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Ozarka E, Teddy L, Blank ML, Waa A, Hoek J. Managing Fear Responses: A Qualitative Analysis of Pictorial Warning Labels Five Years Post-Plain Packaging. Nicotine Tob Res 2024:ntae112. [PMID: 38839052 DOI: 10.1093/ntr/ntae112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/24/2024] [Accepted: 05/01/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Although pictorial warning labels (PWLs) now dominate tobacco packages sold in many countries, few studies have probed how people who smoke respond to the threats presented several years post-plain packaging and larger PWLs. Understanding how people manage the fear and dissonance PWLs arouse, and the strategies they use to rationalize, diminish, and reject risk messages, could inform future PWL design. AIMS AND METHODS We undertook 27 in-depth interviews with people aged 18 and over (16 female, 8 Māori, and 13 aged ≤35) who smoked roll-your-own tobacco and lived in Aotearoa New Zealand. We probed participants' views on current PWLs and how they responded to these, then asked them to use alternative images and headlines to create new PWLs. We drew on the extended parallel processing model to interpret the data, which we analyzed using a reflexive thematic analysis approach. RESULTS People who smoke dislike PWLs, which they think reduce them to diseased body parts. While a minority thought existing PWLs were believable and effective, most reported avoiding PWLs by hiding or cognitively blocking them. Participants used diverse counterarguments to diminish PWLs' relevance and impact, and a minority displayed strong reactance. Several suggested developing PWLs that recognized them as whole people rather than patients in waiting, and recommended greater use of testimonials, particularly from people who had successfully become smoke free. CONCLUSIONS PWLs using more holistic and diverse messages could elicit greater engagement and responsiveness, and motivate cessation more effectively than existing health-oriented warnings. IMPLICATIONS Our findings suggest existing PWLs, which aim to arouse fear of ill health, could be complemented by warnings that emphasize the benefits of quitting. Continuing to use threat-based PWLs could stimulate greater rationalization and reactance. By contrast, PWLs that aim to illustrate how cessation could benefit people who smoke and their families, rather than instill a fear of disease, could avoid message rejection and counter-argument, and may prove a more powerful way of motivating cessation.
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Affiliation(s)
- Ellen Ozarka
- Department of Public Health, University of Otago, Wellington, Aotearoa, New Zealand
| | - Lani Teddy
- Te Rōpū Rangahau Hauora a Eru Pōmare Department of Public Health, University of Otago, Wellington, Aotearoa, New Zealand
| | - Mei-Ling Blank
- Department of Preventive and Social Medicine, University of Otago, Dunedin, Aotearoa, New Zealand
| | - Andrew Waa
- Te Rōpū Rangahau Hauora a Eru Pōmare Department of Public Health, University of Otago, Wellington, Aotearoa, New Zealand
| | - Janet Hoek
- Department of Public Health, University of Otago, Wellington, Aotearoa, New Zealand
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Jones D, Morgan A, Moodie C, Alexandrou G, Ford A, Mitchell D. The Role of e-Cigarette Packaging as a Health Communications Tool: A Focus Group Study With Adolescents and Adults in England and Scotland. Nicotine Tob Res 2024:ntae107. [PMID: 38839060 DOI: 10.1093/ntr/ntae107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/26/2024] [Accepted: 04/25/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION In the United Kingdom, e-cigarette and refill packaging must display a nicotine addiction warning. This study explored how this message is perceived, responses to alternative on-pack messages, and other options for using e-cigarette packaging to discourage youth and people who neither smoke nor use e-cigarettes while encouraging smokers to switch. AIMS AND METHODS Between August and September 2022, 16 focus groups (n = 70) were conducted to explore these topics with adolescents (n = 31, aged 11-17 years) and adults (n = 39, nonsmokers, smokers that use e-cigarettes, smokers that do not use e-cigarettes) in England and Scotland. RESULTS While several participants thought the current nicotine addiction warning could help increase awareness of nicotine addiction, most reported that it failed to capture attention and was not a deterrent. Alternative messages shown on packs (about harm, toxicity, wellness, litter, or relative risk) received mixed responses. Relative risk messages were perceived as most beneficial for smokers switching but also thought to potentially encourage uptake among nonsmokers. Some participants considered certain harm and toxicity messages to potentially dissuade uptake. Participants proposed several ideas to reduce the appeal of e-cigarette packaging and devices to deter youth uptake, including more prominent warnings, standardized packaging, and devices that are plain or include health messages. CONCLUSIONS Packaging can play a crucial role in communicating product and health messages to different consumer groups. Further consideration of how packaging and labeling can meet the needs of non-nicotine users while simultaneously reaching those who may benefit from using e-cigarettes to stop smoking is warranted. IMPLICATIONS While some viewed the nicotine addiction warning required on e-cigarettes and refill packaging in the United Kingdom as helpful in raising awareness of nicotine addiction, it did not resonate with most of our sample of adolescents and adults. The findings suggest that e-cigarette packaging could be better used to encourage smokers to switch to a less harmful alternative, with relative risk messages showing promise. Furthermore, strengthening on-pack messaging (eg increasing salience and rotating messages) and reducing the appeal of packaging (eg drab colors) and devices (eg including warnings) may help increase awareness of e-cigarette harms while deterring use among adolescents and nonsmokers.
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Affiliation(s)
- Daniel Jones
- Institute for Social Marketing and Health, Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Amber Morgan
- Institute for Social Marketing and Health, Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Crawford Moodie
- Institute for Social Marketing and Health, Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Georgia Alexandrou
- Institute for Social Marketing and Health, Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Allison Ford
- Institute for Social Marketing and Health, Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Danielle Mitchell
- Institute for Social Marketing and Health, Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
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Asfar T, Oluwole OJ, Pan Y, Casas A, Garayua AMH, Schmidt M, Noar SM. Youth Exposure and Response to the FDA Health Warning Label on Electronic Cigarettes Packaging: Policy Implications. Nicotine Tob Res 2024; 26:151-160. [PMID: 37688562 PMCID: PMC10803120 DOI: 10.1093/ntr/ntad175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 07/11/2023] [Accepted: 09/07/2023] [Indexed: 09/11/2023]
Abstract
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.
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Affiliation(s)
- Taghrid Asfar
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Olusanya J Oluwole
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Yue Pan
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Alejandra Casas
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Michael Schmidt
- Department of Art and School of Public Health, University of Memphis, Memphis, TN, USA
| | - Seth M Noar
- Hussman School of Journalism and Media, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Thrasher JF, Ferguson SG, Hackworth EE, Wu CL, Lambert VC, Porticella N, Kim M, Hardin JW, Niederdeppe J. Combining Inserts With Warning Labels on Cigarette Packs to Promote Smoking Cessation: A 2-Week Randomized Trial. Ann Behav Med 2024; 58:56-66. [PMID: 37738629 PMCID: PMC10729784 DOI: 10.1093/abm/kaad052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023] Open
Abstract
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.
