings affirm the need for countries to implement or enhance GWLs, in line with the WHO Framework Convention on Tobacco Control (FCTC).

IMPLICATIONS

The evidence on the potential health equity benefit of GWL policies is mixed. To further understand the influence of GWL policies on tobacco use disparities, more systematic research using pre/post-policy designs with control groups is needed. Using a CITS model, we aimed to strengthen the available evidence on the causal influence of this tobacco control approach. Our findings show that the 2012 GWL policy change had a greater impact on adults who smoked from low SES groups than it did on adults who smoked from high SES groups, indicating a potentially positive equity impact and confirming the need for countries to implement or maximize the size of GWLs, as recommended by the WHO FCTC.

How do current tobacco warnings compare to the WHO FCTC guidelines: a content analysis of combustible tobacco warnings worldwide

OBJECTIVE

Many countries have adopted warning labels for combustible tobacco products, yet little research exists describing tobacco warning characteristics globally and to what extent they meet the WHO Framework Convention for Tobacco Control (FCTC) Guidelines. This study evaluates characteristics of combustible tobacco warnings.

DESIGN

We conducted a content analysis to describe the overall landscape of warnings using descriptive statistics and compared to the WHO FCTC Guidelines.

SETTING

We searched existing warning databases for combustible tobacco warnings from English-speaking countries. We compiled warnings meeting inclusion criteria and coded for message and image characteristics using a pre-defined codebook.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Characteristics of combustible tobacco warning text statements and warning images were the primary study outcomes. There were no secondary study outcomes.

RESULTS

We identified a total of 316 warnings from 26 countries or jurisdictions worldwide. Of these warnings, 94% included warning text and an image. Warning text statements most often described health effects to the respiratory (26%), circulatory (19%) and reproductive systems (19%). Cancer was the most frequently mentioned health topic (28%). Fewer than half of warnings included a Quitline resource (41%). Few warnings included messages about secondhand smoke (11%), addiction (6%) or cost (1%). Of warnings with images, most were in colour and showed people (88%), mostly adults (40%). More than 1 in 5 warnings with images included a smoking cue (ie, cigarette).

CONCLUSIONS

While most tobacco warnings followed WHO FCTC guidance on effective tobacco warnings, such as communicating health risks and inclusion of images, many did not include local Quitline or cessation resources. A sizeable minority include smoking cues that could inhibit effectiveness. Full alignment with WHO FCTC guidelines will improve warnings and better achieve the WHO FCTC objectives.

Testing the effectiveness of alcohol health warning label formats: An online experimental study with Australian adult drinkers

Health warning labels (HWLs) on alcohol containers may help reduce population-level alcohol consumption. However, few studies have examined the most effective formats for alcohol HWLs. This study tested the effects of three different types of alcohol HWLs. In an online experiment, N = 1,755 Australian adult drinkers were randomly assigned to one of five conditions: (a) No HWL control; (b) DrinkWise control (industry-developed labels currently on some containers); (c) Text-Only HWLs; (d) Text + Pictogram HWLs; or (e) Text + Photograph HWLs. In the three intervention conditions, participants were exposed to eight HWLs, each depicting a different long-term harm. Exposure occurred during an initial session, and repeatedly over the subsequent eight days. Differences between conditions were assessed immediately following initial exposure and at nine-day follow-up. Compared to participants in the No HWL control, participants exposed to Text + Pictogram HWLs were more likely to have intentions to avoid drinking alcohol completely in the next month (post-exposure) and intentions to drink less alcohol in the next week (follow-up), and participants in all three intervention conditions reported stronger negative emotional arousal (follow-up) and weaker positive emotional arousal (follow-up). Compared to participants in the DrinkWise control, those exposed to Text + Pictogram HWLs had stronger intentions to drink less alcohol in the next week and intentions to avoid drinking alcohol completely in the next month (follow-up), participants in the Text + Photograph condition reported significantly weaker positive emotional arousal, and all three intervention conditions resulted in stronger negative emotional arousal. There would likely be benefits to public health if any of the three types of intervention HWLs were implemented. However, there is some evidence that Text + Pictogram HWLs should be recommended over Text-Only or Text + Photograph HWLs, given they were the only HWLs to increase intentions to drink less.

Strategies to enhance the effects of pictorial warnings for cigarettes: results from a discrete choice experiment

AIMS

To measure the effects of changing attributes of pictorial health warning labels (HWLs) on cigarette packs in a country that has already implemented pictorial HWLs.

MEASURES

For each choice set, participants were presented with two cigarette packs and asked the following three questions: (1) 'If only these two cigarette packs were available, which would you buy?'; (2) 'Each of these two packs has warnings on the front and back about the health effects of smoking. Which of these warnings best informs you about the dangers from smoking?'; and (3) 'Which warning most makes you think about quitting smoking?'. As recommended for best practices in discrete choice experiments, each of these questions was followed by an 'opt-out' question for participants to indicate whether they really believed there was a difference between the options presented (i.e. 'Would you really choose one of them?'; 'Do you really think that either of these warnings informs you about dangers from smoking?'; or 'Do you really think that either of these warnings would make you think about quitting smoking?', respectively). Each choice set could be viewed for as long as the participant wished. For each choice question (i.e. willingness to buy, informative, motivating to quit), the pack chosen was coded as 1 and the other pack as 0, with both packs being given a value of 0 if the participant 'opted out'.

DESIGN

A within-subject discrete choice experiment that involved systematic manipulation of pictorial HWL size [75 versus 30% (current policy)]; inclusion of imagery on the back of the pack [versus none (current policy)]; and color formatting [black on yellow versus yellow on black (current policy)].

SETTING

Mexico, on-line panel.

PARTICIPANTS

Adult smokers (n = 705).

MEASUREMENTS

For each choice set, participants selected one pack as having the most informative HWL about smoking harms, the one that makes them think the most about quitting and the one they were most willing to buy. We assessed the independent and interactive effects of HWL attributes on choices.

FINDINGS

Larger HWL size on the pack front (75 versus 30%) and inclusion of a pictorial image on the pack back were both independently associated with lower willingness to buy a pack [b = -0.228, standard error (SE) = 0.023 and -0.089, SE = 0.016, respectively] and greater perception of an HWL as informative (b = 0.214, SE = 0.022, and 0.191, SE = 0.017, respectively) and motivating to quit (b = 0.251, SE = 0.023 and 0.194, SE = 0.017, respectively). HWL with black text and yellow background were perceived as less informative (b = -0.037, SE = 0.016) and less motivating to quit (b = -0.032, SE = 0.015) compared with yellow text on a black background.

CONCLUSIONS

Among adult Mexican smokers, pictorial health warning labels on cigarette packages that are larger or cover both sides of the pack appear more effective at lowering purchase intentions and increasing risk perceptions and motivation to quit than smaller health warning labels or health warning labels with imagery only on the pack front.

