Negative affect, message reactance and perceived risk: how do pictorial cigarette pack warnings change quit intentions?

Self-reported attention and responses to cigarette package labels at the end of a two-week randomized trial of cigarette package labeling configurations

INTRODUCTION

Cigarette package inserts that describe quitting benefits and tips may promote cessation; however, research is needed to understand better their effects, including potentially enhancing the effects of pictorial health warning labels (PHWLs).

METHODS

A randomized trial with a 2×2 factorial design was conducted with adult smokers (n=356) assigned to either small text-only health warning labels (HWLs; control); inserts with cessation messages, and the small text-only HWLs (inserts-only); large PHWLs (PHWLs-only); both inserts and PHWLs (inserts + PHWLs). Participants received a 14-day supply of their preferred cigarettes with packs labeled to reflect their group. Upon finishing the trial, participants reported their past 14-day frequency of noticing, reading, thinking about smoking harms and cessation benefits, talking about labels, and forgoing cigarettes because of the labels. Ordered logistic models regressed these outcomes on labeling groups, and mediation analyses assessed whether attention (i.e. noticing, reading) to labels mediated effects of labeling exposure on other outcomes (i.e. thinking about harms/benefits, talking, forgoing).

RESULTS

The inserts + PHWLs group reported higher frequencies than the control group for all outcomes. Compared to the control group, both the inserts-only and PHWLs-only groups reported higher frequency of noticing (AOR=3.53 and 2.46, respectively) and reading labels (AOR=2.89 and 1.71), thinking about smoking risks because of the labels (AOR=1.93 and 1.82), and talking about labels (AOR=2.30 and 2.70). Participants in the inserts-only group also reported more frequent thinking about quitting benefits (AOR=1.98). Attention mediated all labeling effects except for the contrast between PHWLs only and control.

CONCLUSIONS

Compared to text-only HWLS, cigarette labeling that involves inserts, PHWLs, or both appears more effective at drawing attention to warnings, which mediated the effects on cessation-related psychosocial and behavioral outcomes.

Managing Fear Responses: A Qualitative Analysis of Pictorial Warning Labels Five Years Post-Plain Packaging

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.

"I Saw it Incidentally but Frequently": Exploring the Effects of Online Health Information Scanning on Lung Cancer Screening Behaviors Among Chinese Smokers

In China, lung cancer is the most common cancer with high mortality. While prior research suggests that health information scanning influences cancer screening within the general population, a deeper exploration of the underlying mechanisms is imperative. This study specifically targets smokers, aiming to investigate whether online health information scanning can effectively encourage lung cancer screening and elucidate the mechanisms driving this association. Data were extracted from a Chinese national survey conducted between January and September 2023, exclusively involving current smokers (N = 992). A moderated mediation model was employed to examine a cognitive-affective sequential chain of mediation through risk perceptions and cancer worry. Results showed that 99.1% of Chinese smokers reported online health information scanning, which possessed significant influence. Online health information scanning was positively associated with effective lung cancer screening among smokers directly (OR = 1.927, p < .01) and indirectly (OR = .065, p < .001). The perceived threat of smoking and cancer worry served as the cognitive and affective mediating mechanisms. Furthermore, a moderating effect of eHealth literacy was observed (OR = 6.292, p < .05). Smokers with higher eHealth literacy are more inclined to undergo effective lung cancer screening. Based on these findings, public health sectors should leverage online platforms to disseminate tailored cancer screening education and implement initiatives to enhance public eHealth literacy.

Developing messages to encourage healthy, sustainable dietary substitutions: A qualitative study with US emerging adults