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Affiliation(s)
- James F Thrasher
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Stuart G Ferguson
- College of Health & Medicine, University of Tasmania, Hobart, Australia
| | - Emily E Hackworth
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Chung-Li Wu
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Victoria C Lambert
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Norman Porticella
- Jeb E. Brooks School of Public Policy and Department of Communication, Cornell University, Ithaca, NY, USA
| | - Minji Kim
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - James W Hardin
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Jeff Niederdeppe
- Jeb E. Brooks School of Public Policy and Department of Communication, Cornell University, Ithaca, NY, USA
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Adams S, Clavijo A, Tamayo R, Maynard O. Cross-sectional online survey of the impact of new tobacco health warnings in Colombia. BMJ Open 2022; 12:e056754. [PMID: 35760539 PMCID: PMC9237901 DOI: 10.1136/bmjopen-2021-056754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 04/11/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES This study aimed to explore the impact of a new set of six pictorial warnings introduced in 2018. DESIGN AND SETTING Using a cross-sectional design, we examined awareness of the new warnings among Colombian smokers across two time points of data collection. PARTICIPANTS Adult smokers (≥18 years of age), defined as having smoked at least 100 cigarettes in their lifetime and currently smoking at least one cigarette per week participated at time 1, prior to the introduction of the new health warnings in Colombia in 2018 (n=1985, 72% male), and at time 2, 12 months post introduction (n=1572, 69% male). PRIMARY OUTCOMES At each time, we examined smokers' responses to warnings on packs (negative affect, thinking about warning messages and cognitive elaboration), attitudes toward smoking (perceived likelihood and severity of harm, self-efficacy, response efficacy and quit intentions), knowledge of the health risks of smoking and responses to the new warnings (negative affect, believability, thinking about the harms, reactance and perceived message effectiveness). RESULTS Awareness of the warnings was low, with only 59% of smokers reporting having seen them at time 2. Between times, we observed a reduction in negative affect toward current warnings (p<0.001), reduced thinking about (p<0.001) and cognitive elaboration of the warning message (p<0.001), and an increase in perceived severity of warnings (p<0.001). When asked about the six new health warnings, we found a reduction in negative affect (p<0.07), cognitions related to harm (p<0.01), believability (p<0.03), reactance (p<0.01) and perceived message effectiveness (p<0.02) between times. CONCLUSIONS Our data indicate that effectiveness was low prior to the introduction of the new health warnings and at 12 months post introduction. Tobacco control policy should seek to improve exposure to and noticeability of tobacco health warnings in Colombia.
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Affiliation(s)
- Sally Adams
- Department of Psychology, University of Bath, Bath, UK
| | - Arturo Clavijo
- Department of Psychology, Universidad Nacional de Colombia, Bogota, Colombia
| | - Ricardo Tamayo
- Department of Psychology, Universidad Nacional de Colombia, Bogota, Colombia
| | - Olivia Maynard
- School of Experimental Psychology, University of Bristol, Bristol, UK
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Moodie C, Best C, Lund I, Scheffels J, Critchlow N, Stead M, McNeill A, Hitchman S, Mackintosh AM. The Response of Smokers to Health Warnings on Packs in the United Kingdom and Norway Following the Introduction of Standardized Packaging. Nicotine Tob Res 2021; 23:1551-1558. [PMID: 33599723 PMCID: PMC8372634 DOI: 10.1093/ntr/ntab027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 02/10/2021] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Standardized packaging was phased in between May 2016 and May 2017 in the United Kingdom and July 2017 and July 2018 in Norway. In both countries, the health warnings on packs prior to standardized packaging being implemented were from the former Tobacco Products Directive library of warnings (text warnings covering 43% of the pack front and pictorial warnings covering 53% of the pack reverse). The warnings on packs, postimplementation, were from the current Tobacco Products Directive library of warnings (novel pictorial warnings covering 65% of the pack front and reverse) for the United Kingdom but unchanged in Norway. AIMS AND METHODS Longitudinal online surveys were conducted prior to standardized packaging (United Kingdom: April-May 2016; Norway: May-June 2017) and postimplementation (United Kingdom: September-November 2017 and May-July 2019; Norway: August-September 2018). We explored smokers' response to the on-pack warnings (salience, cognitive reactions, and behavioral reactions). RESULTS In the United Kingdom, noticing warnings on packs, reading or looking closely at them, thinking about them, thinking about the health risks, avoidant behaviors, forgoing cigarettes, and being more likely to quit due to the warnings significantly increased from waves 1 to 2, and then decreased from waves 2 to 3, but remained higher than at wave 1. In Norway, noticing warnings, reading or looking closely at them, thinking about them, thinking about the health risks, and being more likely to quit due to the warnings significantly decreased from waves 1 to 2; avoidant behaviors and forgoing cigarettes remained unchanged. CONCLUSIONS The inclusion of large novel pictorial warnings on standardized packs increases warning salience and effectiveness. IMPLICATIONS Two longitudinal online surveys in the United Kingdom and Norway explored the impact of standardized packaging on warning salience and effectiveness. That warning salience and effectiveness only increased in the UK postimplementation, where standardized packaging was implemented alongside new larger pictorial warnings on the pack front and reverse, and not in Norway, where standardized packaging was introduced but older smaller text warnings (pack front) and pictorial warnings (pack reverse) were retained, highlights the importance of removing full branding and introducing stronger warnings simultaneously.