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.

Health warning labels and alcohol selection: a randomised controlled experiment in a naturalistic shopping laboratory

BACKGROUND AND AIMS

Health warning labels (HWLs) on tobacco products reduce smoking. There is an absence of evidence concerning the impact of alcohol HWLs on selection or purchasing in naturalistic settings. Using a commercial-standard naturalistic shopping laboratory, this study aimed to estimate the impact on selection of alcoholic drinks of HWLs describing adverse health consequences of excessive alcohol consumption.

DESIGN

A between-subjects randomised experiment with three groups was conducted: group 1: image-and-text HWL; group 2: text-only HWL; group 3: no HWL.

SETTING

A commercial-standard naturalistic shopping laboratory in the United Kingdom.

PARTICIPANTS

Adults (n = 399, 55% female) over the age of 18 years, who purchased beer or wine weekly to drink at home.

INTERVENTIONS

Participants were randomised to one of three groups varying in the HWL displayed on the packaging of the alcoholic drinks: (i) image-and-text HWL (n = 135); (ii) text-only HWL (n = 129); (iii) no HWL (n = 135). Participants completed a shopping task, selecting items from a range of alcoholic and non-alcoholic drinks, and snacks.

MEASUREMENT

The primary outcome was the proportion of alcoholic drinks selected. Secondary outcomes included HWL ratings on negative emotional arousal and label acceptability.

FINDINGS

There was no clear evidence of a difference in the HWL groups for the percentage of drinks selected that were alcoholic compared to no HWL (44%): image-and-text HWL: 46% (odds ratio [OR] = 1.08, 95% confidence interval [CI] = 0.82, 1.42); text-only HWL: 41% (OR = 0.87, 95% CI = 0.67, 1.14). Concordant with there being no difference between groups, there was extreme evidence in favour of the null hypothesis (Bayes factor [BF] < 0.01). Negative emotional arousal was higher (P < 0.001) and acceptability lower (P < 0.001) in the image-and-text HWL group, compared to the text-only HWL group.

CONCLUSIONS

In a naturalistic shopping laboratory, there was no evidence that health warning labels describing the adverse health consequences of excessive alcohol consumption changed selection behaviour.

"When the Fun Stops, Stop": An analysis of the provenance, framing and evidence of a 'responsible gambling' campaign

When the Fun Stops, Stop, is a prominent 'responsible gambling' campaign in the UK, originally funded and delivered by the industry-initiated and funded Senet Group. Since the Senet Group's dissolution in 2020, the campaign has been overseen by the Betting and Gambling Council (BGC), the main gambling industry trade body. There has been no prior analysis of the activities, ideas and framing adopted by the Senet Group, who claimed to be acting as an industry 'watchdog' and oversaw what they characterised as a major public education campaign. We collated written and image-based material related to the Senet Group and its When the Fun Stops, Stop campaign from multiple sources. Guided by Entman's four functions of framing, we analysed the Senet Group's framing of the issues it sought to address, particularly harmful gambling, as well as its causes, and the solutions, focusing on the group's main activity: the delivery of the When the Fun Stops, Stop campaign. We also critically appraised an evaluation of the campaign funded by the Senet Group, using the findings to interrogate the stated claims about the campaign's effectiveness. The analysis showed that the Senet Group's framing of the problem, its causes, and proposed responses resemble those adopted by other industries and industry-funded groups. This involves portraying any harms caused by their products as limited to an atypical minority, rejecting upstream determinants of harm, and promoting individually-targeted voluntary measures, all contrary to the evidence of what works in health promotion, and what would characterise a public health approach. Neither the existing evidence base nor the evidence presented by the Senet Group support their claims about the campaign's effectiveness. These findings add to concerns about industry-funded campaigns in other areas. To minimise conflicts of interest, interventions intended to address gambling-related harms, such as public education campaigns, should be evidence-based and developed, implemented and evaluated completely independent of the industry and industry-funded organisations.

Perceived efficacy of existing waterpipe tobacco warning labels versus novel enhanced generic and waterpipe-specific sets

INTRODUCTION

Since 2008, Egypt has four existing generic bi-annually rotating warning labels (WLs) on 50% of the waterpipe tobacco packs (WTPs). The Ministry of Health Tobacco Control Unit proposed increasing WL size to 80%, removing colours and flavour imagery from WTPs, and plain packaging to help curb the rising epidemic of waterpipe tobacco smoking. Therefore, we measured the perceived efficacy of existing against novel enhanced (generic and waterpipe-specific) WTP WLs and the associated factors among Egyptian waterpipe smokers and nonsmokers.

METHODS

A purposive quota sample of 2014 adults was surveyed in two rounds using face interviews. At each round, participants were randomly shown one of four existing WLs, then one of four novel WLs. Participants rated the perceived efficacy of existing and novel WLs regarding the salience, depth of processing, affective reactions, credibility, relevance, perceived harm and perceived behavioural control. Data were analysed using Generalized Estimating Equations.

RESULTS

Participants rated novel WTP WLs with higher mean perceived efficacy scores than existing WLs for all measures, although both sets collectively scored modestly (59.7; 95% CI: 58.9-60.5 vs 53.0; 95% CI: 52.1-54.0, respectively; p<0.001). Relative to the existing WTP WLs, novel WLs were particularly able to induce higher salience, affective reactions, and depth of processing. Relative to the generic novel WTP WLs, waterpipe-specific WLs induced higher relevance, perceived harm, and affective reactions. Nonsmokers scored higher than waterpipe tobacco smokers, specifically for perceived behavioral control (65.0±32.5 vs 43.6±19.8, respectively; p<0.001). WTP WLs featuring proximal risks, such as dental effects (β = 9.70; 95% CI: 7.00-12.40), fetal harm (β = 9.42; 95% CI: 6.75-12.10), or toxic contents (β = 9.14; 95% CI: 6.58-11.70) were strongly associated with participants' perceived efficacy scores. Among other independent factors, rural residence (β = 24.09; 95% CI: 22.21-25.97), being a nonsmoker (β = 10.51; 95% CI: 8.92-12.10), survey round 2 (β = 6.96, 95% CI: 5.73-8.19), the novel WTP WL set (β = 6.68; 95% CI: 6.19-7.17), and having higher education (β = 6.31; 95% CI: 4.34-8.27) were highly associated with participants' perceived efficacy scores.

CONCLUSIONS

Waterpipe-specific WLs on plain WTPs that feature proximal risks and address different population subgroups need to be developed in conjunction with awareness raising campaigns on WTS harms to reinforce the credibility of WTP WLs. Our findings suggest the proposed WTP WL enhancements by the Tobacco Control Unit may support a more effective WTP labelling policy within a comprehensive waterpipe-specific tobacco control framework.

