Frequency and Content of Conversations About Pictorial Warnings on Cigarette Packs

Comparisons between young adult waterpipe smokers and nonsmokers' reactions to pictorial health warning labels in Lebanon: a randomized crossover experimental study

This study compares the impact of pictorial health warning labels (HWLs) and their placements on waterpipe parts (device, tobacco and charcoal packages) on health communication outcomes between waterpipe smokers and nonsmokers in Lebanon. An online randomized crossover experimental study was conducted among young adults (n = 403, August 2021) who observed three conditions of HWLs: pictorial HWLs on the tobacco package, pictorial HWLs on all waterpipe's parts and text-only HWL on the tobacco package in random order. Participants completed post-exposure assessments of health communication outcomes after each image. Using linear mixed models, we examined the differences in the effect of HWL conditions on several outcomes (i.e. warning reactions) between waterpipe smokers and nonsmokers, controlling for confounders (i.e. age, sex). Nonsmokers reported greater attention (β = 0.54 [95% confidence interval: 0.25-0.82]), cognitive elaboration (0.31 [0.05-0.58]) and social interaction (0.41 [0.18-0.65]) for pictorial HWLs on the tobacco packages than text-only compared with smokers. Pictorial HWLs on three parts versus one part elicited higher cognitive reactions and perceived message effectiveness in nonsmokers compared with waterpipe smokers. These findings provide valuable information for policymakers about the potential of implementing HWLs specific to waterpipes to prevent their use among young adults and limit tobacco-related morbidity and mortality in Lebanon.

Impact of pictorial health warning labels on smoking beliefs and perceptions among waterpipe smokers: an online randomised cross-over experimental study

PURPOSE

Waterpipe tobacco smoking (WTS) has substantially increased among young people in Lebanon, who perceive WTS as safer than cigarettes. Health warning labels (HWLs) can inform the adverse effects associated with smoking. Thus, their application to waterpipe offers a favourable policy to limit WTS epidemic. This study assessed the effectiveness of pictorial HWLs and their placements on waterpipe parts (device, tobacco and charcoal package) on several communication outcomes.

METHODS

We conducted a randomised cross-over experimental study among 276 waterpipe smokers (aged 18-34) between 13 and 26 August 2021. Participants observed three conditions: pictorial HWLs on tobacco packages, pictorial HWLs on three parts of the waterpipe (device, tobacco and charcoal package) and text only on tobacco package in random order. Participants completed baseline and postexposure assessments evaluating HWL effectiveness on attention, reaction, attitudes and beliefs, perceived effectiveness of HWLs and intention to quit WTS. Planned comparisons using Friedman test followed by pairwise Wilcoxon signed-rank test for multiple comparisons were conducted.

RESULTS

Compared with text only, pictorial HWLs elicited greater attention (p=0.011), higher cognitive elaboration (p=0.021), perceived message effectiveness (p=0.007), negative affect reactions (p<0.01) and greater psychological reactance (p=0.01). No significant differences were found for most communication outcomes between pictorial HWLs on three parts of the waterpipe compared with tobacco package only.

CONCLUSIONS

Pictorial HWLs on tobacco package were superior to text only for several communication outcomes. These findings provide strong evidence for potential implementation of pictorial HWLs on waterpipe tobacco packages to increase smokers' awareness of the health effects of WTS and correct false safety perceptions.

Examining the effect of waterpipe specific pictorial health warning labels among young adults in Lebanon and Tunisia: Protocol of a factorial experiment study design