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Affiliation(s)
- Crawford Moodie
- Institute for Social Marketing and Health, Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Catherine Best
- Institute for Social Marketing and Health, Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Ingeborg Lund
- Department of Alcohol, Tobacco and Drugs, Norwegian Institute for Public Health, Oslo, Norway
| | - Janne Scheffels
- Department of Alcohol, Tobacco and Drugs, Norwegian Institute for Public Health, Oslo, Norway
| | - Nathan Critchlow
- Institute for Social Marketing and Health, Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Martine Stead
- Institute for Social Marketing and Health, Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Ann McNeill
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sara Hitchman
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Anne Marie Mackintosh
- Institute for Social Marketing and Health, Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
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Pang B, Saleme P, Seydel T, Kim J, Knox K, Rundle-Thiele S. The effectiveness of graphic health warnings on tobacco products: a systematic review on perceived harm and quit intentions. BMC Public Health 2021; 21:884. [PMID: 34011338 PMCID: PMC8135180 DOI: 10.1186/s12889-021-10810-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 04/12/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Examination of the format and framing of the graphic health warnings (GHWs) on tobacco products and their impact on tobacco cessation has received increasing attention. This review focused on systematically identifying and synthesizing evidence of longitudinal studies that evaluate different GHW formats and specifically considered GHW influence on perceived risk of tobacco use and quit intentions. METHODS Ten databases were systematically searched for relevant records in December 2017 and again in September 2019. Thirty-five longitudinal studies were identified and analyzed in terms of the formatting of GHWs and the outcomes of perceived risk and quit intentions. Quality assessment of all studies was conducted. RESULTS This review found graphics exceeding 50% of packs were the most common ratio for GHWs, and identified an ongoing reliance on negatively framed messages and limited source attribution. Perceived harms and quit intentions were increased by GHWs. However, wear-out effects were observed regardless of GHW format indicating the length of time warnings are present in market warrants ongoing research attention to identify wear out points. Quit intentions and perceived harm were also combined into a cognitive response measure, limiting the evaluation of the effects of each GHW format variables in those cases. In addition, alternative GHW package inserts were found to be a complimentary approach to traditional GHWs. CONCLUSIONS This review demonstrated the role of GHWs on increasing quit intentions and perceptions of health risks by evaluating quality-assessed longitudinal research designs. The findings of this study recommend testing alternate GHW formats that communicate quit benefits and objective methodologies to extend beyond self-report.
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Affiliation(s)
- Bo Pang
- Social marketing @ Griffith, Department of Marketing, Griffith University, 170 Kessels Road, Nathan, QLD 4111 Australia
| | - Pamela Saleme
- Social marketing @ Griffith, Department of Marketing, Griffith University, 170 Kessels Road, Nathan, QLD 4111 Australia
| | - Tori Seydel
- Social marketing @ Griffith, Department of Marketing, Griffith University, 170 Kessels Road, Nathan, QLD 4111 Australia
| | - Jeawon Kim
- Social marketing @ Griffith, Department of Marketing, Griffith University, 170 Kessels Road, Nathan, QLD 4111 Australia
| | - Kathy Knox
- Social marketing @ Griffith, Department of Marketing, Griffith University, 170 Kessels Road, Nathan, QLD 4111 Australia
| | - Sharyn Rundle-Thiele
- Social marketing @ Griffith, Department of Marketing, Griffith University, 170 Kessels Road, Nathan, QLD 4111 Australia
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Dhani R, Artini A, Pannindriya ST, Albert A, Ahsan A, Kusuma D. Effects of Pictorial Health Warnings on Cognitive, Affective, and Smoking Behavior: A Mixed Methods Study in Four Cities in Indonesia. Asian Pac J Cancer Prev 2021; 22:397-405. [PMID: 33639653 PMCID: PMC8190365 DOI: 10.31557/apjcp.2021.22.2.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Indexed: 11/25/2022] Open
Abstract
While studies have shown the importance of pictorial health warnings (PHW) as a tobacco control strategy, empirical evidence on the efficacy of PHW in prompting smoking behavior remains inconclusive. The study aimed to examine the association between PHW and cognitive reactions, emotional/affective reactions, and smoking behavior. We conducted a mixed-methods study, which included a cross-sectional face-to-face survey of 401 smokers in four cities (Jakarta, Bandung, Semarang, and Yogyakarta) and three focus group discussions among 24 participants in Jakarta. We applied multiple logit regression in STATA for quantitative data analysis and explanatory sequential design for qualitative data analysis. Quantitatively, we found high (63-84% of respondents) understanding about PHW objectives (cognitive reactions), including to remind health risks and encourage smoking cessation. With only 40% PHW, we found relatively low (32%-39%) negative emotional reactions, including feeling scared, annoyed and disgusted and relatively low proportions (33-40%) of respondents that reported quit attempt. Consistent with the quantitative findings, qualitative data provided contexts, including in explaining that the professional worker group was the least affected by PHW, while the student and non-professional groups were the most vulnerable. All this is supportive of governments in Indonesia and other countries to increase the PHW size.
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Affiliation(s)
- Rendro Dhani
- Faculty of Communication Studies, Institut Komunikasi dan Bisnis LSPR, Jakarta, Indonesia
| | - Artini Artini
- Faculty of Communication Studies, Institut Komunikasi dan Bisnis LSPR, Jakarta, Indonesia
| | | | - Albert Albert
- Faculty of Communication Studies, Institut Komunikasi dan Bisnis LSPR, Jakarta, Indonesia
| | - Abdillah Ahsan
- Faculty of Economics and Business, University of Indonesia, Depok, Indonesia
| | - Dian Kusuma
- Policy Innovation, Imperial College Business School, London, UK
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Brennan E, Maloney E, Ophir Y, Cappella JN. Designing Effective Testimonial Pictorial Warning Labels for Tobacco Products. HEALTH COMMUNICATION 2019; 34:1383-1394. [PMID: 29985636 PMCID: PMC6326893 DOI: 10.1080/10410236.2018.1493417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
- Emily Brennan
- Centre for Behavioural Research in Cancer, Cancer Council Victoria
| | - Erin Maloney
- Penn Tobacco Center of Regulatory Science, Annenberg School for Communication, University of Pennsylvania
| | - Yotam Ophir
- Penn Tobacco Center of Regulatory Science, Annenberg School for Communication, University of Pennsylvania
| | - Joseph N Cappella
- Penn Tobacco Center of Regulatory Science, Annenberg School for Communication, University of Pennsylvania
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Lambert V, Ferguson SG, Niederdeppe J, Hammond D, Hardin JW, Thrasher JF. Exploring the impact of efficacy messages on cessation-related outcomes using Ecological Momentary Assessment. Tob Induc Dis 2019; 16:44. [PMID: 31516442 PMCID: PMC6659513 DOI: 10.18332/tid/94460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/17/2018] [Accepted: 08/20/2018] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Observational studies indicate that cigarette package inserts with efficacy messages about the benefits of quitting (i.e. response efficacy) and recommendations for successful cessation increase smokers' self-efficacy to quit and promote sustained cessation. However, the effects of inserts with such efficacy messages have not been studied using experimental designs. This study used ecological momentary assessment (EMA) to assess smokers' responses to efficacy inserts. METHODS In a randomized case-crossover study among smokers from the United States (n=23), participants received a one-week supply of cigarettes with efficacy inserts and a one-week supply without any inserts, and were randomized to use the packs with inserts on either the first or second week of the study. For 14 consecutive days, participants used a smartphone to answer brief surveys on cessation-related variables during smoking sessions and at the beginning of each day. Multilevel mixed-effects linear and logistic regression models compared responses during the insert period to those of the non-insert period. RESULTS The insert period was associated with greater desire to quit (b=0.21, p=0.012), motivation to quit (b=0.18, p=0.001), self-efficacy to cut down (b=0.26, p<0.001) and to quit (b=0.28, p<0.000), and response efficacy/perceived benefits of quitting (b=0.13, p=0.012). Insert exposure was not significantly associated with forgoing cigarettes (OR=1.9, p=0.2). CONCLUSIONS Results from this EMA study suggest that inserts with efficacy messages may promote determinants of smoking cessation. This is consistent with observational research in Canada, which is the only country to use inserts with efficacy messages as well as pictorial warnings about smoking risks on the outside of packs. Future studies should assess the extent to which efficacy inserts can not only be used to communicate health information to smokers but also work in synergy with pictorial warnings.