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.

Impact of health warning labels communicating the risk of cancer on alcohol selection: an online experimental study

AIMS

Evidence from tobacco research suggests that health warning labels (HWLs) depicting the adverse consequences of consumption change smoking behaviours, with image-and-text (also known as 'pictorial' or 'graphic') HWLs most effective. There is an absence of evidence concerning the potential impact of HWLs placed on alcohol products on selection of those products. This study aimed to obtain a preliminary assessment of the possible impact of (i) image-and-text, (ii) text-only, and (iii) image-only HWLs on selection of alcoholic versus non-alcoholic drinks.

DESIGN

A between-subjects randomised experiment with a 2 (image: present versus absent) × 2 (text: present versus absent) factorial design.

SETTING

The study was conducted on the online survey platform Qualtrics.

PARTICIPANTS

Participants (n = 6024) were adults over the age of 18 who consumed beer or wine regularly (i.e. at least once a week), recruited through a market research agency.

INTERVENTIONS

Participants were randomised to one of four groups varying in the HWL displayed on the packaging of alcoholic drinks: (i) image-and-text HWL; (ii) text-only HWL; (iii) image-only HWL; and (iv) no HWL. HWLs depicted bowel cancer, breast cancer and liver cancer, which were each displayed twice across six alcoholic drinks. Each group viewed six alcoholic and six non-alcoholic drinks and selected one drink that they would like to consume.

MEASUREMENTS

The primary outcome was the proportion of participants selecting an alcoholic versus a non-alcoholic drink.

FINDINGS

Alcoholic drink selection was lower for all HWL types compared with no HWL (image-and-text: 56%; image-only: 49%; text-only: 61%; no HWL: 77%), with selection lowest for HWLs that included an image. Image-and-text HWLs reduced the odds of selecting an alcoholic drink compared with text-only HWLs (OR = 0.80, 95% CI = 0.69, 0.92), but increased the odds of selecting an alcoholic drink compared with image-only HWLs (OR = 1.34, 95% CI = 1.16, 1.55).

CONCLUSIONS

Health warning labels communicating the increased risk of cancers associated with alcohol consumption reduced selection of alcoholic versus non-alcoholic drinks in a hypothetical choice task in an online setting; labels displaying images had the largest effect. Their impact in laboratory and real-world field settings using physical products awaits investigation.

Effects of self-affirmation on responses toward graphic cigarette warning labels: testing the mediating role of perceived susceptibility and self-efficacy

Purpose

The purpose of this study is to examine the effects of self-affirmation on African American smokers' intentions to quit smoking sooner and desire to stop smoking altogether in response to viewing graphic cigarette warning labels. It also tested the mediating role of perceived susceptibility and self-efficacy in explaining the impact of self-affirmation.

Design/methodology/approach

African American smokers (N = 158) were recruited to participate in a controlled experiment. Participants first completed a short questionnaire about their demographic background and smoking-related attitudes and behavior. They were then randomly assigned to engage in either a self-affirmation task or a control task and viewed two graphic cigarette warning labels subsequently. Participants then responded to a questionnaire about their perceived susceptibility to smoking-related diseases, perceived self-efficacy to quit smoking, intentions to quit smoking and desire to stop smoking altogether.

Findings

Results showed that engaging in self-affirmation prior to exposure to graphic cigarette warning labels increased African American smokers' perceived susceptibility to smoking-related diseases, but decreased their perceived self-efficacy to quit smoking. Furthermore, self-affirmation indirectly enhanced smokers' intentions to quit smoking sooner and desire to stop smoking altogether through increased perceived susceptibility. It also had an unexpected negative indirect effect on intentions to quit smoking sooner through decreased self-efficacy.

Originality/value

This study is one of the few studies that investigates the effect of self-affirmation on African American smokers' responses toward graphic cigarette warning labels.

Impact of health warning labels on snack selection: An online experimental study

Excessive consumption of energy-dense food increases the risk of obesity, which in turn increases the risk of non-communicable diseases, including heart disease, type 2 diabetes and most non-smoking-related cancers. Health warning labels (HWLs) that communicate the adverse health consequences of excess energy consumption could reduce intake of energy-dense foods. The aim of the current study was to estimate the impact on selection of energy-dense snacks of (a) image-and-text HWLs (b) text-only HWLs and (c) calorie information. In a between-subjects, 3 (HWL: image-and-text, text-only, no label) x 2 (calorie information: present, absent), factorial experimental design, participants (N = 4134) were randomised to view a selection of energy-dense and non-energy-dense snacks with one of five label types or no label. The primary outcome was the proportion of participants selecting an energy-dense snack in a hypothetical vending machine task. The proportion of participants selecting an energy-dense snack was reduced in all label groups, relative to the no label group (no label: 59%; calories only: 54%; text-only HWL: 48%; text-only HWL with calories: 44%; image-and-text HWL: 37%; image-and-text HWL with calories: 38%). Compared to the no label group, participants were least likely to select an energy-dense snack in the image-and-text HWL group (OR = 0.46, 95%CI = 0.40, 0.54, p < 0.001). Health warning labels - particularly those including an image and text - have the potential to reduce selection of energy-dense snacks in an online setting. Their impact on selection and consumption in real-world settings awaits testing.

Image-and-text health warning labels on alcohol and food: potential effectiveness and acceptability

BACKGROUND

Health warning labels (HWLs) using images and text to depict the negative health consequences of tobacco consumption are effective and acceptable for changing smoking-related outcomes. There is currently limited evidence concerning their potential use for reducing consumption of alcoholic drinks and energy-dense foods. The aim of this research was to describe the potential effectiveness and acceptability of image-and-text (also known as pictorial or graphic) HWLs applied to: i. alcoholic drinks and ii. energy-dense snack foods.

METHODS

Two online studies were conducted using between-subjects designs with general population samples. Participants rated one of 21 image-and-text HWLs on alcoholic drinks (n = 5528), or one of 18 image-and-text HWLs on energy-dense snacks (n = 4618). HWLs comprised a graphic image with explanatory text, depicting, respectively, seven diseases linked to excess alcohol consumption, and six diseases linked to excess energy intake. Diseases included heart disease and various cancers. Outcomes were negative emotional arousal, desire to consume the labelled product, and acceptability of the label. Free-text comments relating to HWLs were content analysed.

RESULTS

For both alcoholic drinks and energy-dense snacks, HWLs depicting bowel cancer generated the highest levels of negative emotional arousal and lowest desire to consume the product, but were the least acceptable. Acceptability was generally low for HWLs applied to alcohol, with 3 of 21 rated as acceptable, and was generally high for snacks, with 13 of 18 rated as acceptable. The majority of free-text comments expressed negative reactions to HWLs on alcohol or energy-dense snacks.