Prior research shows that adopting simple dietary substitutions (e.g., replacing beef with poultry or plant-based entrees) can improve dietary quality and reduce the negative environmental consequences of food production, but little is known about how to encourage people to adopt these substitutions. This study aimed to examine reactions to messages encouraging healthy, sustainable dietary substitutions among emerging adults ages 18-25. We conducted four online focus groups with a diverse sample of US emerging adults (n = 28; 61% female). Focus groups explored emerging adults' reactions to messages encouraging them to adopt three target dietary substitutions: replacing beef and pork with poultry and plant-based entrees; replacing juice with whole fruit; and replacing dairy milk with non-dairy milk. We transcribed discussions verbatim and adopted a thematic approach to analyzing the transcripts. Results showed that participants perceived messages to be most effective at encouraging the target dietary substitutions when the messages: encouraged specific, achievable dietary changes; linked these dietary changes to clear consequences; included personally relevant content; included statistics; were succinct; and used a positive tone. Across the target dietary substitutions, two message topics (small changes, big benefits, which emphasized how small dietary changes can have large positive health and environmental impacts, and warning, which discussed the negative health and environmental impacts of dietary choices) were generally perceived to be most effective. A few participants expressed doubt that the target dietary substitutions would have meaningful environmental impacts. Results suggest that campaign messages to encourage healthy, sustainable dietary substitutions may be more effective if the messages make the target dietary substitutions seem achievable and use statistics to clearly describe the positive impacts of making these changes.

"I Can See a Story from the Warning": Understanding the Role of Perceived Narrativity in Pictorial Warning Labels

This study examined the role of perceived narrativity in pictorial warning labels (PWLs) in countering warning reactance and increasing warning effectiveness and support in the context of communicating the cancer risk of alcohol. Findings from a randomized experiment (N = 1,188) showed that PWLs with imagery of lived experience were perceived higher in narrativity than those with imagery of graphic health effects. Adding a one-sentence narrative (vs. non-narrative) text statement to PWLs with imagery of lived experience did not affect perceived narrativity. Perceived narrativity predicted lower reactance to warnings and subsequently higher intentions to stop drinking and higher policy support. Total effects showed that PWLs with imagery of lived experience and non-narrative text led to the lowest reactance, the highest intentions to stop drinking, and the highest level of policy support. This study adds to a growing body of evidence that PWLs featuring narrative content are promising in communicating health risks.

Combining Inserts With Warning Labels on Cigarette Packs to Promote Smoking Cessation: A 2-Week Randomized Trial

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.

Is evoking fear effective? Exploratory findings from a randomised experiment on the impacts of health warning labels on sugar-sweetened beverages

OBJECTIVE

Health warning labels (HWL) have been suggested to be effective in reducing consumption of sugar-sweetened beverages (SSB). Yet, the efficacy and acceptability of SSB HWL of different formats (textual/pictorial) and severity remain unclear. This exploratory study aims to examine the extent and mechanism through which HWL of different formats and severity may affect responses towards the HWL and SSB consumption.

DESIGN

Randomised online experiment. Participants were exposed to images of a hypothetical SSB bearing a HWL of one of three conditions: text-only HWL, moderately severe pictorial HWL and highly severe pictorial HWL. They then responded to theory-based affective, cognitive and behavioural measures.

SETTING

Singapore.

PARTICIPANTS

One hundred and twenty-seven young adult consumers from a public university.

RESULTS

Direct effects were found for fear, avoidance, reactance and acceptability of the HWL, but not attitude, intention or motivation to consume less SSB. Pictorial (moderately severe and highly severe) HWL were associated with greater fear, avoidance, and reactance, and lower acceptability than text-only HWL. There was weak evidence that highly severe pictorial HWL resulted in greater reactance than moderately severe pictorial HWL. Fear mediated the effect of HWL of different severity levels on avoidance, reactance, intention and motivation, but not for attitude or acceptability.

CONCLUSIONS

Exploratory findings indicate that although pictorial HWL were less acceptable, they may still be effective in influencing intention and motivation to reduce SSB consumption through the psychological mechanism of fear. Hence, graphic HWL should not be dismissed too quickly when considering strategies for reducing SSB consumption.

Emotional Appeals and Norms: How Normative Perceptions Moderate the Persuasive Impacts of Discrete Emotional Appeals within Tobacco Pictorial Warnings in China

Tobacco pictorial warnings could employ a variety of emotional appeals to enhance effectiveness; however, little research exists to guide the selection of discrete emotional appeals. Further, it remains unclear how contextual pro-smoking norms might influence the persuasive impacts of discrete emotional appeals within pictorial warnings, especially in China, where the overall smoking rate and social acceptance remain high. To fill these gaps, this study leveraged the largest set of pictorial warnings (K = 510) tested to date. Using a randomized large-K multiple-message design, we evaluated the impacts of disgust, fear, self-anger, contempt, shame, and hope appeals among Chinese adult male smokers (N = 2,306) on perceived message effectiveness (PME). Results showed that fear, self-anger, shame, and hope appeals significantly increased PME, while disgust and contempt appeals appeared less effective. Importantly, the PME of nearly all emotional appeals - except hope appeals - was weakened for Chinese adult male smokers with higher pro-smoking normative perceptions, highlighting the importance of considering local contextual influences when implementing pictorial warnings.