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Affiliation(s)
- Victoria Lambert
- Department of Health Promotion, Education, & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, United States
| | | | - Jeff Niederdeppe
- Department of Communication, Cornell University, Ithaca, United States
| | - David Hammond
- School of Public Health & Health Systems, University of Waterloo, Waterloo, Canada
| | - James W Hardin
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, United States
| | - James F Thrasher
- Department of Health Promotion, Education, & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, United States.,Department of Tobacco Research, Center for Population Health Studies, National Institute of Public Health, Cuernavaca, Mexico
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Swayampakala K, Thrasher JF, Yong HH, Nagelhout GE, Li L, Borland R, Hammond D, O'Connor RJ, Hardin JW. Over-Time Impacts of Pictorial Health Warning Labels and their Differences across Smoker Subgroups: Results from Adult Smokers in Canada and Australia. Nicotine Tob Res 2019. [PMID: 28637294 DOI: 10.1093/ntr/ntx134] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Kamala Swayampakala
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, USA
| | - James F Thrasher
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, USA.,Department of Tobacco Research, Centre for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | | | - Gera E Nagelhout
- Department of Health Promotion, Maastricht University (CAPHRI), Maastricht, the Netherlands.,Department of Family Medicine, Maastricht University (CAPHRI), Maastricht, the Netherlands
| | - Lin Li
- Cancer Council Victoria, Melbourne, Australia
| | - Ron Borland
- Cancer Council Victoria, Melbourne, Australia
| | - David Hammond
- School of Public Health & Health Systems, University of Waterloo, Canada
| | - Richard J O'Connor
- Department of Health Behavior, Roswell Park Cancer Institute, New York, USA
| | - James W Hardin
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, USA
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13
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Brewer NT, Jeong M, Hall MG, Baig SA, Mendel JR, Lazard AJ, Noar SM, Kameny MR, Ribisl KM. Impact of e-cigarette health warnings on motivation to vape and smoke. Tob Control 2019; 28:tobaccocontrol-2018-054878. [PMID: 31292169 PMCID: PMC6824616 DOI: 10.1136/tobaccocontrol-2018-054878] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/07/2019] [Accepted: 03/19/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND A prevailing hypothesis is that health warnings for electronic cigarettes (e-cigarettes) could drive people away from vaping and towards smoking cigarettes. We consider an alternative hypothesis that e-cigarette warnings discourage both vaping and smoking. METHODS Participants were a national convenience sample of 2218 US adults who used e-cigarettes, cigarettes or both. In August 2018, we randomised participants to one of three warning types (control text about littering, text-only e-cigarette warning or pictorial e-cigarette warning). We further randomised participants viewing e-cigarette warnings to one of three topics (nicotine addiction, health hazards of use, or both health hazards and harms of use). The preregistered primary outcome was intentions to quit vaping among e-cigarette users. Secondary outcomes included interest in smoking and Tobacco Warnings Model constructs: attention, negative affect, anticipated social interactions and cognitive elaboration. RESULTS Text warnings elicited higher intentions to quit vaping than control among e-cigarette users (d=0.44, p<0.001), and pictorial warnings elicited still higher intentions to quit vaping than text (d=0.12, p<0.05). Text warnings elicited lower interest in smoking compared with control among smokers (p<0.05); warnings had no other effects on interest in smoking among smokers or non-smokers. Text warnings about health hazards elicited higher intentions to quit vaping than nicotine addiction warnings. E-cigarette warnings also increased Tobacco Warnings Model constructs. DISCUSSION E-cigarette health warnings may motivate users to quit vaping and discourage smoking. The most promising warnings include health hazards (other than nicotine addiction) and imagery. We found no support for the hypothesis that e-cigarette warnings could encourage smoking cigarettes.
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Affiliation(s)
- Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michelle Jeong
- Center for Tobacco Studies, Rutgers School of Public Health, New Brunswick, New Jersey, USA
| | - Marissa G Hall
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sabeeh A Baig
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Sociomedical Science, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Jennifer R Mendel
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Allison J Lazard
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
- School of Media and Journalism, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Seth M Noar
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
- School of Media and Journalism, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Madeline R Kameny
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
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14
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Brennan E, Bayly M, Scollo M, Zacher M, Wakefield MA. Observed smoking and tobacco pack display in Australian outdoor cafés 2 years after implementation of plain packaging. Eur J Public Health 2019; 28:702-707. [PMID: 29596579 DOI: 10.1093/eurpub/cky051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Implementation of tobacco plain packaging (PP) in Australia in December 2012 was associated with significant reductions in the percentage of patrons at outdoor cafés observed to be displaying tobacco packs and actively smoking, immediately post-implementation and 1 year later. This study examines whether these positive effects were sustained through to 2 years post-PP. Methods An observational study conducted at cafés, restaurants and bars with outdoor seating in Melbourne, Australia documented the number of: patrons; patrons actively smoking; tobacco packs on display; orientation and type of displayed packs and whether or not children were present. Data were collected pre-PP (2012), early post-PP (2013), 1 year post-PP (2014) and 2 years post-PP (2015). Multilevel Poisson regressions analyzed changes in each outcome, adjusting for important covariates. Results Overall, positive effects of PP implementation on tobacco pack display and active smoking were not fully sustained through to 2 years post-PP for the total sample. Interactions between phase and the presence of children indicated that pack display and active smoking were lower in all post-implementation phases (compared with pre-PP) at venues where children were present but not at venues where children were not present. Conclusions Children at outdoor cafés were still being exposed to less tobacco packaging and active smoking, 2 years after implementation of the packaging changes. More regular refreshment of graphic health warnings is likely to be required to sustain these effects, and to reduce pack display behaviour at venues with no children.