CONCLUSIONS

Image-and-text health warning labels depicting bowel cancer showed greatest potential for reducing selection and consumption of alcoholic drinks and energy-dense snacks, although they were the least acceptable. Laboratory and field studies are needed to assess their impact on selection and consumption.

Designing Effective Testimonial Pictorial Warning Labels for Tobacco Products

Warning labels on tobacco products sometimes feature images and stories of real people whose health has been affected by smoking. We examined effects of some of the design elements that may contribute to the effectiveness of these testimonial pictorial warning labels (PWLs). Beginning with a testimonial PWL that contained an image of a person and a basic warning statement (e.g., "Smoking can kill you"), we examined the impact of adding: (a) text detailing the person's name, age and health status (identifiers); and (b) explanatory statements that elaborated on the basic warning using a testimonial or non-testimonial message. In an online experiment, 1255 adult smokers in the United States were randomly assigned to one of six experimental conditions (2 [identifier: none/identifier] × 3 [explanatory statement: none/non-testimonial/testimonial]), or a control condition (text only warning labels that currently appear on packs in the United States). In each condition, participants were exposed to multiple labels each focused on a different health effect. Effectiveness was assessed using emotional responses, engagement and behavioral intentions measured immediately post-exposure, and quit attempts measured at five-week follow up. Testimonial PWLs were more effective than the text only labels. However, there was little evidence that adding identifiers or the explanatory statements enhanced effectiveness; rather, there was some evidence that testimonial explanatory statements reduced effectiveness. These findings suggest that the most effective design for testimonial PWLs may be to combine a basic warning statement with an image of a real person, without any additional textual components.

Graphic Warning Labels Affect Hypothetical Cigarette Purchasing Behavior among Smokers Living with HIV

Cigarette pack graphic warning labels (GWLs) are associated with increased knowledge of tobacco-related harms; scant research has evaluated their effects on behavior among vulnerable populations. We used a behavioral economic approach to measure the effects of GWLs and price on hypothetical cigarette purchasing behavior among HIV-positive smokers. Participants (n = 222) completed a cigarette valuation task by making hypothetical choices between GWL cigarette packs at a fixed price ($7.00) and text-only warning label cigarette packs at increasing prices ($3.50 to $14.00; $0.25 increments). More than one-quarter (28.8%) of participants paid more to avoid GWLs. The remaining participants’ purchasing decisions appear to have been driven by price: 69.8% of participants chose the cheaper pack. Across all participants, overall monetary choice value observed for GWL cigarette packs (mean = $7.75) was greater than if choice was driven exclusively by price ($7.00). Most (87.4%) preferred the text-only warning label when GWL and text-only cigarette packs were equally priced. Correlation analysis indicated GWL pack preference was associated with agreement with statements that GWLs would stop individuals from having a cigarette or facilitate thoughts about quitting. These data suggest that GWLs may influence some HIV-positive smokers in such a way that they are willing to pay more to avoid seeing GWLs.

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

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.

Over-Time Impacts of Pictorial Health Warning Labels and their Differences across Smoker Subgroups: Results from Adult Smokers in Canada and Australia

Introduction

This study examines patterns of change in different smoker subgroups' responses to new pictorial health warning labels (HWLs) over the initial, two year post-implementation period in Canada, where HWLs include package inserts with cessation messages, and Australia, where "plain" packaging (i.e., prohibition of brand imagery) was also implemented.

Methods

Data were collected from online consumer panels in Canada (nsmokers = 3153; nobservations = 5826) and Australia (nsmokers = 2699; nobservations = 5818) from September 2012 to September 2014, with approximately 1000 adult smokers surveyed in each country every four months, using replenishment to maintain sample size. Data were analyzed using generalized estimating equation models where main effects and interactions among time, country, and socio-demographic factors on HWL responses (i.e., attention to HWLs; cognitive and behavioral responses to HWLs) were examined.

Results

Over time, attention to HWLs declined but cognitive and forgoing responses to HWLs increased, in both Canada and Australia. In both countries, compared to smokers with low income and/or education, smokers with high income and/or education showed an increase over time in attention and cognitive responses to HWLs (p < .05). In Australia only, compared to older smokers, younger smokers showed less decline over time in attention and greater increase in cognitive and forgoing responses to HWLs (p < .001).

Conclusions

Novel HWL policies in Canada and Australia appear effective in staving off "wear out" over the first 2 years after implementation, particularly amongst smokers who are from higher SES groups and, in Australia, who are younger.

Implications

Previous research shows that the effects of health warning label (HWL) on smokers decline over time, but no studies to date have evaluated whether trends differ across socio-demographic groups. This study suggests that innovative policy configurations that combine prominent pictorial HWLs with inserts (Canada) and with "plain" packaging (Australia) may delay wear out over the first 2 years after implementation. While this study found evidence for wear out in attention to HWLs, other HWL responses (cognitive responses, forgoing cigarettes) actually increased over time, with greater increases amongst smokers with higher income and/or education.

Testing the Effects of Certain versus Hypothetical Language in Health Risk Messages

This paper tests how the certainty or hypotheticality conveyed through language can be harnessed to enhance the effectiveness of targeted messaging about health risks. We conducted two experiments with adult smokers (n = 317) and middle school youth (n = 321) from low-income communities in the context of pictorial cigarette warning labels. We manipulated hypotheticality of risk through verb modality: 1. non-modal (present tense, e.g., smoking causes cancer), and modal/hypothetical (2. may, 3. can, and 4. will). For adult smokers, definitive (present tense) wording led to greater health risk beliefs, compared to hypothetical wording, among adult males but not females. For youth, contrary to what might seem intuitive, the more hypothetical may verb modality was more effective than the present tense language in promoting health risk beliefs. Among youth, greater health risk beliefs were also associated with reduced susceptibility to use cigarettes. No differences in negative affect by hypotheticality of language were found for either population. We discuss these findings in relation to the theoretical implications for the concept of hypotheticality and the application of construal level theory to strategic health communication.

The Influence of Health Numeracy and Health Warning Label Type on Smoking Myths and Quit-Related Reactions

INTRODUCTION

Health numeracy helps individuals understand risk information, but limited data exist concerning numeracy's role in reactions to varying types of health warning labels (HWLs) for cigarettes.

METHODS

A nationally representative online panel of adult current smokers received two exposures (1 week apart) to nine HWLs with either text-only or pictorial images with identical mandated text. Following the second exposure, participants (n = 594) rated their beliefs in smoking myths (eg, health-promoting behaviors can undo the risks of smoking) and how much the warnings made them want to quit smoking. Generalized estimating equation regression examined the relation of objective health numeracy and its interaction with HWL type to smoking-myth beliefs and quit-related reactions.