Designing Cancer Warning Labels for Alcoholic Beverages: Examining the Impact of Visual Elements

Alcohol is a known carcinogen. However, public awareness of cancer risk associated with alcohol use is low. A promising approach to raising awareness is to include cancer warning labels on alcohol-containing products, but there is limited knowledge of the design and effect of such warnings. The present study investigated the impact of visual elements on the effectiveness of cancer warning labels. In a randomized online experiment, alcohol consumers (N = 1,190) were randomly assigned to one of three conditions: exposure to (a) text-only warning labels, (b) pictorial warning labels showing graphic health effects (e.g., diseased organs), and (c) pictorial warning labels showing lived experience (e.g., cancer patients in a medical setting). The results showed that whereas the three warning types did not differ significantly in behavioral intentions, pictorial warnings featuring health effects led to greater disgust and anger than text-only warnings and pictorial warnings featuring lived experience. Moreover, anger predicted lower intentions to reduce alcohol use and was a significant mediator of the effects of warning type on behavioral intentions. The findings highlight the role of emotions in responses to health warning labels with different visual elements and suggest that text-only warnings and pictorial warnings with lived experience may be useful in preventing boomerang effects.

How Do Young Adult Drinkers React to Varied Alcohol Warning Formats and Contents? An Exploratory Study in France

Research on alcohol warnings has increased in the last decade, providing key evidence to governments on warning format and contents. The bulk of this research, however, has been conducted in Anglosphere countries, whereas fewer studies have focused on other countries which have high per capita alcohol consumption, and where the high social acceptability of drinking is liable to affect how people accept and react to prevention measures. Since France has one of the highest per capita alcohol consumption rates in the world according to the World Health Organization (WHO), we therefore explore how young adults in France react to warnings on alcoholic beverage advertisements. We conducted 25 in-depth interviews, in 2017, with 18-25-year-old drinkers in France. Respondents were asked open-ended questions on the perceived impact of various warning contents (i.e., on health risk, social-cost risk, and on short- vs. long-term risk) and formats (text only vs. larger text combined with colored pictograms). Warnings that targeted youth-relevant risks (i.e., road accidents or sexual assault) were considered to be the most meaningful and credible, although warnings communicating longer term risks (i.e., brain, cancer) were also thought to be influential. Less familiar risks, such as marketing manipulation and calorie intake, elicited the most negative reactions. Larger text-and-pictogram warnings were considered to be the most effective format in capturing attention and increasing awareness. Regardless of format and content, however, these warnings were not perceived as effective for decreasing alcohol consumption.

Effects of Sugary Beverage Text and Pictorial Warnings: A Randomized Trial

INTRODUCTION

Multiple U.S. localities have introduced legislation requiring sugar-sweetened beverage (SSB) warnings. This study effects of different warning designs on beverage selections and perceptions.

STUDY DESIGN

The study was an RCT.

SETTING/PARTICIPANTS

An online virtual convenience store and survey were used with a nationally representative sample of primary caregivers of 6-11-year-olds (n=961). Data were collected in January 2020 and analyzed in May-July 2020.

INTERVENTION

Participants were randomized to view SSBs with 1 of 4 front-of-package label designs: (1) no-warning control, (2) health-related text warning, (3) sugar pictorial warning (image of beverage sugar content in cubes/teaspoons/packets with health-related warning text), or (4) health pictorial warning (image of possible health consequences of overconsuming SSBs with health-related warning text).

MAIN OUTCOME MEASURES

Outcomes included participants' beverage choice for their child and perceptions of beverages, their assigned labels, and warning policies.

RESULTS

Proportionally fewer participants chose a SSB in the sugar pictorial warning condition (-13.4 percentage points; 95% CI= -21.6 to -0.1 percentage points; p=0.007) and in the health pictorial warning condition (-14.7 percentage points; 95% CI= -22.8 to -0.1 percentage points; p=0.004) compared to the control. Sugar pictorial warnings led to more accurate added-sugar content estimates than all conditions and greater label trust and support for sugar-sweetened beverage warning policies than health pictorial warnings.