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Affiliation(s)
- Emily Brennan
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, VIC 3004, Australia
| | - Megan Bayly
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, VIC 3004, Australia
| | - Michelle Scollo
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, VIC 3004, Australia
| | - Meghan Zacher
- Department of Sociology, Harvard University, Cambridge, MA 02138, USA
| | - Melanie A Wakefield
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, VIC 3004, Australia
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15
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Woelbert E, d'Hombres B. Pictorial health warnings and wear-out effects: evidence from a web experiment in 10 European countries. Tob Control 2019; 28:e71-e76. [PMID: 30610081 PMCID: PMC6824613 DOI: 10.1136/tobaccocontrol-2018-054402] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 10/12/2018] [Accepted: 10/31/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE This paper examines whether there are possible wear-out effects associated with repeated exposure to pictorial health warnings on tobacco products. Wear-out effects can be general, that is, people get used to the presence of pictorial warnings in general, or specific to the content of the warnings (ie, the images used). Distinguishing between these two types of wear-out is important for understanding how to maintain the effectiveness of health warnings over time. METHODS This study used data from two surveys carried out in 10 European countries. Participants (n=12 600) were exposed in a random order to a series of health warnings and assessed the salience of the warnings as well as their effects on smoking intentions. Using these data and country variations in health warning legislation, we tested whether warning pictures are subject to general and/or specific wear-out effects. RESULTS Responses were stronger to combined text+picture warnings than to text-only warnings. This effect was lower for smokers living in countries where combined warnings were already in place at the time of the data collection, compared with smokers residing in countries where text-only warnings were in use. This result, observed for combined warnings with new pictures, is in line with the presence of general wear-out effects. Combined warnings with an unknown pictorial content were more effective than those including pictorial warnings already in use, suggesting that specific wear-out effects are also at play. CONCLUSIONS These findings strengthen the evidence that pictorial health warnings are an effective tool for tobacco control policies and suggest that, even in the presence of a general wear-out effect among smokers, periodically introducing new pictures helps to maintain warning effectiveness over time.
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Affiliation(s)
- Eva Woelbert
- European Commission, Joint Research Centre (JRC), Ispra, Italy
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16
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Ngoc Bich N, Thu Ngan T, Bao Giang K, Thi Hai P, Thi Thu Huyen D, Ngoc Khue L, Tuan Lam N, Van Minh H, Thi Quynh Nga P, The Quan N, Loan VH. Salience and Impact of Health Warning Label on Cigarette Packs in Vietnam: Findings From the Global Adult Tobacco Survey 2015. Behav Med 2019; 45:30-39. [PMID: 29652628 DOI: 10.1080/08964289.2018.1434117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Viet Nam is among the countries having highest rate of male smokers in the world. The country has joined the Global Tobacco Surveillance System since 2010. Under this system, two rounds of Global Adult Tobacco Survey (GATS) were conducted in 2010 and 2015. Those two surveys provide excellent comparable data on tobacco usage and its related aspects in Vietnam. This study using the data from GATS 2015 to examine the salience and impact of cigarette pack health warnings on quitting intention in Vietnam. The Vietnam GATS 2015 was a nationally representative survey in which 9,513 households were selected using two-stage random systematic sampling method. Results of multivariate analysis showed that the strongest predictor for quit intention because of health warnings was "ever made a quit attempt in the past 12 months" followed by "believes that tobacco smoking causes serious illness". Compared to GATS 2010, GATS 2015 observed the increase in salience of cigarette health warnings. However, the current pictorial health warnings are losing their impact on motivating intention to quit. The results highlight that it is time to start the rotation cycle to refresh the current health warning set. Actions to select a new and more impressive set of pictorial health warnings should be developed as soon as possible.
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Affiliation(s)
| | - Tran Thu Ngan
- a Hanoi University of Public Health , Hanoi , Vietnam
| | | | - Phan Thi Hai
- c Vietnam Steering Committee on Smoking and Health , Hanoi , Vietnam
| | | | - Luong Ngoc Khue
- c Vietnam Steering Committee on Smoking and Health , Hanoi , Vietnam
| | - Nguyen Tuan Lam
- d World Health Organization Office in Viet Nam , Hanoi , Vietnam
| | | | | | | | - Vu Hoang Loan
- a Hanoi University of Public Health , Hanoi , Vietnam
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17
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Jongenelis MI, Pratt IS, Slevin T, Chikritzhs T, Liang W, Pettigrew S. The effect of chronic disease warning statements on alcohol-related health beliefs and consumption intentions among at-risk drinkers. HEALTH EDUCATION RESEARCH 2018; 33:351-360. [PMID: 30085037 DOI: 10.1093/her/cyy025] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 07/12/2018] [Indexed: 06/08/2023]
Abstract
Informing drinkers of the health risks associated with alcohol consumption via warning statements located on alcohol products can increase their capacity to make healthier choices. This study assessed whether exposing at-risk drinkers to warning statements relating to specific chronic diseases increases the extent to which alcohol is believed to be a risk factor for those diseases and influences consumption intentions. Australians drinking at levels associated with long-term risk of harm (n = 364; 72% male) completed an online survey assessing their drinking habits, beliefs in the link between alcohol and various diseases and drinking intentions. Respondents were then exposed to one of five statements advising of the potential risks associated with alcohol consumption (either cancer, liver damage, diabetes, mental illness or heart disease). Beliefs and drinking intentions were reassessed. Significant increases in the extent to which alcohol was believed to be a risk factor for diabetes, heart disease, mental illness and cancer were found. With the exception of the liver damage and heart disease statements, exposure to each statement was associated with a significant reduction in consumption intentions. Warning statements advising of the specific chronic diseases associated with alcohol consumption can produce favourable changes in drinking intentions among at-risk drinkers.