RESULTS

Health numeracy was not significantly associated with smoking-myth beliefs; the interaction with HWL type was also nonsignificant. Adult smokers with lower health numeracy had higher quit-related reactions than those with higher numeracy following exposure to HWLs. The type of HWL significantly modified numeracy's associations with quit-related reactions; no significant association existed between text-only HWLs and quit-related reactions, whereas among those who viewed the pictorial warnings, lower numeracy was associated with greater quit-related reactions (β = -.23; p < .001).

CONCLUSIONS

Lower as compared to higher health numeracy was significantly associated with higher quit-related reactions to HWLs and especially with pictorial HWLs. Health numeracy and HWL type were not associated with the endorsement of smoking myths. The role of health numeracy in effectively communicating risks to smokers warrants thoughtful consideration in the development of tobacco HWLs.

IMPLICATIONS

Health numeracy plays an important role in an individual's ability to understand and respond to health risks. Smokers with lower health numeracy had greater quit-related reactions to pictorial health warnings than those who viewed text-only warning labels. Development and testing of health warning labels should consider health numeracy to most effectively communicate risk to US smokers.

Temporal Effects of Message Congruency on Attention to and Recall of Pictorial Health Warning Labels on Cigarette Packages

OBJECTIVES

Recent research has shown that message congruency is beneficial to recall of pictorial health warning label (PWL) content after initial exposure. Despite less attention to the text warning, smokers exposed to congruent PWLs were more likely to recall the text and the message. This study aimed to replicate these findings and to examine whether congruency also affects recall after multiple exposures over time.

METHODS

A total of 320 daily smokers (39.7% female; cigarettes/day: M = 15.31, SD = 7.15) were randomized to one congruent or incongruent PWL and attended 4 laboratory sessions over 10 days. During each session, eye movements were recorded while viewing the PWL and open-ended recall of label content was assessed after exposure.

RESULTS

Smokers who were exposed to a congruent PWL were more likely to recall the text (p = .01) and the message (p = .02) and less likely to recall the image (p = .003) of the PWL after initial exposure. By day 4, incongruent PWLs were recalled equally well as congruent PWLs. Independent of condition, image recall was initially high and remained high whereas text and message recall was relatively low initially but increased over time. It was not until day 7 that about 80% of text and message recall was observed.

CONCLUSIONS

Even when exposed to the same PWL over time, smokers require multiple exposures to recall the text and the message of a PWL. More research on the effects of congruency in the natural environment, where smokers are exposed to multiple PWLs, is needed.

IMPLICATIONS

The findings of this study, and of previous work showing that message congruency in PWLs is beneficial to initial recall of PWL content, could potentially help to address legal challenges regarding the implementation of PWLs in the United States. Factually correct text warnings have been uncontested on US cigarettes packages since 1966. Congruent PWLs simply provide a means to visually support the same information as the existing text using a medium that better garners attention to the health information. Investigating and understanding longer-term effects of congruency are important and can empirically inform future warning label development, both in the United States via the Family Smoking Prevention and Tobacco Control Act, and via other governing bodies.

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.

Do graphic health warning labels on cigarette packages deter purchases at point-of-sale? An experiment with adult smokers

This experiment tested whether the presence of graphic health warning labels on cigarette packages deterred adult smokers from purchasing cigarettes at retail point-of-sale (POS), and whether individual difference variables moderated this relationship. The study was conducted in the RAND StoreLab (RSL), a life-sized replica of a convenience store that was developed to evaluate how changing POS tobacco advertising influences tobacco use outcomes during simulated shopping experiences. Adult smokers (n = 294; 65% female; 59% African-American; 35% White) were assigned randomly to shop in the RSL under one of two experimental conditions: graphic health warning labels present on cigarette packages versus absent on cigarette packages. Cigarette packages in both conditions were displayed on a tobacco power wall, which was located behind the RSL cashier counter. Results revealed that the presence of graphic health warning labels did not influence participants' purchase of cigarettes as a main effect. However, nicotine dependence acted as a significant moderator of experimental condition. Graphic health warning labels reduced the chances of cigarette purchases for smokers lower in nicotine dependence but had no effect on smokers higher in dependence.

Delphi study among international expert panel to develop waterpipe-specific health warning labels

BACKGROUND

Waterpipe (WP) smoking is increasing globally. The rise of WP has been fuelled by widespread misperception of reduced-harm compared to cigarettes. Health warning labels (HWLs) are one strategy to communicate smoking-related risks and address reduced-harm misperceptions. Therefore, the development of WP-specific HWLs represents a priority for WP control.

METHODS

A panel of experts in WP science developed 28 WP-specific HWLs corresponding to five themes (health risks, addiction, harm to others, WP-specific harm, WP harm compared to cigarettes). Subsequently, a three-round Delphi study was conducted among international expert panel to reach consensus on a set of the most effective HWLs for each theme. Levels of agreement between participants were assessed using interquartile deviations, and the rank between the tied HWLs was based on the median.

RESULTS

Starting with 28 candidate HWLs stratified according to five WP-related themes, our international expert panel reached consensus on the 13 most important WP-specific HWLs. Labels with the highest agreement were related to oral and heart disease, WP's harmful effects on newborn children and the amount of smoke inhaled from WP compared to cigarettes.

CONCLUSION

This study is the first to systematically develop and evaluate potential WP-specific HWLs based on the scientific evidence about WP's harmful effects, scientific understanding of HWL for cigarettes and the opinions of experts in WP science, tobacco control and health communication. The final selected HWLs can be adapted based on the context and policy landscape of the target country and can be further fine-tuned based on feedback from WP smokers and non-smokers.

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.

Effect of stimuli on sun protective habits: A randomized double-blind controlled study

BACKGROUND

Visual imagery has been shown to improve adherence to health messages but has scarcely been investigated in sun protection campaigns.

OBJECTIVE

To determine the effectiveness of pictorial- and textual-based sun protective messages in a largely Hispanic population.

METHODS

One hundred and forty-five participants received standard of care (SOC) as defined as sun protective counseling and were then randomized to receive either (a) images of sun damage, (b) a textual pamphlet about sun damage, or (c) no further messages. Analysis-of-variance tests for repeated measures were used to estimate the effects of the different stimuli on participants' knowledge and intention to sun protect.

RESULTS

All stimulus groups demonstrated an improvement in perceived effectiveness of sun protective habits (p < 0.05). However, pictorial and textual stimuli were both more effective than SOC in improving intentions to sun protect (p < 0.05), but there was no differential effect between the two.

CONCLUSIONS

Both pictorial and textual stimuli were more effective than SOC in improving intentions to sun protect, but there was no differential effect between the two.

Which type of tobacco product warning imagery is more effective and sustainable over time? A longitudinal assessment of smokers in Canada, Australia and Mexico

OBJECTIVE

This study examined smokers' responses to pictorial health warnings (PHWs) with different types of imagery under natural exposure conditions.

