Reactions to tobacco warning labels: predictors and outcomes of adaptive and maladaptive responses

Psychometric evaluation of a new instrument to hookah tobacco smoking-related factors in the Iranian female university students based on the Extended Parallel Process Model

BACKGROUND

The higher prevalence of hookah tobacco smoking (HTS) has become worrisome in women. Thus, it is essential to identify and measure the perceptions associated with this unhealthy behavior as well as the type of response to risk messages to design the effective programs. This study aimed to psychometric evaluation of a new instrument, named the Extended Parallel Process Model-Hookah Tobacco Smoking Questionnaire (EPPM-HTSQ), for female university students.

MATERIAL AND METHODS

This methodological study was conducted in 2019-2020 in central and western Iran. The first version of the instrument was developed with 97 items. Face, Content, and construct validity methods were used to assess the EPPM-HTSQ validity. The data viability for factorability was guided through Kaiser-Meyer-Olkin (KMO) measure of sample adequacy (Values >0.7) and Bartlett's test of Sphericity (P < 0.05). The Exploratory Factor Analysis (EFA) method with varimax rotation and SPSS software was performed to identify the main factors of the questionnaire and interpretable factors. The internal consistency and external reliability were determined. The test-retest was used for evaluating the stability of tools.

RESULTS

During the assessment of the face and content validity 71 items remained in the questionnaire. EFA led to the extraction of nine dimensions: "Focusing on superior rewards," "Response Efficacy," "Perceived physical threat," "Perceived social threat," "Self-efficacy," "Fear control," "Attitude," "Fear," and "Intention" Kaiser-Meyer-Olkin (KMO) test (0.957) and Bartlett's test (P < 0.001). Cronbach's alpha (0.871-0.951) and ICC (0.985-0.998) were approved for scale dimensions.

CONCLUSION

Important findings of the present study were the development and validation of the EPPM-HTSQ for measuring EPPM variables in relation to HTS; introducing a new variable "focusing on superior rewards"; as well as, the new classification of the concept of "perceived threat." The final version of the EPPM-HTSQ is a valid and reliable tool, but it is suggested to be re-evaluated in other studies with different populations and sample sizes.

Perceived threat and fear responses to e-cigarette warning label messages: Results from 16 focus groups with U.S. youth and adults

AIMS

A warning on e-cigarette packaging is one way the U.S. government can inform the public of known harms of e-cigarette use. Currently, the only required warning on these products is: "WARNING: This product contains nicotine. Nicotine is an addictive chemical." This exploratory study aims to inform potential future investigations and FDA decisions regarding alternative warnings that may generate fear in addition to being intentionally informational.

METHOD

Data were obtained from responses by 16 online focus groups with adult (N = 47, age range = 18-64) and youth (N = 32, age range 14-16) participants with various smoking and vaping experiences. We showed each focus group a set of hypothetical e-cigarette warning labels to determine how they respond to currently existing public statements that communicate information on the toxicity of ingredients in e-cigarettes, potential health risks, addiction to nicotine, and the uncertainty of the science regarding health effects of using these products. The focus group interviews were audio recorded and transcribed. Transcripts were subjected to a multiphase coding process to identify common response themes. Codes derived from the Extended Parallel Processing Model were then applied to understand impact of potentially fear-inducing language by warning category and age group.

RESULTS

For adults, all warnings-except those about addiction-gave rise to spontaneous danger control (intended) responses, such as quit intentions. Warnings highlighting cognitive and uncertain effects may be particularly promising for adult consumers of tobacco products because both gengerated danger control and response efficacy without evidence of fear control. However, responses also suggest that warnings risk discouraging some adults who use combustible cigarettes from transitioning to e-cigarettes for harm reduction. For youth, while evidence of response efficacy and danger control emerged among youth exposed to messages in all warning categories but one-addiction-unproductive reactions indicative of fear control were also prevalent among youth respondent across most warning types. On average, youth were more skeptical than adults about the harms of using e-cigarettes.

POLICY IMPLICATIONS

Implications of study findings for the development of future effective e-cigarette warning messages are explored.

Danger control and fear control during public health emergencies: Considering the roles of fear and hope in the EPPM across different levels of trust

Public health emergencies pose considerable threats to global health and safety. The control of these emergencies requires the efforts of healthcare professionals and calls for the public to take protective actions. The present study not only puts fear back in the extended parallel process model (EPPM) but also considers another similarly productive emotion: hope. We examined the mechanisms behind the effects of four cognitive perceptions on protective actions (i.e., danger control) and information avoidance (i.e., fear control). A national online survey was conducted with 1676 participants during the outbreak of COVID-19 in China from February 1 to 29, 2020. The results revealed that perceived severity and susceptibility could lead to fear, positively affecting protective actions. On the other hand, perceived response efficacy and self-efficacy induced hope, which was positively associated with protective actions but negatively associated with information avoidance. Furthermore, the mechanisms behind the relationships among cognitions, emotions, and behaviors varied across levels of trust in healthcare systems.