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Affiliation(s)
| | - Iain S Pratt
- School of Psychology, Curtin University, GPO Box U1987, Perth, WA, Australia
- Cancer Council Western Australia, 420 Bagot Road Subiaco, WA, Australia
| | - Terry Slevin
- School of Psychology, Curtin University, GPO Box U1987, Perth, WA, Australia
- Cancer Council Western Australia, 420 Bagot Road Subiaco, WA, Australia
| | - Tanya Chikritzhs
- National Drug Research Institute, Curtin University, GPO Box U1987, Perth, WA, Australia
| | - Wenbin Liang
- National Drug Research Institute, Curtin University, GPO Box U1987, Perth, WA, Australia
| | - Simone Pettigrew
- School of Psychology, Curtin University, GPO Box U1987, Perth, WA, Australia
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18
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Anshari D, Yong HH, Borland R, Hammond D, Swayampakala K, Thrasher J. Which type of tobacco product warning imagery is more effective and sustainable over time? A longitudinal assessment of smokers in Canada, Australia and Mexico. BMJ Open 2018; 8:e021983. [PMID: 30007932 PMCID: PMC6089327 DOI: 10.1136/bmjopen-2018-021983] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Dien Anshari
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
- Department of Health Education and Behavioral Sciences, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia
| | - Hua-Hie Yong
- Nigel Gray Fellowship Group, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Ron Borland
- Nigel Gray Fellowship Group, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - David Hammond
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Kamala Swayampakala
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Jim Thrasher
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
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Parada H, Hall MG, Boynton MH, Brewer NT. Trajectories of Responses to Pictorial Cigarette Pack Warnings. Nicotine Tob Res 2018; 20:876-881. [PMID: 29059340 PMCID: PMC5991219 DOI: 10.1093/ntr/ntx182] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 08/15/2017] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Humberto Parada
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, McGavran-Greenberg Hall, Chapel Hill, NC, USA
| | - Marissa G Hall
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Rosenau Hall, Chapel Hill, NC, USA
| | - Marcella H Boynton
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Rosenau Hall, Chapel Hill, NC, USA
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Rosenau Hall, Chapel Hill, NC, USA
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Jradi H, Saddik B. Graphic warnings and text warning labels on cigarette packages in Riyadh Kingdom of Saudi Arabia: Awareness and perceptions. Ann Thorac Med 2018; 13:22-29. [PMID: 29387252 PMCID: PMC5772104 DOI: 10.4103/atm.atm_45_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Graphic warning labels have been shown to be effective in smoking initiation and cessation and were implemented in Saudi Arabia in 2012. To date, no study has assessed the effectiveness of these labels and the Saudi population's perceptions on the effectiveness of cigarette health warning labels. METHODS We used a cross-sectional qualitative study comprising of nine focus groups among 3 different community group members including health-care workers, adult women and adult men. We conducted in-depth interviews among community leaders. Both focus groups and interviews assessed awareness levels and elicited perceptions about health warning labels on cigarette boxes currently used in the Kingdom of Saudi Arabia. RESULTS While most participants in the study were aware and supported the use of graphic warning labels on cigarette packages, the awareness of the specific details on the labels was low. Participants perceived the effectiveness of current labels somewhat vague in smoking cessation and advocated for stronger and more aggressive graphics. Community leaders, however, preferred text-only labels and did not support aggressive labels which were deemed culturally and religiously inappropriate. CONCLUSIONS The study suggests that while graphic warning labels are perceived as necessary on cigarette packages the currently used messages are not clear and therefore do not serve their intended purposes. Measures should be undertaken to ensure that pictorial cigarette labels used in Saudi Arabia are culturally and ethnically appropriate and are rotated on a regular basis to ensure salience among smokers and nonsmokers alike.
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Affiliation(s)
- Hoda Jradi
- Department of Community and Environmental Health, College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Basema Saddik
- Department of Community and Environmental Health, College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department of Family and Community Medicine and Behavioral Sciences, College of Medicine, University of Sharjah, Sharjah, UAE
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21
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Brennan E, Maloney EK, Ophir Y, Cappella JN. Potential Effectiveness of Pictorial Warning Labels That Feature the Images and Personal Details of Real People. Nicotine Tob Res 2018; 19:1138-1148. [PMID: 27932628 DOI: 10.1093/ntr/ntw319] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 11/28/2016] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Emily Brennan
- Centre for Behavioural Research in Cancer, Cancer Council Victoria,Melbourne,Australia
| | - Erin K Maloney
- Penn Tobacco Center of Regulatory Science, Annenberg School for Communication, University of Pennsylvania,Philadelphia, PA
| | - Yotam Ophir
- Penn Tobacco Center of Regulatory Science, Annenberg School for Communication, University of Pennsylvania,Philadelphia, PA
| | - Joseph N Cappella
- Penn Tobacco Center of Regulatory Science, Annenberg School for Communication, University of Pennsylvania,Philadelphia, PA
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22
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Levy DT, Mays D, Yuan Z, Hammond D, Thrasher JF. Public health benefits from pictorial health warnings on US cigarette packs: a SimSmoke simulation. Tob Control 2017; 26:649-655. [PMID: 27807299 PMCID: PMC5966722 DOI: 10.1136/tobaccocontrol-2016-053087] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 10/01/2016] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- David T Levy
- Department of Oncology, Cancer Prevention & Control Program, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Darren Mays
- Department of Oncology, Cancer Prevention & Control Program, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Zhe Yuan
- Department of Oncology, Cancer Prevention & Control Program, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - David Hammond
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - James F Thrasher
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, USA
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O'Connor RJ, Rees VW, Rivard C, Hatsukami DK, Cummings KM. Internalized smoking stigma in relation to quit intentions, quit attempts, and current e-cigarette use. Subst Abus 2017; 38:330-336. [PMID: 28481713 DOI: 10.1080/08897077.2017.1326999] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Reducing the social acceptability of smoking is associated with lowered smoking prevalence. However, denormalization strategies can also contribute to the stigmatization that some smokers may feel about their smoking. Smoking stigma may be more acute if smokers are also members of other stigmatized groups, such as racial/ethnic minorities. This study examined correlates of smoking self- and felt-stigma and discrimination, among current smokers. METHODS Participants were recruited in the United States via a national commercial consumer panel to complete a cross-sectional, Web-based survey. Participants were 1528 current cigarette smokers aged 14 and older. Measures included the Internalized Stigma of Smoking Inventory (ISSI), Heaviness of Smoking Index, quit intentions, past-year quit attempts, and current use of electronic cigarettes (e-cigarettes). RESULTS Self-stigma was significantly associated with higher intent to quit in the next 6 months (odds ratio [OR] = 2.47, P < .01) and in the next 30 days (OR = 4.21, P < .01), relative to no intention to quit, as well as having made 1 or 2 quit attempts in the past year (OR = 1.60, P < .01) or 3 or more quit attempts (OR = 1.74, P < .01) and associated with daily e-cigarette use (OR = 1.73, P < .05). Felt-stigma was positively associated with intent to quit in the next 30 days (OR = 1.54, P < .01), having made 3 or more quit attempts in the past year (OR = 1.35, P < .01), and both daily (OR = 2.05, P < .05) and some-day (OR = 1.30, P < .05) e-cigarette use. Discrimination was associated only with increased odds of daily e-cigarette use (OR = 1.83, P < .05). CONCLUSIONS Smokers who reported greater feelings of stigmatization about their smoking were more likely to report having made recent quit attempts, report a stronger intention quit smoking in the future, and report use of e-cigarettes, suggesting that feelings of self-and felt-stigmatization are related to greater motivation to stop smoking.