Waterpipe tobacco smoking (WTS) has increased substantially in the Eastern Mediterranean Region (EMR), affecting young adults who perceive waterpipe as safer than cigarette smoking. Applying pictorial health warning labels (HWLs) on tobacco products has been effective in communicating health risks associated with tobacco smoking. However, there are few experimental studies that examined pictorial HWLs specific to WTS. Methods/design: This report describes the design and protocol of the first factorial experimental study that aims to test the effectiveness of pictorial HWLs based on their placement on waterpipe device, tobacco, and charcoal packages among young adult smokers and non-smokers residing in Lebanon and Tunisia. After completing a baseline assessment, participants will be randomly assigned to 3 experimental conditions in a 3 (HWL: pictorial HWL on tobacco package vs. pictorial HWL on 3 placements [device, tobacco, and charcoal packages] vs. text-only HWL on tobacco package) x 4 (pictorial HWLs) x 2 (waterpipe smokers vs. non-smokers) factorial design. We will use a within/between-subject design, where pictorial HWLs and time (pre vs. post-exposure) are the within-subject factors and waterpipe smoking status as the between-subjects factor. Participants will complete post-exposure measures that include attention, perceived harm, intention to quit (smokers) or initiate smoking (non-smokers). Discussion: This is the first international study examining the placements of pictorial HWLs using efficient within/between subject design. Findings will provide additional evidence to convince policymakers to consider three placements of HWLs specific to WTS as a promising regulatory target to curb WTS.

Message perceptions and effects perceptions as proxies for behavioral impact in the context of anti-smoking messages

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In the context of anti-smoking messages, effects perceptions (perceived behavioral impact) mediated message impact on quit intentions and six quitting and related behaviors while message perceptions (persuasive potential) did not.

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The sizes of indirect effects involving effects perceptions ranged from small to medium.

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These findings provide support for the diagnostic value of effects perceptions in testing messages for behavior change in the context of tobacco use and, possibly, other risky health behaviors.

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The use of effects perceptions in formative research may increase the efficiency with which behavior change interventions can be developed and optimized under resource constraints.

Researchers commonly use message perceptions (persuasive potential) or effects perceptions (perceived behavioral impact) in formative research to select tobacco risk messages. We sought to identify whether message perceptions or effects perceptions are more useful as proxies for the behavioral impact of tobacco risk messages. In a three-week trial, 703 U.S. adult smokers (ages ≥ 21) were randomly assigned to receive brief messages on their cigarette packs about toxic chemicals in cigarette smoke (chemical messages) or control messages about properly disposing of cigarette litter. The final follow-up survey assessed message perceptions, effects perceptions, quit intentions, and six behavioral outcomes. We conducted multiple mediation analysis in a structural equation modeling framework to test the indirect effects of messages by way of message perceptions and effects perceptions. Message perceptions did not independently mediate the impact of chemical messages on any of the outcomes (7 p-values ≥ 0.01). In contrast, effects perceptions mediated the impact of chemical messages on avoiding the messages, seeking chemical information, intentions to quit smoking, butting out a cigarette, forgoing a cigarette, and making a quit attempt (6 p-values ≤ 0.001). No mediation was present for social interactions about the message (p-value = 0.72). The effect sizes for these mediated effects were small to medium. Thus, effects perceptions, but not message perceptions, were a proxy for risk messages’ impact on quit intentions and six quitting and related behaviors. These findings point to the diagnostic value of effects perceptions in formative research on tobacco risk messages.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

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

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

Understanding Why Pictorial Cigarette Pack Warnings Increase Quit Attempts

BACKGROUND

Our randomized trial found that pictorial cigarette pack warnings elicited more quit attempts than text-only warnings.

PURPOSE

In the current study, we sought to identify psychological mechanisms that explain why pictorial cigarette pack warnings change behavior.

METHODS

In 2014 and 2015, we recruited 2,149 adult smokers in NC and CA, USA. We randomly assigned smokers to receive on their cigarette packs for 4 weeks either a text-only warning (one of the USA's current warnings on the side of cigarette packs) or a pictorial warning (one of the USA's proposed text warnings with pictures on the top half of the front and back of cigarette packs).

RESULTS

Pictorial warnings increased attention to, reactions to, and social interactions about cigarette pack warnings (all p < .05). However, pictorial warnings changed almost no belief or attitude measures. Mediators of the impact of pictorial warnings included increased attention, negative affect, social interactions, thinking about the warning and harms of smoking, and intentions to quit (all p < .05). Analyses also found that pictorial warnings led to greater avoidance of the warnings, which was associated with more quit attempts (p < .05).