METHODS

Adult smokers from online panels in Canada (n=2357), Australia (n=1671) and Mexico (n=2537) were surveyed every 4 months from 2012 to 2013. Participants were shown PHWs on packs in their respective countries and asked about: (1) noticing PHWs; (2) negative affects towards PHWs; (3) believability of PHWs; (4) PHW-stimulated discussions; and (5) quit motivation due to PHWs. Country-specific generalised estimating equation models regressed these outcomes on time (ie, survey wave), PHW imagery type (ie, symbolic representations of risk, suffering from smoking and graphic depictions of bodily harm) and interactions between them.

RESULTS

In all countries, PHW responses did not significantly change over time, except for increased noticing PHWs in Canada and Mexico, increased negative affect in Australia and decreased negative affect in Mexico. For all outcomes, symbolic PHWs were rated lower than suffering and graphic PHWs in Canada (the only country with symbolic PHWs). Graphic PHWs were rated higher than suffering PHWs for negative affect (all countries), discussions (Canada) and quit motivation (Australia). Suffering PHWs were rated higher than graphic PHWs for noticing PHWs (Canada), believability (all countries), discussions (AustraliaandMexico) and quit motivation (Mexico). Changes in noticing, believability and discussions varied somewhat by imagery type across countries.

CONCLUSIONS

The different PHW imagery appears to have different pathways of influence on adult smokers. Reactions to specific PHWs are similar over 1-2 years, suggesting that wear-out of PHW effects is due to decreased attention rather than the diminishing effectiveness of content.

Evaluación emocional y actitudinal de advertencias sanitarias de tabaco en adultos y jóvenes de Argentina

 Objetivo. Evaluar el impacto emocional y las respuestas cognitivas y actitudinales de las advertencias sanitarias, para evitar el consumo del tabaco. Material y métodos. Se evaluaron 27 advertencias sanitarias de control del tabaco, procedentes de Argentina y de otros países, en 151 adoles­centes y 168 adultos. Se aplicó un instrumento estandarizado para medir valencia y activación emocional y un cuestionario estructurado para la medición cognitivo-actitudinal. Se analiza­ron las correlaciones según edad y sexo, nivel de instrucción, condición de fumador, etapa de cambio en fumadores y susceptibilidad en adolescentes no fumadores. Resultados. Se observó alta correlación entre las valoraciones cognitivo-actitudinales y las emocionales. Las advertencias basadas en imágenes cruentas y de sufrimiento generaron más respuestas actitudinales asociadas con el abandono y la prevención del consumo del tabaco. Conclusiones. Se recomienda el uso de advertencias con altos niveles de activación emocional tanto para adultos como para adolescentes.

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.

Trajectories of Responses to Pictorial Cigarette Pack Warnings

Background

Pictorial warnings on cigarette packs are a cost-effective policy-level intervention for smoking cessation; however, little research has examined changes in the impact of warnings over time, especially shortly following the first exposure to pictorial warnings. We sought to characterize the trajectories of responses to pictorial cigarette pack warnings soon after first exposure.

Methods

Participants were 2149 adult smokers in North Carolina and California, United States. In 2014-2015, we randomized smokers to have pictorial (intervention) or text-only (control) warnings on their cigarette packs for 4 weeks. Weekly surveys assessed psychosocial and behavioral outcomes.

Results

After 1 week, smokers in the intervention arm reported higher levels of most outcomes, compared with the control arm. Over subsequent weeks, smokers in both trial arms had decreases in thinking about the harms of smoking (β = -0.046), positive (β = -0.036), and negative (β = -0.042) smoking reinforcement attitudes, and increases in quit intentions (β = 0.070) and cigarette forgoing (β = 0.137) (all p < .05). Only negative affective reactions decreased more in the intervention versus control condition (pinteraction < .01).

Conclusions

The impact of pictorial cigarette pack warnings on emotions and cognitions may wane over time. In contrast, quit intentions and cigarette forgoing may continue to increase, at least during the initial period after introduction. Rotation of pictorial warnings may help prevent warning wear-out.

Implications

Cigarette smoking is the leading cause of preventable morbidity and mortality and warnings on cigarette packs are a cost-effective policy-level intervention. Prior studies reporting on cigarette pack warning "wear out" have been limited by being short-term single-session experimental studies. Ours are the first study to experimentally examine the trajectories of several outcomes after first exposure and report that the impact of pictorial cigarette pack warnings on emotions and cognitions may wane over time while quit intentions and cigarette forgoing may continue to increase.

Trials Registration

ClinicalTrials.gov identifier: NCT02247908; https://clinicaltrials.gov/ct2/show/NCT02247908.

Severity and susceptibility: measuring the perceived effectiveness and believability of tobacco health warnings

BACKGROUND

Pictorial tobacco health warning labels (HWLs) have been shown to be more effective than text-only HWLs in changing smoking attitudes and intentions. However, there is contradictory evidence regarding how the severity of the content of HWLs influences responses to them.

METHODS

We examined the perceived believability and effectiveness of HWLs in an online study using a convenience sample of non-smokers (N = 437) and smokers (N = 436). HWLs were in one of three presentation formats: (text-only, a moderately severe image or highly severe image) and focussed on three disease outcomes (lung cancer, blindness or tooth and gum disease). Participants rated the effectiveness and believability of each HWL and also rated their perceived susceptibility to each disease.

RESULTS

A 2 (smoking status) × 3 (presentation format) × 3 (disease outcome) ANOVA was run for both believability and effectiveness ratings. The most severe pictorial HWLs received the highest believability and effectiveness ratings and as expected, the text-only HWLs received the lowest. Lung cancer HWLs were rated most believable and effective, with the blindness HWLs receiving the lowest scores. A 2 (smoking status) × 3 (disease outcome) ANOVA was conducted on the ratings of perceived susceptibility to the three diseases. Smokers considered themselves to be more susceptible to all three diseases, and among smokers, perceived susceptibility to the diseases was positively correlated with effectiveness and believability ratings of the HWLs.

CONCLUSION

Our findings support previous evidence that pictorial HWLs are rated as more effective and believable than text-only warnings, and provide some support for the use of severe or 'grotesque' HWLs on tobacco products. Our data also suggest that HWLs should aim to increase perceived susceptibility to disease, as this was positively related to perceived message effectiveness and believability.

Assessing Smoking Cessation Messages with a Discrete Choice Experiment

Objectives

Our aim was to identify message characteristics for cigarette pack inserts that aim to help smokers quit.