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Affiliation(s)
- Richard J O'Connor
- a Department of Health Behavior , Roswell Park Cancer Institute , Buffalo , New York , USA
| | - Vaughan W Rees
- b Department of Social and Behavioral Sciences , Harvard T.H. Chan School of Public Health , Boston , Massachusetts , USA
| | - Cheryl Rivard
- a Department of Health Behavior , Roswell Park Cancer Institute , Buffalo , New York , USA
| | - Dorothy K Hatsukami
- c Department of Psychiatry , University of Minnesota , Minneapolis , Minnesota , USA
| | - K Michael Cummings
- d Department of Psychiatry and Behavioral Science , Medical University of South Carolina , Charleston , South Carolina , USA
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24
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Brewer NT, Hall MG, Noar SM, Parada H, Stein-Seroussi A, Bach LE, Hanley S, Ribisl KM. Effect of Pictorial Cigarette Pack Warnings on Changes in Smoking Behavior: A Randomized Clinical Trial. JAMA Intern Med 2016; 176:905-12. [PMID: 27273839 PMCID: PMC5458743 DOI: 10.1001/jamainternmed.2016.2621] [Citation(s) in RCA: 187] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Pictorial warnings on cigarette packs draw attention and increase quit intentions, but their effect on smoking behavior remains uncertain. OBJECTIVE To assess the effect of adding pictorial warnings to the front and back of cigarette packs. DESIGN, SETTING, AND PARTICIPANTS This 4-week between-participant randomized clinical trial was carried out in California and North Carolina. We recruited a convenience sample of adult cigarette smokers from the general population beginning September 2014 through August 2015. Of 2149 smokers who enrolled, 88% completed the trial. No participants withdrew owing to adverse events. INTERVENTIONS We randomly assigned participants to receive on their cigarette packs for 4 weeks either text-only warnings (one of the Surgeon General's warnings currently in use in the United States on the side of the cigarette packs) or pictorial warnings (one of the Family Smoking Prevention and Tobacco Control Act's required text warnings and pictures that showed harms of smoking on the top half of the front and back of the cigarette packs). MAIN OUTCOMES AND MEASURES The primary trial outcome was attempting to quit smoking during the study. We hypothesized that smokers randomized to receive pictorial warnings would be more likely to report a quit attempt during the study than smokers randomized to receive a text-only Surgeon General's warning. RESULTS Of the 2149 participants who began the trial (1039 men, 1060 women, and 34 transgender people; mean [SD] age, 39.7 [13.4] years for text-only warning, 39.8 [13.7] for pictorial warnings), 1901 completed it. In intent-to-treat analyses (n = 2149), smokers whose packs had pictorial warnings were more likely than those whose packs had text-only warnings to attempt to quit smoking during the 4-week trial (40% vs 34%; odds ratio [OR], 1.29; 95% CI, 1.09-1.54). The findings did not differ across any demographic groups. Having quit smoking for at least the 7 days prior to the end of the trial was more common among smokers who received pictorial than those who received text-only warnings (5.7% vs 3.8%; OR, 1.53; 95% CI, 1.02-2.29). Pictorial warnings also increased forgoing a cigarette, intentions to quit smoking, negative emotional reactions, thinking about the harms of smoking, and conversations about quitting. CONCLUSIONS AND RELEVANCE Pictorial warnings effectively increased intentions to quit, forgoing cigarettes, quit attempts, and successfully quitting smoking over 4 weeks. Our trial findings suggest that implementing pictorial warnings on cigarette packs in the United States would discourage smoking. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02247908.
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Affiliation(s)
- Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill2Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Marissa G Hall
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill2Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Seth M Noar
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill3School of Media and Journalism, University of North Carolina, Chapel Hill
| | - Humberto Parada
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Al Stein-Seroussi
- Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina
| | - Laura E Bach
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Sean Hanley
- Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina
| | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill2Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
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25
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Gantiva C, Guerrero L, Rico A, Ramírez N, Díaz M, González M, Romo-González T. Influence of Cigarette Package Brand on the Emotional Impact of Tobacco-Warning Images That Cover 30% of Cigarette Packs in Smokers and Nonsmokers. Nicotine Tob Res 2016; 18:1324-30. [PMID: 26574553 DOI: 10.1093/ntr/ntv257] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 11/04/2015] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Research on the emotional impact of tobacco-warning images (TWIs) has not evaluated the role of context (ie, cigarette packs) as a modulator of the emotional response to TWIs. The objective of the present study was to identify the influence of the cigarette package brand on the emotional impact of TWIs that cover 30% of cigarette packs in smokers and nonsmokers using a specific methodology for the study of emotion. METHODS The participants included 95 smokers and 111 nonsmokers who observed three TWIs under two conditions: TWIs that covered 30% of cigarette packs and TWIs alone, without brands. Additionally, 18 pictures from the International Affective Picture System were presented as comparison stimuli and to reduce the effect of habituation. The Self-Assessment Manikin was used to assess valence, arousal, and dominance dimensions. RESULTS TWIs that covered 30% of cigarette packs were evaluated as least aversive, with lower ratings of arousal and higher ratings of dominance in both groups. Differences in the valence, arousal, and dominance dimensions were found between groups. Smokers rated TWIs that covered 30% of cigarette packs as less aversive and more arousing and gave them lower dominance scores compared with nonsmokers. CONCLUSION The results suggest that cigarette packages modulate the emotional impact of TWIs, especially in smokers, and the minimum size of TWIs (ie, 30% of the front and back of the package) is not sufficiently large to generate an emotional impact associated with avoidance behavior. IMPLICATIONS Cigarette packages modulate the emotional impact of TWIs, especially in smokers. The cigarette package itself is an appetitive context that captures the attention of the observer and decreases the aversive emotional response to the TWIs. The minimum size of TWIs (ie, 30% of the front and back of the package) is not sufficiently large to generate an emotional impact associated with avoidance behavior.
