Disparagement of health warning labels on cigarette packages and cessation attempts: results from four countries

Effectiveness of Mental Health Warnings on Tobacco Packaging in People With and Without Common Mental Health Conditions: An Online Randomised Experiment

Background

Health warning labels on tobacco packaging are a cost-effective means of health risk communication. However, while an extensive range of physical health risks are well-portrayed via current tobacco health warnings in the UK, there are none that currently portray the negative impact of smoking on mental health.

Aims

(i) develop novel mental health warning labels for tobacco packaging and (ii) test perceptions of these warnings in smokers and non-smokers, with and without mental health problems.

Methods

Six mental health warning labels were developed with a consultancy focus group. These warning labels were tested in an online randomised experiment, where respondents (N = 687) rated six Mental Health Warning Labels (MHWLs) and six Physical Health Warning Labels (PHWLs) on measures of perceived effectiveness, believability, arousal, valence, acceptability, reactance and novelty of information.

Results

MHWLs were perceived as low to moderately effective (mean = 4.02, SD = 2.40), but less effective than PHWLs (mean = 5.78, SD = 2.55, p < 0.001, η p 2 = 0.63). MHWLs were perceived as less believable, arousing, unpleasant, and acceptable than PHWLs. MHWLs evoked more reactance and were rated as more novel. Perceptions of MHWLs did not differ in people with and without mental health problems except for reactance and acceptability, but consistent with the PHWL literature, perceptions of MHWLs differed between non-smokers and smokers.

Conclusion

MHWLs could be an effective means to communicate novel information about the effects of smoking on mental health. MHWLs are perceived as less effective, believable, arousing, unpleasant, and acceptable than PHWLs, but MHWLs evoke more reactance and are rated as more novel.

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

AIMS

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

DESIGN

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

SETTING

The study was conducted on the online survey platform Qualtrics.

PARTICIPANTS

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

INTERVENTIONS

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

MEASUREMENTS

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

FINDINGS

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

CONCLUSIONS

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

Avoidance of tobacco health warnings? An eye-tracking approach

AIMS

Among three eye-tracking studies, we examined how cigarette pack features affected visual attention and self-reported avoidance of and reactance to warnings.

DESIGN

Study 1: smoking status × warning immediacy (short-term versus long-term health consequences) × warning location (top versus bottom of pack). Study 2: smoking status × warning framing (gain-framed versus loss-framed) × warning format (text-only versus pictorial). Study 3: smoking status × warning severity (highly severe versus moderately severe consequences of smoking).

SETTING

University of Bristol, UK, eye-tracking laboratory.

PARTICIPANTS

Study 1: non-smokers (n = 25), weekly smokers (n = 25) and daily smokers (n = 25). Study 2: non-smokers (n = 37), smokers contemplating quitting (n = 37) and smokers not contemplating quitting (n = 43). Study 3: non-smokers (n = 27), weekly smokers (n = 26) and daily smokers (n = 26).

MEASUREMENTS

For all studies: visual attention, measured as the ratio of the number of fixations to the warning versus the branding, self-reported predicted avoidance of and reactance to warnings and for study 3, effect of warning on quitting motivation.

FINDINGS

Study 1: greater self-reported avoidance [mean difference (MD) = 1.14; 95% confidence interval (CI) = 0.94, 1.35, P < 0.001, ηp2  = 0.64] and visual attention (MD = 0.89, 95% CI = 0.09, 1.68, P = 0.03, ηp2  = 0.06) to long-term warnings, but not for reactance (MD = 0.14, 95% CI = -0.04, 0.32, P = 0.12, ηp2  = 0.03). Increased visual attention to warnings on the upper versus lower half of the pack (MD = 1.8; 95% CI = 0.33, 3.26, P = 0.02, ηp2  = 0.08). Study 2: higher self-reported avoidance of (MD = 0.70; 95% CI = 0.59,0.80, P < 0.001, ηp2  = 0.61) and reactance to (MD = 0.37; 95% CI = 0.27, 0.47, P < 0.001, ηp2  = 0.34) loss-framed warnings but little evidence of a difference for visual attention (MD = 0.52; 95% CI = -0.54, 1.58, P = 0.30, ηp2  = 0.01). Greater visual attention, avoidance and reactance to pictorial versus text-only warnings (all Ps < 0.001, ηp2  > 0.25). Study 3: greater self-reported avoidance of (MD = 0.37; 95% CI = 0.25, 0.48, P < 0.001, ηp2  = 0.33) and reactance to (MD = 0.14; 95% CI = 0.05, 0.23, P = 0.003, ηp2  = 0.11) highly severe warnings but findings were inconclusive as to whether there was a difference in visual attention (MD = -0.55; 95% CI = -1.5, 0.41, P = 0.24, ηp2  = 0.02).

CONCLUSIONS

Subjective and objective (eye-tracking) measures of avoidance of health warnings on cigarette packs produce different results, suggesting these measure different constructs. Visual avoidance of warnings indicates low-level disengagement with warnings, while self-reported predicted avoidance reflects higher-level engagement with warnings.