Methods

US adult smokers from an online consumer panel (N = 665) participated in a discrete choice experiment with a 2x2x2x2x4 within-subjects balanced incomplete block design, manipulating: image (vs no image), text type (testimonial vs informational), cessation resource information (vs none), call to action (vs none), and message topic (well-being, financial benefit, cravings, social support). Participants evaluated 9 choice sets, each with 4 inserts, selecting: (1) the most and least helpful for quitting; and (2) the most and least motivating to quit. Linear models regressed choices on insert characteristics, controlling for sociodemographics and smoking-related variables. We assessed interactions between insert characteristics and smoker attributes (ie, education, quit intention, self-efficacy).

Results

Inserts were most helpful and motivating when they included an image, provided cessation resource information, or referenced well-being and financial benefits. Significant interactions indicated that inserts with cessation resource information were relatively more helpful and motivating among smokers with low self-efficacy, an intention to quit, or lower education.

Conclusion

Cigarette pack inserts with imagery and cessation resource information may be particularly effective in promoting smoking cessation.

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.

Potential Effectiveness of Pictorial Warning Labels That Feature the Images and Personal Details of Real People

Introduction

Pictorial warning labels (PWL) that use photographs and the personal details of real people whose health has been affected by smoking (testimonial PWL) provide factual information about the consequences of tobacco use.

Methods

Nine hundred and twenty-four adult current smokers participated in an online experiment that tested responses to four types of warning labels: (1) non-testimonial text warning labels (currently on packs in the United States); (2) non-testimonial PWL (previously proposed by the United States Food and Drug Administration); (3) image only testimonial PWL (created for study); (4) image + personal details testimonial PWL (created for study). Participants were randomly assigned to condition and then exposed to up to five warning labels addressing different health effects. Differences between conditions were assessed using emotional responses and a set of intention measures immediately following exposure, and self-reported behavior change at 5-week follow-up.

Results

Compared to the non-testimonial text warning labels, all PWL elicited stronger emotional responses and intentions to forgo cigarettes and avoid the warning labels. Non-testimonial PWL and image + personal details testimonial PWL elicited stronger intentions to quit, whereas image only testimonial PWL generated a greater amount of quitting activity in the weeks following exposure. There were no significant differences in responses when comparing the non-testimonial PWL with both types of testimonial PWL.

Conclusions

PWL that use images of real people convey factual information about the health effects of tobacco use. These testimonial PWL may be a promising alternative to the images previously proposed for use on PWL in the United States.

Implications

In the United States, the PWL developed by the Food and Drug Administration (FDA) in 2011 were found by the courts to be unconstitutional, in part because they were deemed to present an opinion rather than fact. Findings from this experimental study indicate that PWL that use the images and personal details of real people to convey factual information about the health effects of tobacco use may satisfy the FDA's requirement for a set of PWL that (1) have the potential to positively impact the determinants of smoking cessation behavior, (2) meet legislative requirements under the Family Smoking Prevention and Tobacco Control Act and (3) may be more acceptable to the courts than the previously proposed and now dismissed PWL that carried non-factual images.

Public health benefits from pictorial health warnings on US cigarette packs: a SimSmoke simulation

INTRODUCTION

While many countries have adopted prominent pictorial warning labels (PWLs) for cigarette packs, the USA still requires only small, text-only labels located on one side of the cigarette pack that have little effect on smoking-related outcomes. Tobacco industry litigation blocked implementation of a 2011 Food and Drug Administration's (FDA) rule requiring large PWLs. To inform FDA action on PWLs, this study provides research-based estimates of their public health impacts.

METHODS

Literature was reviewed to identify the impact of cigarette PWLs on smoking prevalence, cessation and initiation. Based on this analysis, the SimSmoke model was used to estimate the effect of requiring PWLs in the USA on smoking prevalence and, using standard attribution methods, on smoking-attributable deaths (SADs) and key maternal and child health outcomes.

RESULTS

Available research consistently shows a direct association between PWLs and increased cessation and reduced smoking initiation and prevalence. The SimSmoke model projects that PWLs would reduce smoking prevalence by 5% (2.5%-9%) relative to the status quo over the short term and by 10% (4%-19%) over the long term. Over the next 50 years, PWLs are projected to avert 652 800 (327 000-1 190 500) SADs, 46 600 (17 500-92 300) low-birth-weight cases, 73 600 (27 800-145 100) preterm births and 1000 (400-2000) cases of sudden infant death syndrome.

CONCLUSIONS

Requiring PWLs on all US cigarette packs would be appropriate for the protection of the public health, because it would substantially reduce smoking prevalence and thereby reduce SADs and the morbidity and medical costs associated with adverse smoking-attributable birth outcomes.

Systematic Review of Measures Used in Pictorial Cigarette Pack Warning Experiments

BACKGROUND

We sought to describe characteristics and psychometric properties of measures used in pictorial cigarette pack warning experiments and provide recommendations for future studies.

METHODS

Our systematic review identified 68 pictorial cigarette pack warning experiments conducted between 2000 and 2016 in 22 countries. Two independent coders coded all studies on study features, including sample characteristics, theoretical framework, and constructs assessed. We also coded measurement characteristics, including construct, number of items, source, reliability, and validity.

RESULTS

We identified 278 measures representing 61 constructs. The most commonly assessed construct categories were warning reactions (62% of studies) and perceived effectiveness (60%). The most commonly used outcomes were affective reactions (35%), perceived likelihood of harm (22%), intention to quit smoking (22%), perceptions that warnings motivate people to quit smoking (18%), and credibility (16%). Only 4 studies assessed smoking behavior. More than half (54%) of all measures were single items. For multi-item measures, studies reported reliability data 68% of the time (mean α = 0.88, range α = 0.68-0.98). Studies reported sources of measures only 33% of the time and rarely reported validity data. Of 68 studies, 37 (54%) mentioned a theory as informing the study.

CONCLUSIONS

Our review found great variability in constructs and measures used to evaluate the impact of cigarette pack pictorial warnings. Many measures were single items with unknown psychometric properties. Recommendations for future studies include a greater emphasis on theoretical models that inform measurement, use of reliable and validated (preferably multi-item) measures, and better reporting of measure sources.

IMPLICATIONS

Robust and consistent measurement is important for building a strong, cumulative evidence base to support pictorial cigarette pack warning policies. This systematic review of experimental studies of pictorial cigarette warnings demonstrates the need for standardized, theory-based measures.

Estimating the effects of novel on-pack warnings on young adult smokers and susceptible non-smokers

Background

On-pack tobacco warnings can deter smoking initiation and provide powerful cessation cues. However, these warnings typically feature graphic health images, which many young adults dismiss as irrelevant. We estimated responses to more diverse warnings and examined how these performed relative to each other.

Methods

We conducted a behavioural likelihood experiment and a choice modelling experiment in which 474 smokers and 476 susceptible non-smokers aged between 16 and 30 years evaluated 12 warnings featuring health, social, financial and cosmetic themes. The choice data were analysed by estimating Sequential-Best-Worst Choice and Scale-Adjusted Latent Class Models.