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Affiliation(s)
- Carlos Gantiva
- Department of Psychology, University of San Buenaventura, Bogotá, Bogotá, Colombia;
| | - Lorena Guerrero
- Department of Psychology, University of San Buenaventura, Bogotá, Bogotá, Colombia
| | - Andrea Rico
- Department of Psychology, University of San Buenaventura, Bogotá, Bogotá, Colombia
| | - Natalia Ramírez
- Department of Psychology, University of San Buenaventura, Bogotá, Bogotá, Colombia
| | - Maite Díaz
- Department of Psychology, University of San Buenaventura, Bogotá, Bogotá, Colombia
| | - Miyer González
- Department of Psychology, University of San Buenaventura, Bogotá, Bogotá, Colombia
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Wigg S, Stafford LD. Health Warnings on Alcoholic Beverages: Perceptions of the Health Risks and Intentions towards Alcohol Consumption. PLoS One 2016; 11:e0153027. [PMID: 27105210 PMCID: PMC4841515 DOI: 10.1371/journal.pone.0153027] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 03/21/2016] [Indexed: 11/19/2022] Open
Abstract
Objectives Research has demonstrated that packaging which includes pictorial health warnings are more effective in altering smokers’ perceptions and intentions as well as changing smoking behaviours compared to text-only health warnings. However, very few studies have investigated the effectiveness of health warnings on alcoholic beverages Methods Participants (N = 60) viewed alcoholic beverages presenting one of three health warnings (No health warning, Text-only, Pictorial) and then responded to questions relating to level of fear arousal and their perceptions toward alcohol use. Results We found that pictorial health warnings were associated with significantly higher fear arousal, increased perceptions of the health risks of consuming alcohol as well as greater intentions to reduce and quit alcohol consumption compared to the control. Conclusions These novel findings suggest pictorial health warnings on alcoholic beverages may be an important way of making the public aware of the health risks of alcohol consumption.
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Affiliation(s)
- Sophie Wigg
- Department of Psychology, University of Portsmouth, Portsmouth, United Kingdom
| | - Lorenzo D. Stafford
- Department of Psychology, University of Portsmouth, Portsmouth, United Kingdom
- * E-mail:
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27
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Giang KB, Chung LH, Minh HV, Kien VD, Giap VV, Hinh ND, Cuong NM, Manh PD, Duc HA, Yang JC. Relative Importance of Different Attributes of Graphic Health Warnings on Tobacco Packages in Viet Nam. Asian Pac J Cancer Prev 2016; 17:79-84. [PMID: 27087187 DOI: 10.7314/apjcp.2016.17.s1.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Graphic health warnings (GHW) on tobacco packages have proven to be effective in increasing quit attempts among smokers and reducing initial smoking among adolescents. This research aimed to examine the relative importance of different attributes of graphic health warnings on tobacco packages in Viet Nam. A discrete choice experimental (DCE) design was applied with a conditional logit model. In addition, a ranking method was used to list from the least to the most dreadful GHW labels. With the results from DCE model, graphic type was shown to be the most important attribute, followed by cost and coverage area of GHW. The least important attribute was position of the GHW. Among 5 graphic types (internal lung cancer image, external damaged teeth, abstract image, human suffering image and text), the image of lung cancer was found to have the strongest influence on both smokers and non-smokers. With ranking method, the image of throat cancer and heart diseases were considered the most dreadful images. GHWs should be designed with these attributes in mind, to maximise influence on purchase among both smokers and non-smokers.
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28
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Tran TN, Le VA, Nguyen TTM, Nguyen NB. Changes in Vietnamese Male Smokers' Reactions Towards New Pictorial Cigarette Pack Warnings Over Time. Asian Pac J Cancer Prev 2016; 17:71-8. [DOI: 10.7314/apjcp.2016.17.s1.71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Impact of graphic pack warnings on adult smokers' quitting activities: Findings from the ITC Southeast Asia Survey (2005-2014). J Smok Cessat 2016; 11:124-134. [PMID: 27525045 DOI: 10.1017/jsc.2015.21] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Malaysia introduced graphic health warning labels (GHWLs) on all tobacco packages in 2009. We aimed to examine if implementing GHWLs led to stronger warning reactions (e.g., thinking about the health risks of smoking) and an increase in subsequent quitting activities; and to examine how reactions changed over time since the implementation of the GHWLs in Malaysia and Thailand where GHWL size increased from 50-55% in 2010. Data came from six waves (2005-2014) of the International Tobacco Control Southeast Asia Survey. Between 3,706 and 4,422 smokers were interviewed across these two countries at each survey wave. Measures included salience of warnings, cognitive responses (i.e., thinking about the health risks and being more likely to quit smoking), forgoing cigarettes, and avoiding warnings. The main outcome was subsequent quit attempts. Following the implementation of GHWLs in Malaysia, reactions increased, in some cases to levels similar to the larger Thai warnings, but declined over time. In Thailand, reactions increased following implementation, with no decline for several years, and no clear effect of the small increase in warning size. Reactions, mainly cognitive responses, were consistently predictive of quit attempts in Thailand, but this was only consistently so in Malaysia after the change to GHWLs. In conclusion, GHWLs are responded to more frequently, and generate more quit attempts, but warning wear-out is not consistent in these two countries, perhaps due to differences in other tobacco control efforts.
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30
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Yong HH, Borland R, Hammond D, Thrasher JF, Cummings KM, Fong GT. Smokers' reactions to the new larger health warning labels on plain cigarette packs in Australia: findings from the ITC Australia project. Tob Control 2015; 25:181-7. [PMID: 25700365 DOI: 10.1136/tobaccocontrol-2014-051979] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 01/28/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVES This study examined whether larger sized Australian cigarette health warning labels (HWLs) with plain packaging (PP) were associated with increased desirable reactions towards the HWLs postimplementation. METHODS Data were from the International Tobacco Control (ITC) longitudinal cohort survey assessing Australian smokers one wave prior to the policy change in 2011 (n=1104) and another wave after the policy change in 2013 (n=1093). We assessed initial attentional orientation (AO) to or away from warnings, plus other reactions, including cognitive reactions towards the HWLs and quit intentions. RESULTS As expected, AO towards the HWLs and reported frequency of noticing warnings increased significantly after the policy change, but not more reading. Smokers also thought more about the harms of smoking and avoided the HWLs more after the policy change, but frequency of forgoing cigarettes did not change. The subgroup that switched from initially focusing away to focusing on the HWLs following the policy change noticed and read the HWLs more, and also thought more about the harmful effects of smoking, whereas the subgroup (5.4%) that changed to focusing away from the HWLs showed opposite effects. We tested the mediational model of Yong et al and confirmed it for predicting quit intentions, with larger effects post-policy. CONCLUSIONS Increasing the size of HWLs and introducing them on PP in Australia appears to have led to an overall increase in desired levels and strength of some reactions, but evidence of reactance was among a small minority.
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Affiliation(s)
- Hua-Hie Yong
- Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Ron Borland
- Cancer Council Victoria, Melbourne, Victoria, Australia
| | - David Hammond
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - James F Thrasher
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - K Michael Cummings
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Geoffrey T Fong
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada. Ontario Institute for Cancer Research, Toronto, Ontario, Canada
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