CONCLUSIONS

Pictorial warnings increased quit attempts by eliciting aversive reactions and by keeping the message vividly in smokers' minds. Contrary to predictions from several theories of health behavior, the warnings exerted little of their influence through changes in beliefs and attitudes and none of their influence through changes in risk perception. We propose the Tobacco Warnings Model based on these findings.

CLINICAL TRIAL INFORMATION

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

Sugary drink warnings: A meta-analysis of experimental studies

BACKGROUND

Policymakers worldwide are considering requiring warnings for sugary drinks. A growing number of experimental studies have examined sugary drink warnings' impacts, but no research to our knowledge has synthesized this literature. To inform ongoing policy debates, this study aimed to identify the effects of sugary drink warnings compared with control conditions.

METHODS AND FINDINGS

We systematically searched 7 databases on June 21, 2019, and October 25, 2019. We also searched reference lists of relevant articles. Two investigators independently screened titles, abstracts, and full texts to identify peer-reviewed articles that used an experimental protocol to examine the effects of sugary drink warnings compared to a control condition. Two investigators independently extracted study characteristics and effect sizes from all relevant full-text articles. We meta-analyzed any outcome assessed in at least 2 studies, combining effect sizes using random effects meta-analytic procedures. Twenty-three experiments with data on 16,241 individuals (mean proportion female, 58%) were included in the meta-analysis. Most studies took place in Latin America (35%) or the US or Canada (46%); 32% included children. Relative to control conditions, sugary drink warnings caused stronger negative emotional reactions (d = 0.69; 95% CI: 0.25, 1.13; p = 0.002) and elicited more thinking about the health effects of sugary drinks (d = 0.65; 95% CI: 0.29, 1.01; p < 0.001). Sugary drink warnings also led to lower healthfulness perceptions (d = -0.22; 95% CI: -0.27, -0.17; p < 0.001) and stronger disease likelihood perceptions (d = 0.15; 95% CI: 0.06, 0.24; p = 0.001). Moreover, sugary drink warnings reduced both hypothetical (d = -0.32; 95% CI: -0.44, -0.21; p < 0.001) and actual consumption and purchasing behavior (d = -0.17; 95% CI: -0.30, -0.04; p = 0.012). Statistically significant effects were not observed for perceptions of added sugar or positive sugary drink attitudes (p's > 0.10). Moderation analyses revealed that health warnings (e.g., "Beverages with added sugar contribute to obesity") led to greater reductions in hypothetical sugary drink purchases than did nutrient warnings (e.g., "High in sugar"; d = -0.35 versus -0.18; Qb = 4.04; p = 0.04). Limitations of this study include that we did not review grey literature and that we were unable to conduct moderation analyses for several prespecified moderators due to an insufficient number of studies.

CONCLUSIONS

This international body of experimental literature supports sugary drink warnings as a population-level strategy for changing behavior, as well as emotions, perceptions, and intentions.

PROTOCOL REGISTRY

PROSPERO ID 146405.

Impact of e-cigarette health warnings on motivation to vape and smoke

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.

A Secondary Audience's Reactions to "The Real Cost" Advertisements: Results From a Study of U.S. Young Adult Smokers and Susceptible Nonsmokers

INTRODUCTION

Exposure to "The Real Cost" campaign has prevented smoking initiation among its target audience (U.S. youth aged 12-17 years). This study examines reactions to "The Real Cost" advertisements among a potential secondary audience: U.S. young adults.

METHODS

An online convenience sample of young adult (ages 18-29 years) smokers (n=225) and susceptible nonsmokers (n=339) participated in a within-subjects experiment in 2017. Participants viewed three TV ads from "The Real Cost" campaign and reported their past exposure to, conversations about, and reactions to the ads. In 2017, analyses examined message-level and person-level predictors of perceived message effectiveness using multilevel modeling.