Research on Youth and Young Adult Tobacco Use, 2013-2018, From the Food and Drug Administration-National Institutes of Health Tobacco Centers of Regulatory Science

The Tobacco Regulatory Science Program is a collaborative research effort between the National Institutes of Health (NIH) and the Food and Drug Administration (FDA). In 2013, the NIH funded 14 Tobacco Centers of Regulatory Science (TCORS), which serve as partners in establishing research, training, and professional development programs to guide FDA. Each of the fourteen TCORS, and two other NIH-funded research programs, the Center for the Evaluation of Nicotine in Cigarettes (CENIC) and the Consortium on Methods Evaluating Tobacco (COMET), pursued specific research themes relevant to FDA's priorities. A key mandate for FDA is to reduce tobacco use among young people. This article is a review of the peer-reviewed research, including published and in-press manuscripts, from the TCORS, CENIC, and COMET, which provides specific data or other findings on youth (ages 10-18 years) and/or young adults (ages 18-34 years), from 2013 to 2018. Citations of all TCORS, CENIC, and COMET articles from September 2013 to December 2017 were collected by the TCORS coordinating center, the Center for Evaluation and Coordination of Training and Research. Additional citations up to April 30, 2018 were requested from the principal investigators. A scoring rubric was developed and implemented to assess study type, primary theme, and FDA priority area addressed by each article. The major subareas and findings from each priority area are presented. There were 766 articles in total, with 258 (34%) focusing on youth and/or young adults. Findings relevant to FDA from this review concern impact analysis, toxicity, health effects, addiction, marketing influences, communications, and behavior.

IMPLICATIONS

The Tobacco Centers of Regulatory Science, CENIC, and COMET have had a high output of scientific articles since 2013. These Centers are unique in that the FDA supports science specifically to guide future regulatory actions. The 258 articles that have focused on youth and/or young adults are providing data for regulatory actions by the FDA related to the key priority areas such as the addictiveness of non-cigarette products, the effects of exposure to electronic cigarette marketing on initiation and cessation, and the impact of flavored products on youth and young adult tobacco use. Future regulations to reduce tobacco use will be guided by the cumulative evidence. These Centers are one innovative mechanism to promote important outcomes to advance tobacco regulatory science.

Why smokers avoid cigarette pack risk messages: Two randomized clinical trials in the United States

BACKGROUND

Message avoidance (e.g., trying not to look at the message) may be motivated by reactance, a maladaptive rejection of the message. An alternative view is that avoidance indicates that a message is eliciting fear and other negative affect, thereby increasing the likelihood of behavioral change. We sought to identify which psychological mechanism-reactance or fear and other negative affect-explains message avoidance. We also examined whether avoidance was associated with more forgoing or butting out of cigarettes.

METHOD

Trial 1 randomly assigned 2149 adult U.S. smokers to receive either pictorial warnings (intervention) or text-only warnings (control) on their cigarette packs for four weeks in 2014 and 2015. Trial 2 randomly assigned 719 adult U.S. smokers to receive either messages about toxic chemicals in cigarette smoke (intervention) or messages about not littering cigarette butts (control) for three weeks in 2016 and 2017. Negative affect included fear, anxiety, disgust, sadness, and guilt. Reactance included perceived threat to freedom, anger, and counterarguing.

RESULTS

Intervention messages led to greater message avoidance in both trials (both p < .001). In Trial 1, intervention messages elicited greater negative affect, which in turn was associated with greater avoidance (mediated effect = 0.21, p < .001). In contrast, reactance explained only a small part of the effect in Trial 1 (mediated effect = 0.03, p < .001). Similarly, in Trial 2, intervention messages elicited greater negative affect, which was associated with more avoidance (mediated effect = 0.12, p < .001); reactance did not explain any of the effect. In both trials, avoidance was associated with more forgoing or butting out of cigarettes (ps < .001).

CONCLUSIONS

Smokers may avoid cigarette pack risk messages because they evoke aversive types of emotion. These studies add to a growing body of evidence that, in the context of cigarette pack messages, avoidance is not a form of defensive processing but instead a sign of deeper processing.

Testing Cessation Messages for Cigarette Package Inserts: Findings from a Best/Worst Discrete Choice Experiment

This study assessed smokers' responses to different smoking cessation topics and imagery for cigarette package inserts. Adult smokers from Canada (n = 1000) participated in three discrete choice experiments (DCEs): DCE 1 assessed five cessation benefit topics and five imagery types; DCE 2 assessed five messages with tips to improve cessation success and five imagery types; DCE 3 assessed four reproductive health benefits of cessation topics and four imagery types. In each DCE, participants evaluated four or five sets of four inserts, selecting the most and least motivating (DCEs 1 & 3) or helpful (DCE 2) for quitting. Linear mixed models regressed choices on insert and smoker characteristics. For DCE 1, the most motivating messages involved novel disease topics and imagery of younger women. For DCE 2, topics of social support, stress reduction and nicotine replacement therapy were selected as most helpful, with no differences by imagery type. For DCE 3, imagery influenced choices more than topic, with imagery of a family or a mom and baby selected as most motivating. Statistically significant interactions for all three experiments indicated that the influence of imagery type on choices depended on the message topic. Messages to promote smoking cessation through cigarette pack inserts should consider specific combinations of message topic and imagery.