Conversations about pictorial cigarette pack warnings: Theoretical mechanisms of influence

Designing and testing social media campaign messages to promote COVID-19 vaccine confidence among rural adults: A community-engaged approach featuring rural community leader and clinician testimonials

Despite the growing availability of effective COVID-19 vaccines in rural communities in the United States, widespread vaccine hesitancy delays COVID-19 vaccine coverage in rural communities and threatens to worsen pre-pandemic rural-urban disparities in other vaccination rates, including influenza and routine pediatric immunizations. Therefore, there is an urgent need to develop communication-based interventions to improve vaccine confidence in rural America. This study demonstrates the efficacy of a community-engaged approach to developing social media campaign messages in promoting COVID-19 vaccine uptake and pro-vaccine social diffusion among rural adults. Using a community-engaged approach, we developed social media campaign videos varying in (a) featured messengers (clinicians versus community leaders) and (b) the presence of personal testimonials. We conducted a national online experiment (N = 1,364 rural adults) in spring 2022. We found that videos featuring clinicians serving rural communities and their testimonials increased (a) vaccination intentions in the unvaccinated group (4-point scale, b = 0.23, p =.015) and (b) intention to discuss the messages with others (4-point scale, b = 0.14, p =.037), share the message (4-point scale, b = 0.15, p =.026), and promote the vaccines to others (9-point scale, b = 0.48, p =.013). Results suggest that vaccine promotional social media campaigns targeting rural populations can benefit from including clinician testimonials.

Do Vaping Prevention Messages Impact Adolescents and Young Adults? A Meta-Analysis of Experimental Studies

Vaping prevention messages are widely used to communicate the health harms and addiction risks of vaping and discourage vaping among adolescents and young adults. We conducted a meta-analysis of experimental studies to examine the effects of these messages and to understand their theoretical mechanisms. Systematic, comprehensive searches generated 4,451 references, among which 12 studies (cumulative N = 6,622) met inclusion criteria for the meta-analysis. Across these studies, a total of 35 different vaping-related outcomes were measured, and 14 outcomes assessed in two or more independent samples were meta-analyzed. Results showed that compared to control, exposure to vaping prevention messages led to higher vaping risk perceptions, including harm perceptions (d = 0.30, p < .001), perceived likelihood of harm (d = 0.23, p < .001), perceived relative harm (d = 0.14, p = .036), addiction perceptions (d = 0.39, p < .001), perceived likelihood of addiction (d = 0.22, p < .001), and perceived relative addiction (d = 0.33, p = .015). Also, compared to control, exposure to vaping prevention messages led to more vaping knowledge (d = 0.37, p < .001), lower intentions to vape (d = -0.09, p = .022), and higher perceived message effectiveness (message perceptions; d = 0.57, p < .001; effects perceptions; d = 0.55, p < .001). Findings suggest vaping prevention messages have an impact, yet may operate through different theoretical mechanisms than cigarette pack warnings.

Yet Again Conversations Matter: The Importance of Interpersonal Discussions, Educational Campaigns, and Advertising on Cannabis-Related Risk Perceptions, Attitudes, and Intentions in At-Risk Young Adults

The present study seeks to evaluate the relationships between cannabis-related communication and outcomes of interest such as cannabis-related risk perceptions, attitudes, and behaviors among young adults. Young adults who were at risk for cannabis use were surveyed online in 2020. Results showed that exposure to online educational messages was associated with higher intentions of engaging in peer intervention, while exposure to online advertising was related to higher intention to use cannabis. Anti-cannabis interpersonal discussion was associated with increased risk perceptions, less favorable cannabis attitudes, and a higher likelihood of peer intervention. More pro-cannabis interpersonal discussion was associated with decreased risk perceptions, more favorable cannabis attitudes, higher use intention, and decreased likelihood of peer intervention. In addition, pro-cannabis interpersonal discussion mediated the relationship between exposure to advertising and cannabis risk perceptions, intentions to use cannabis, attitudes about cannabis, and the likelihood of peer intervention. In contrast, anti-cannabis interpersonal discussion mediated the relationship between exposure to educational messages online and cannabis risk perceptions and the likelihood of peer intervention. These findings underscore the need to regulate online cannabis marketing and the importance of investing in online education campaigns to increase public understanding of the risks associated with cannabis consumption in young adulthood.