RESULTS

About half of smokers (47%) and susceptible nonsmokers (51%) had seen at least one of the three ads in the past 3 months. About one in four smokers (23%) and susceptible nonsmokers (24%) had at least one conversation about the ads in the past 3 months. Susceptible nonsmokers rated the ads higher on perceived message effectiveness than smokers (p<0.01), but lower on message relevance and negative affective reactions to the ads (both p<0.05). In both samples, ads that elicited higher negative affective reactions and message relevance, and lower message reactance (i.e., resistance) received higher perceived message effectiveness ratings (all p<0.05).

CONCLUSIONS

"The Real Cost" ads have reached and generated conversations among a convenience sample of young adult smokers and susceptible nonsmokers. Increasing the perceived relevance and emotional reactions of campaigns may increase their impact. Future studies should examine reactions to "The Real Cost" campaign and effects on smoking behavior using nationally representative samples of young adults.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

Conversations about pictorial cigarette pack warnings: Theoretical mechanisms of influence

BACKGROUND

Social interactions are a key mechanism through which health communication campaigns influence behavior. Little research has examined how conversations about pictorial warnings motivate behavior.

PURPOSE

We sought to establish whether and how smokers' conversations explain the effect of pictorial warnings on quit attempts.

METHODS

US adult smokers (n = 2149) participated in a controlled trial that randomly assigned them to have their cigarette packs labeled with pictorial or text-only warnings for four weeks. Surveys assessed the number of conversations sparked by pictorial warnings and the theoretical mechanisms cognitive elaboration and social norms at each visit. Analyses used structural equation modeling to test our theorized mediation models.

RESULTS

The number of conversations about the warnings mediated the relationship between exposure to pictorial warnings and quit attempts (p < .001). In serial mediation analysis examining possible theoretical mechanisms, the number of conversations was associated with greater cognitive elaboration, which in turn was associated with being more likely to make a quit attempt (p < .05). Social norms did not explain the influence of conversations on quit attempts.

CONCLUSIONS

Pictorial warnings increased conversations about the warnings, which led to greater cognitive elaboration, which led to greater quit attempts. Our findings suggest designing warnings that increase conversations in order to better inform and motivate smokers. Furthermore, these findings improve our understanding of why conversations matter in health communication.

"That's probably what my mama's lungs look like": how adolescent children react to pictorial warnings on their parents' cigarette packs

BACKGROUND

Pictorial cigarette pack warnings discourage smoking, but most evidence comes from studies of adults. Our qualitative study explored adolescents' reactions to pictorial warnings on their parents' cigarette packs.

METHODS

We interviewed 24 adolescents whose parents received pictorial warnings on their cigarette packs as part of a randomized clinical trial. We conducted a thematic content analysis of the interview transcripts.

RESULTS

Pictorial cigarette pack warnings led adolescents to imagine the depicted health effects happening to their parents, which elicited negative emotions. The warnings inspired adolescents to initiate conversations with their parents and others about quitting smoking. Adolescents believed the warnings would help smokers quit and prevent youth from starting smoking. Some current smokers said the warnings made them consider quitting.

CONCLUSIONS

Conversations about the pictorial warnings may amplify their effectiveness for smokers, their adolescent children, and friends of the adolescent children. Cigarette pack warnings may reach a broad audience that includes adolescent children of smokers.

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.

Placing Health Warnings on E-Cigarettes: A Standardized Protocol

Health warnings for e-cigarettes are a promising and novel tobacco control intervention for reducing e-cigarette use. We developed a new protocol for evaluating e-cigarette warnings by placing them on users' own devices to reflect real-world exposure. Study 1 participants were a national convenience sample of 606 U.S. adult e-cigarette users surveyed online in March 2017. Most Study 1 participants were willing to have their e-cigarette devices (87%) and refills (83%) labeled. Study 2 participants were a convenience sample of 22 adult e-cigarette users recruited in California, United States in April 2017. We applied the U.S. Food and Drug Administration's proposed e-cigarette warning to users' own devices and refills. Most Study 2 participants (81%) reported using e-cigarette devices with our warning labels at least 90% of the time during the study. Nearly all (95%) said they would participate in the study again, and 100% would recommend the study to a friend. Conversations about e-cigarette harms, conversations about quitting e-cigarettes, and intentions to quit using e-cigarettes increased during the study (all p < 0.05). These studies show that our naturalistic labeling protocol was feasible, acceptable to participants, and had high retention over three weeks. Using the protocol can yield important evidence on the impact of e-cigarette warnings to inform tobacco warning policies.