Results

Smokers found all test warnings aversive, particularly warnings featuring the effect of smoking on vulnerable third parties, including babies and animals, and showing a dying smoker. Susceptible non-smokers found graphic health warnings and a warning that combined graphic health with loss of physical attractiveness, significantly more aversive than other images tested.

Conclusions

Illustrating the harms smoking causes to vulnerable groups may reduce the temporal distance and perceived control over smoking that young adults use to rationalise health warnings. Introducing more diverse warnings could recognise heterogeneity within smoker and susceptible non-smoker populations, and complement warnings featuring long-term health harms.

Does Adding Information on Toxic Constituents to Cigarette Pack Warnings Increase Smokers' Perceptions About the Health Risks of Smoking? A Longitudinal Study in Australia, Canada, Mexico, and the United States

BACKGROUND

Health warning labels (HWLs) on cigarette packs in Australia, Canada, Mexico, and the United States include varying information about toxic cigarette smoke constituents and smoking-related health risks. HWL information changed more recently in Australia, Canada, and Mexico than in the United States.

AIMS

To investigate whether smokers' knowledge of toxic constituents and perceived smoking-related risks increased after adding this information to HWLs and how knowledge of toxic constituents is associated with perceptions of smoking-related risks.

METHODS

Data come from a longitudinal, online cohort of 4,621 adult smokers surveyed every 4 months from September 2012 (Wave 1) to January 2014 (Wave 5) in Australia, Canada, and Mexico, with the United States being surveyed from Waves 2 to 5. Generalized estimating equation models estimated the association between perceived smoking-related risk at follow-up and prior wave knowledge of toxic constituents, adjusting for attention to HWLs, sociodemographics, and smoking-related characteristics.

RESULTS

Between 2012 and 2014, knowledge of toxic constituents increased in Australia, Canada, and Mexico ( p < .001), but not in the United States. Higher levels of both attention to HWLs and knowledge of toxic constituents were associated with a higher perceived risk of smoking-related conditions at follow-up across all countries except for the United States.

CONCLUSIONS

Our results suggest that information about toxic constituents on prominent HWLs not only increases smoker's knowledge of toxic constituents, but that it may also reinforce the effects of HWL messages about specific, smoking-related health outcomes.

Effect of message congruency on attention and recall in pictorial health warning labels

OBJECTIVE

The nine pictorial health warning labels (PWLs) proposed by the US Food and Drug Administration vary in format and feature of visual and textual information. Congruency is the degree to which visual and textual features reflect a common theme. This characteristic can affect attention and recall of label content. This study investigates the effect of congruency in PWLs on smoker's attention and recall of label content.

METHODS

120 daily smokers were randomly assigned to view either congruent or incongruent PWLs, while having their eye movements recorded. Participants were asked to recall label content immediately after exposure and 5 days later.

RESULTS

Overall, the image was viewed more and recalled better than the text. Smokers in the incongruent condition spent more time focusing on the text than smokers in the congruent condition (p=0.03), but dwell time of the image did not differ. Despite lower dwell time on the text, smokers in the congruent condition were more likely to correctly recall it on day 1 (p=0.02) and the risk message of the PWLs on both day 1 (p=0.01) and day 5 (p=0.006) than smokers in the incongruent condition.

CONCLUSIONS

This study identifies an important design feature of PWLs and demonstrates objective differences in how smokers process PWLs. Our results suggest that message congruency between visual and textual information is beneficial to recall of label content. Moreover, images captured and held smokers' attention better than the text.

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

INTRODUCTION

The impact of pregnancy-related health warning labels (HWLs) appearing on cigarette packages on women of reproductive age and other socio-demographic groups is not well understood. The current study analyzes how different age/gender groups respond to pregnancy-related HWLs as compared to non-pregnancy HWLs.

METHODS

Data were analyzed from four waves of an online longitudinal study with adult smokers aged 18-64 in Australia, Canada, Mexico, and the US. Participants were classified into four age\gender groups: women 40 and under; men 40 and under; women over 40; men over 40. Participants rated one pregnancy-related and several non-pregnancy related labels on worry, believability, and motivation to quit. Country-specific adjusted linear GEE were estimated regressing ratings for each of the three key outcomes for 1) pregnancy-related HWLs and 2) a rating difference score that subtracted the average ratings of the non-pregnancy warning from the rating of the pregnancy warning. All models adjusted for socio-demographics and smoking related variables.

RESULTS

In Mexico and Australia, where graphic pregnancy-related HWL imagery is used (i.e., premature infant), women of reproductive age reported stronger believability, worry, and quit motivation than all other groups. Results were similar in the US, where text only HWLs are used. In contrast in Canada, where the pregnancy-related HWL imagery features a pregnant woman, ratings were unassociated with gender/age groups. Stronger effects among women of reproductive age were limited to pregnancy HWLs in each country, except Canada.

CONCLUSIONS

HWLs that depict graphic effects to illustrate smoking-related pregnancy risks appear to be perceived as particularly effective among women of reproductive age.

Motivation to quit smoking and acceptability of shocking warnings on cigarette packages in Lebanon

INTRODUCTION

Health warnings on tobacco packages have been considered an essential pillar in filling the gap of knowledge and communicating the health risks of tobacco use to consumers. Our primary objective was to report the perception of smokers on the textual health warnings already appearing on tobacco packages in Lebanon versus shocking pictures about the health-related smoking consequences and to evaluate their impact on smoking behaviors and motivation.

METHODS

A pilot cross-sectional study was undertaken between 2013 and 2015 in five hospitals in Lebanon. Participants answered a questionnaire inquiring about sociodemographic characteristics, chronic respiratory symptoms, smoking behavior and motivation to quit smoking. Only-text warning versus shocking pictures was shown to the smokers during the interview.

RESULTS

Exactly 66% of the participants reported that they thought shocking pictorial warnings would hypothetically be more effective tools to reduce/quit tobacco consumption compared to only textual warnings. Also, 31.9% of the smokers who were motivated to stop smoking reported that they actually had stopped smoking for at least 1 month secondary to the textual warnings effects. A higher motivation to quit cigarette smoking was seen among the following groups of smokers: males (odds ratio [OR] =1.8, P=0.02), who had stopped smoking for at least 1 month during the last year due to textual warning (OR =2.79, P<0.001), who considered it very important to report health warning on cigarette packs (OR =1.92, P=0.01), who had chronic expectoration (OR =1.81, P=0.06) and who would change their favorite cigarette pack if they found shocking images on the pack (OR =1.95, P=0.004).

CONCLUSION

Low-dependent smokers and highly motivated to quit smokers appeared to be more hypothetically susceptible to shocking pictorial warnings. Motivation to quit was associated with sensitivity to warnings, but not with the presence of all chronic respiratory symptoms.