The Effect of Graphic Health Warning Labels Placed on the ENDS Device on Young Adult Users' Experience, Exposure and Intention to Use: A Pilot Study

This proof-of-concept study aims to evaluate the effect of placing graphic health warning labels (GHWLs) on the ENDS device on users' experience, puffing patterns, harm perception, nicotine exposure, and intention to quit or use in the future. JUUL users (n = 26, age 18-24 years; 69% male; 85% Hispanic) were recruited to complete two 60 minutes ad libitum sessions that differed by GHWL on the device (GHWL vs. no-GHWL control) in an experimental clinical lab study. Compared to the control session, using JUUL with GHWL on the device was significantly associated with reduced positive experiences such as pleasure, product liking, and user satisfaction (p-value < 0.05 for all). Also, after exposure to GHWL, participants were less interested in using the same product again (p-value = 0.007), even if it was the only product available on the market compared to control (p-value = 0.03). Trends toward reduced puffing behavior and nicotine boost were also noted during the GHWL, compared to control sessions. This pilot study shows that placing GHWL on the ENDS device may be an effective and promising strategy to reduce ENDS use among young people.

The impact of cigarette pack anti-littering messages

OBJECTIVE

Tobacco butts are the most littered item worldwide and pose a critical environmental and public health hazard. Given the positive impact of required graphic warnings on smoking, we sought to assess the impact of a policy requiring cigarette pack anti-littering messages on smokers' littering intentions.

METHODS

We randomly assigned US adult smokers (n = 719) to receive labels on the side of their cigarette packs for three weeks: anti-littering messages or messages about chemicals in cigarette smoke.

RESULTS

Anti-littering messages elicited higher intentions to refrain from littering in the next month compared to chemical messages (p < .05). Anti-littering messages also led to increased knowledge about cigarette butts being the most common form of litter, the number of conversations about littering, and thinking about the proper disposal of cigarettes (all p < .05). Finally, smoking from packs labeled with anti-littering messages led to fewer weeks littering from car windows compared to packs labeled with chemical messages (p < .05), but did not affect completely refraining from littering cigarette butts. Mediators of the messages' impact on littering intentions were thinking about proper cigarette butt disposal and perceived message effectiveness (both p < .05).

CONCLUSIONS

Policies requiring anti-littering messages on cigarette packs would raise awareness about the problem of cigarette butt litter and bolster intentions to not litter.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Does warning language impact perceptions? Results from an exploratory experiment comparing English, Spanish, and Dual language E-Cigarette warnings among Spanish speakers in the US

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We explored the impact of English only, Spanish only, or dual language warnings.

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Dual language exposure increased affect, reactance, and message effectiveness.

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Warning language may impact warning effectiveness among Spanish speakers.

Tobacco warnings written in English may not be as effective among Spanish speakers. We explored whether warning perceptions differ based on exposure to English, Spanish, or dual language warnings. From November 2, 2020 – December 29, 2020, we conducted an online experiment with a convenience sample of 776 Spanish-speaking adults in the US, randomizing each to one of three warning conditions: English only, Spanish only, or dual (both English and Spanish). Multivariable linear and logistic regressions examined associations between warning exposure and perceptions. Of 776 participants, 291 preferred to read in Spanish, 55.5% were male, 62.5% were Hispanic, and 48.1% reported past 30-day e-cigarette use. Negative affect (β = 1.79, p = 0.007), perceived message effectiveness (β = 0.84, p = 0.007), and psychological reactance (β = 1.55, p < 0.001) were greater among participants exposed to the dual language warnings compared to those exposed to the English warnings. Results of this exploratory study suggest that e-cigarette warning statements presented in both English and Spanish may result in stronger reactions among Spanish speakers. With increasing prevalence of Spanish speakers in the US, future work should continue to examine this topic.

Mediational Effects on Motivation to Quit Smoking After Exposure to a Cigarette Pictorial Warning Label Among Young Adults

BACKGROUND

Young adults are vulnerable to cigarette package marketing. Pictorial warning labels are recommended for tobacco control. Research should address questions raised in legal challenges including causal mechanisms. Evidence is mixed and understudied among young adults (e.g., discrete emotions and risk perceptions).

PURPOSE

This study investigated mediators of pictorial warning label effects on motivation to quit smoking among young adult smokers.

METHODS

This study analyzed data from a randomized trial with a 4 week exposure to a cigarette pictorial warning among young adult smokers (N = 229) aged 18-30 with assessments at baseline, immediately post-intervention, and 3 months. Mediation analyses used latent change scores to test the effects post-intervention on fear, anger, and risk perceptions. We also examined whether post-intervention measures predicted change in motivation to quit smoking at 3 months. The first model assessed aggregate risk perceptions and the second model assessed discrete risk perceptions (deliberative, affective).

RESULTS

Pictorial warning label exposure led to increases in fear which led to increased motivation to quit smoking for the first (B = 0.12, 95% CI = 0.04, 0.26) and second (B = 0.12, 95% CI = 0.03, 0.25) model. Exposure modestly increased motivation to quit by way of fear and affective risk perceptions (B = 0.01, 95% CI = 0.00, 0.04). Exposure had a direct relationship on increased motivation to quit as well.

CONCLUSIONS

Findings demonstrate factors contributing to change in motivation to quit smoking among young adult smokers after pictorial warning label exposure. Affective processes are mediators of pictorial warning label effects.