Increasing Effectiveness of Messages about Chemicals in Cigarette Smoke

OBJECTIVES

Federal law requires informing the public on toxic chemicals in cigarette smoke. We sought the public's advice about communicating information about these chemicals.

METHODS

Adolescents, young adults, and adults (N = 59), including smokers and non-smokers, participated in 9 focus groups that discussed inclusion of messages about toxic chemicals on cigarette packs, in media campaigns, and on a website. We transcribed, coded, and analyzed focus group audio-recordings.

RESULTS

Participants had 3 suggestions for message content to increase the impact of messages about cigarette smoke chemicals. First, they wanted to see messages rotated more frequently to increase message novelty. Second, they recommended using stories and pictures to help connect people to the abstract idea of chemicals in smoke. Third, they cautioned against making messages that might seem overblown and could appeal to the rebellious nature of adolescents. Some participants mentioned that chemical information on a website might discourage people from smoking; others mentioned that people might use it to choose which brand to smoke.

CONCLUSIONS

Legislation provides the impetus to design new chemical disclosure messages for cigarette packs and other media. Our findings can help increase the impact of these messages.

Public support for pictorial warnings on cigarette packs: an experimental study of US smokers

BACKGROUND

Understanding factors that influence public support for "nudging" policies, like pictorial cigarette pack warnings, may offer insight about how to increase such support. We sought to examine factors that influence smokers' support for requiring pictorial warnings on cigarette packs.

METHODS

In 2014 and 2015, we randomly assigned 2149 adult US smokers to receive either pictorial warnings or text-only warnings on their cigarette packs for 4 weeks. The outcome examined in the current study was support for a policy requiring pictorial warnings on cigarette packs in the US.

RESULTS

Support for pictorial warnings was high at baseline (mean: 3.2 out of 4). Exposure to pictorial warnings increased policy support at week 4 (β = .05, p = .03). This effect was explained by increases in perceived message effectiveness (p < .001) and reported conversations about policy support (p < .001). Message reactance (i.e., an oppositional reaction to the warning) partially diminished the impact of pictorial warnings on policy support (p < .001).

CONCLUSIONS

Exposing people to a new policy through implementation could increase public support for that policy by increasing perceived effectiveness and by prompting conversations about the policy. Reactance may partially weaken the effect of policy exposure on public support.

Cigarette pack messages about toxic chemicals: a randomised clinical trial

Background

The USA can require tobacco companies to disclose information about harmful and potentially harmful chemicals in cigarette smoke, but the impact of these messages is uncertain. We sought to assess the effect of placing messages about toxic chemicals on smokers’ cigarette packs.

Methods

Participants were 719 adult cigarette smokers from California, USA, recruited from September 2016 through March 2017. We randomly assigned smokers to receive either factual messages about chemicals in cigarette smoke and their health harms (intervention) or messages about not littering cigarette butts (control) on the side of their cigarette packs for 3 weeks. The primary trial outcome was intention to quit smoking.

Results

In intent-to-treat analyses, smokers whose packs had chemical messages did not have higher intentions to quit smoking at the end of the trial than those whose packs had control messages (P=0.56). Compared with control messages, chemical messages led to higher awareness of the chemicals (28% vs 15%, P<0.001) and health harms (60% vs 52%, P=0.02) featured in the messages. In addition, chemical messages led to greater negative affect, thinking about the chemicals in cigarettes and the harms of smoking, conversations about the messages and forgoing a cigarette (all P<0.05).

Discussion

Chemical messages on cigarette packs did not lead to higher intentions to quit among smokers in our trial. However, chemical messages informed smokers of chemicals in cigarettes and harms of smoking, which directly supports their implementation and would be critical to defending the messages against cigarette company legal challenges.

Trial registration number

NCT02785484.