When Cigarette Smoking Meets COVID-19: How the Two Types of Threat and Efficacy Perceptions Interactively Predict Danger Control and Fear Control Processes

Growing evidence indicates that communicating the combined risk of smoking and COVID-19 encourages smoking cessation. Guided by the Extended Parallel Process Model (EPPM), we examined how perceived threats of smoking and COVID-19 independently and interactively predicted danger control responses (i.e., quit intentions and COVID-19-protective behavioral intentions) and fear control responses (i.e., fear and fatalism). We also explored the direct and interactive impacts of perceived efficacy of quitting smoking and COVID-protective behaviors on message outcomes. Structural equation modeling results (N = 747 U.S. adults who smoke) indicated that the perceived efficacy of COVID-protective behaviors positively predicted quit intentions. Higher perceived threat of COVID-19 and greater quitting efficacy predicted higher quit intentions directly and indirectly via fear. As perceived COVID-protective efficacy increased, the positive association between perceived quitting efficacy and quit intentions also increased. Smoking-related threat and efficacy perceptions did not predict COVID-protective behavioral intentions. This study added to EPPM by considering how threat and efficacy perceptions deriving from two different yet closely related risks affect protective behaviors. Thus, combining multiple threats in a single message might be a promising strategy to motivate smoking cessation amid the pandemic.

Reducing Misperceptions About Very Low Nicotine Content Cigarettes: Insights From Adults Who Smoke

INTRODUCTION

Many people incorrectly think that very low nicotine content (VLNC) cigarettes are less carcinogenic than current cigarettes. This risk misperception by people who smoke could reduce motivation to quit under a nicotine reduction policy. We qualitatively examined perspectives on campaign messages designed to reduce misperceptions.

AIMS AND METHODS

Adults who smoke from North Carolina participated in online interviews. After being introduced to the idea of a VLNC policy, participants were shown VLNC messages and asked about their perceptions on the clarity, understandability, persuasiveness, and meaning of the messages. We conducted a thematic content analysis of the transcripts.

RESULTS

Thirty adults who smoke cigarettes participated (15 females, 13 males, 2 nonbinary) with a mean age of 43 years. Central themes that emerged were: (1) Confusion about the proposed VLNC cigarette policy affected how messages were interpreted; (2) Messages that promote self-efficacy for quitting rather than guilt or fear were better received; and (3) Direct and succinct messages were seen as more able to grab attention and inform people who smoke. Some participant concerns focused on whether VLNC cigarettes would relieve their nicotine cravings and whether they would need to smoke more VLNC cigarettes to feel satisfied.

CONCLUSION

Campaign messages to educate the public about the harmful effects of smoking VLNC cigarettes may be more effective if people who smoke are informed about the policy's rationale to understand why nicotine is removed rather than the other harmful chemicals. Messages should also acknowledge the difficulty of quitting and be short and direct to capture attention.

IMPLICATIONS

Adults who smoke have some confusion about nicotine reduction in cigarettes and this affects how they perceive potential communication campaign messages about the risk of smoking VLNC cigarettes. In our qualitative research, we found that adults who smoke prefer messages about VLNC cigarettes that acknowledge the challenge of quitting and that are direct and succinct. With further development, campaign messages may be able to reduce misperceptions about VLNC cigarettes and maximize the public health benefit of a nicotine reduction policy.

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.

Fear appeals to promote better health behaviors: an investigation of potential mediators

Background: Fear appeals are widely used in health communication, despite conflicting views on their effectiveness. Unresolved issues include possible mediation mechanisms and the effect of defensive reactions aimed at controlling a perceived danger.

Methods: The present study compared the impact of three versions of an existing online course on how to prevent noncommunicable diseases. Participants, recruited in South America via a crowdsourcing platform, were divided randomly between three versions of the course – ‘threat only’/‘threat plus coping information’/‘coping information plus threat’ (reverse order). We then asked them to complete a questionnaire measuring perceived efficacy, perceived threat, defensive reactions, and intention to change unhealthy behaviors.

Results: Using a serial parallel mediation model to test the course's impact on our dependent variables did not reveal any significant differences between the three versions. Perceived efficacy was positively associated with intention to change behavior, as well as with lower suppression, lower reappraisal, and greater denial. Suppression was the only defensive reaction to be associated with intention to change behavior: greater suppression was linked to less intention to change.

Conclusions: Our results open interesting perspectives for research into defensive reactions.

Higher negative emotions in response to cigarette pictorial warning labels predict higher quit intentions among smokers

BACKGROUND

Cigarette pictorial warning labels (PWLs) could produce stronger quit intentions than text-only warning labels (TWLs) due to greater emotional arousal. Yet, it remains unclear whether PWLs that elicit different levels of emotions produce different outcomes. To better understand the role of negative emotions in the effects of PWLs, this study developed two sets of PWLs arousing different emotional levels (high vs low) but equally high on informativeness and compared them to each other and to the current TWLs.

METHODS

Adult US smokers (n=1503) were randomised to view nine high-emotion-arousing or low-emotion-arousing PWLs or TWLs. After each label, participants reported the negative emotions they felt while looking at the label. After seeing all the labels, participants reported their intentions to quit smoking. Mediation analyses tested whether message condition influenced quit intentions indirectly through negative emotions.

RESULTS

Compared with TWLs, PWLs produced higher levels of negative emotions (b=0.27, SE=0.04, p<0.001). Compared with low-emotion arousing PWLs, high-emotion-arousing PWLs produced higher levels of negative emotions (b=0.24, SE=0.07, p<0.001). Higher negative emotions predicted stronger quit intentions (b=0.20, SE=0.03, p<0.001). Negative emotions mediated the effects of PWLs versus TWLs and high-emotion-arousing versus low- emotion-arousing PWLs on quit intentions.

CONCLUSIONS

The results provide additional evidence for negative emotions as the mechanism through which PWLs motivate smokers to consider quitting. The findings call on the Food and Drug Administration to design and implement high-emotion-arousing cigarette warning labels.