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

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

Reactions to messages about smoking, vaping and COVID-19: two national experiments

Introduction

The pace and scale of the COVID-19 pandemic, coupled with ongoing efforts by health agencies to communicate harms, have created a pressing need for data to inform messaging about smoking, vaping, and COVID-19. We examined reactions to COVID-19 and traditional health harms messages discouraging smoking and vaping.

Methods

Participants were a national convenience sample of 810 US adults recruited online in May 2020. All participated in a smoking message experiment and a vaping message experiment, presented in a random order. In each experiment, participants viewed one message formatted as a Twitter post. The experiments adopted a 3 (traditional health harms of smoking or vaping: three harms, one harm, absent) × 2 (COVID-19 harms: one harm, absent) between-subjects design. Outcomes included perceived message effectiveness (primary) and constructs from the Tobacco Warnings Model (secondary: attention, negative affect, cognitive elaboration, social interactions).

Results

Smoking messages with traditional or COVID-19 harms elicited higher perceived effectiveness for discouraging smoking than control messages without these harms (all p <0.001). However, including both traditional and COVID-19 harms in smoking messages had no benefit beyond including either alone. Smoking messages affected Tobacco Warnings Model constructs and did not elicit more reactance than control messages. Smoking messages also elicited higher perceived effectiveness for discouraging vaping. Including traditional harms in messages about vaping elicited higher perceived effectiveness for discouraging vaping (p <0.05), but including COVID-19 harms did not.

Conclusions

Messages linking smoking with COVID-19 may hold promise for discouraging smoking and may have the added benefit of also discouraging vaping.

Cessation Conversations and Quit Attempts: Differences by Ethnicity and Language Preference

Objectives: Conversations about pictorial cigarette health warning labels (HWLs) encourage quit attempts, and prior research suggests prevalence of these conversations varies by ethnicity. We assessed the frequency of conversations about text-only HWLs among Latino and non-Latino white smokers and the relationship between conversations and subsequent quit attempts. Methods: Latino and non-Latino white adult smokers in the United States (N = 4403) were surveyed every 4 months over 2 years. Surveys queried smoking behaviors, recent quit attempts, HWL responses, including HWL conversations, and socio-demographic variables. Negative binomial generalized estimating equation (GEE) models regressed the frequency of HWL conversations on study variables. Logistic GEE models regressed quit attempts at follow-up surveys on responses from the prior wave, including frequency of HWL conversations and their interaction with ethnicity. Results: Spanish preference Latinos reported the most HWL conversations (85%), followed by English preference Latinos (59%), and non-Latino Whites (35%). More frequent HWL conversations predicted subsequent quit attempts (AOR = 1.74, 95% CI = 1.32, 2.30), but ethnicity did not moderate this effect. Conclusions: Latinos appear to talk more frequently about HWLs than non-Latino Whites but are no more likely to quit as a result. Cessation campaigns should use messages that encourage conversations about quitting.

Tool to assess appeal-aversion response to graphic warning labels on cigarette packs among US smokers

INTRODUCTION

Graphic warning labels on cigarette packaging are mandated in 118 countries and are under consideration in the USA. We propose an appeal-aversion assessment tool to help regulators choose among graphic packaging options.

METHODS

After familiarisation with different cigarette packaging, adult daily smokers (n=338) from San Diego, California, USA completed a discrete choice appeal-aversion purchasing task and provided information on nicotine dependence and sociodemographics (2017-2019). The conjoint analysis estimated the importance and price utility for product attributes (ie, packaging, price, tobacco origin and quitline number). The price premiums that smokers would be willing to pay to avoid purchasing graphic packaging were calculated.

RESULTS

Among purchase determinants, the price was the most important attribute (65.5%), followed by packaging design (27.1%). Compared with blank packaging without marketing, branded industry packs had appeal valuations (US$0.54; 95% CI: US$0.44 to US$0.65), whereas graphic warning packs had aversion valuations that varied with the salience of the image (blindness=-US$2.53, 95% CI: -US$2.76 to -US$2.31; teeth damage=-US$2.90, 95% CI: -US$3.17 to -US$2.63; and gangrenous foot=-US$3.70, 95% CI: -US$4.01 to -US$3.39). The aversion was such that 46.2% of participants were willing to pay a 50+% premium over their current cigarette price to have their branded packs rather than a graphic pack. These appeal-aversion valuations were moderated by sex, income and nicotine dependence (p<0.05).

CONCLUSIONS

Smokers indicated a willingness to pay substantial premiums to avoid purchasing graphic packaging. Results suggest that mandating graphic warnings on US cigarette packs would induce price aversion and may deter cigarette purchasing. Price valuations from this appeal-aversion tool could be useful for regulators to differentiate between graphic warning labels.

Experimental Studies of Front-of-Package Nutrient Warning Labels on Sugar-Sweetened Beverages and Ultra-Processed Foods: A Scoping Review

Policies that require front-of-package (FoP) nutrient warnings are becoming increasingly common across the globe as a strategy to discourage excess consumption of sugary drinks and ultra-processed food. However, a better understanding of the pathway through which FoP nutrient warnings work, as well as a review of how outcomes being measured in recent studies map onto this pathway, are needed in order to inform policy on the most effective FoP label design for reducing purchases of ultra-processed foods. This scoping review describes a conceptual model for how FoP nutrient warnings affect consumer behavior, examines which of these outcomes are currently being measured, and summarizes evidence from randomized controlled experiments. Twenty-two studies which experimentally tested nutrient warnings against a control label or other labeling systems were included for full-text review. Our conceptual model includes attention; comprehension, cognitive elaboration, and message acceptance; negative affect and risk perception; behavioral intentions, and behavioral response, along with other elements such as external factors and interpersonal communications. We found that many studies focused on outcomes such as attention, comprehension, and behavioral intentions, but considerable gaps in the evidence remain, particularly for intermediary steps on the pathway to behavioral change, such as negative affect and social interactions. FoP nutrient warnings were visually attended to by consumers, easy to understand, helped consumers identify products high in nutrients of concern, and discouraged them from purchasing these products, although other labeling systems were perceived as containing more information and performed better at helping consumers rank the healthfulness of products. More research is needed to understand whether and how nutrient warnings work in the real world to discourage consumer purchases of sugary drinks and ultra-processed food.

Information Diffusion and Social Norms Are Associated with Infant and Young Child Feeding Practices in Bangladesh

BACKGROUND

Interaction within mothers' social networks can theoretically diffuse messages from interventions and campaigns into norms and practices for infant and young child feeding (IYCF).

OBJECTIVES

We hypothesized that mothers' social networks, diffusion of information, and social norms differed in intensive [intensive interpersonal counseling (IPC), community mobilization (CM), and mass media (MM)] compared with nonintensive (standard IPC and less-intensive CM and MM) intervention areas, were associated with IYCF practices, and partly explained practice improvement.

METHODS

We conducted household surveys at endline in 2014 and follow-up in 2016 (n = ∼2000 each round). We used multiple regression to test differences and changes in networks, diffusion, and norms within intervention areas. We analyzed paths from intervention exposure to IYCF practices through networks, diffusion, and norms.

RESULTS

Mothers' networks were larger in intensive than in nonintensive areas in 2014 and increased in both areas over time [25-38 percentage points (pp)]. The prevalence of receipt of IYCF information was high, with no changes over time in intensive areas but an increase in nonintensive areas (8-16 pp). In both areas, more family members and health workers provided IYCF information over time. Sharing of information increased 17-23 pp in intensive and 11-41 pp in nonintensive areas over time. Perceived descriptive norms improved 8-16 pp in intensive and 17-28 pp in nonintensive areas. Perceived injunctive norms were high in both areas. Breastfeeding practices were associated with networks, diffusion, and norms (OR: 1.6-4.4 times larger comparing highest with lowest quartile). Minimum dietary diversity was associated with larger networks and diffusion (OR: 1.5-2.2) but not with social norms. Indirect paths from intervention exposure to practices explained 34-78% of total effects.

CONCLUSIONS

Diffusion of IYCF information through social networks, reinforced by positive social norms for messages promoted over time, will contribute to positive changes in IYCF practices that may be achieved and sustained through large-scale social and behavior change interventions. This trial was registered at clinicaltrials.gov as NCT0274084.

Impact of tobacco-pack pictorial warnings on youth and young adults: A systematic review of experimental studies

INTRODUCTION

We conducted a systematic review of the experimental literature on the impact of tobacco-pack pictorial warning labels (PWLs) on youth and young adults.

METHODS

We systematically searched computerized databases and the reference lists of relevant articles. We included studies that used an experimental protocol to assess PWLs. Studies had to report findings for youth or young adult samples (aged <30 years). Thirty-one studies met the inclusion criteria, with a total sample size of 27506. Two coders independently coded all study characteristics and outcomes.

RESULTS

Twenty-eight studies experimentally evaluated PWLs for cigarette packs while three studies evaluated PWLs for smokeless tobacco packs. Generally, PWLs led to higher attention, stronger cognitive and affective reactions, more negative pack attitudes and smoking attitudes, and increased intentions not to use tobacco products compared to text warnings. PWLs were perceived to be more effective than text warnings for both cigarette packs and smokeless tobacco packs.

CONCLUSIONS

The systematic review showed that PWLs on tobacco products are effective across a wide range of tobacco-related outcomes among young people. Gaps in the literature include a lack of research on tobacco initiation and cessation and a dearth of literature on non-cigarette tobacco products.