CONCLUSIONS

SSB warning policies may be most effective if they mandate images of beverages' added sugar content accompanied by warning text.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT03648138.

Role of affective reactivity induced by cigarette packaging including graphic warning labels: the CASA Study

OBJECTIVE

To identify whether three types of cigarette pack designs, including three versions of graphic warning label (GWL) plain packs, one GWL absent and branding absent pack (blank) and the smoker's own GWL absent and branding present pack (US), elicit different valence, type and levels of affect.

DESIGN

US daily smokers (n=324) were asked to handle each of the five pack types and 'think aloud' their reactions. To avoid a muted familiarity response, exposure to their own US pack followed exposure to at least one GWL plain pack. Reactions were scored on a reactivity scale (-3 to +3) and the text was coded for speech polarity (-1 to +1) and emotive word frequency.

RESULTS

Reactivity scores had excellent inter-rater reliability (agreement ≥86%; intraclass correlation coefficient ≥0.89) and were correlated with speech polarity (r=0.21-0.37, p<0.001). When considering their US pack, approximately two-thirds of smokers had a low (31.5%) to medium (34.6%) positive response (reactivity=1.29; polarity=0.14) with expressed feelings of joy and trust. Blank packaging prompted a largely (65.4%) neutral response (reactivity=0.03; polarity=0.00). The gangrenous foot GWL provoked mostly medium (46.9%) to high (48.1%) negative responses (reactivity=-2.44; polarity=-0.20), followed by neonatal baby (reactivity=-1.85; polarity=-0.10) and throat cancer (reactivity=-1.76; polarity=-0.08) warnings. GWLs varied in their elicitation of disgust, anger, fear and sadness.

CONCLUSION

Initial reactions to GWL packs, a blank pack, and smokers' current US pack reflected negative, neutral, and positive affect, respectively. Different versions of the GWL pack elicited different levels and types of immediate negative affect.

Responses to pictorial versus text-only cigarillo warnings among a nationally representative sample of US young adults

BACKGROUND

The US Food and Drug Administration requires six text-only warnings for cigar products, including cigarillos. Research has demonstrated the superiority of pictorial over text-only cigarette warnings, yet the relative effectiveness of pictorial warnings for cigarillos has not been examined. We examined the impact of pictorial cigarillo warnings compared with text-only warnings.

METHODS

Data were collected from a nationally representative sample of US young adult (18-29) cigarillo users and susceptible non-users. Participants were randomised to one of three experimental conditions: text-only or one of two pictorial conditions (combined for analyses). For each warning, we assessed negative emotional reactions, cognitive elaboration (ie, thinking about cigarillo risks) and perceived message effectiveness (PME).

RESULTS

Participants (N=661) were 46.5% female, 64.7% white and 21.9% Hispanic; 34.1% reported past 30-day cigarillo use; 41.4% were lifetime users (excluding past 30-day use); and 24.4% were susceptible non-users. Pictorial warnings elicited more negative emotional reactions and higher PME than text-only warnings (p values<0.01), with interactions showing the largest effects for past 30-day users (emotional reactions: d=0.99, PME: d=0.63). For cognitive elaboration, there was no main effect of warning type, but an interaction revealed effects for past 30-day users (p<0.05, d=0.46).

CONCLUSIONS

Pictorial cigarillo warnings elicited greater negative emotional reactions and PME compared with text-only warnings. These effects and the effects on cognitive elaboration were strongest for past 30-day users. Our findings extend research on cigarette warnings to cigarillos, demonstrating that pictorial warnings are superior to text-only warnings for cigarillos in eliciting beneficial responses.

Smokers' Affective Responses to COVID-19-Related Health Warnings on Cigarette Packets: The Influence of Delay Discounting

INTRODUCTION

The addition of graphic health warnings to cigarette packets can facilitate smoking cessation, primarily through their ability to elicit a negative affective response. Smoking has been linked to COVID-19 mortality, thus making it likely to elicit a strong affective response in smokers. COVID-19-related health warnings (C19HW) may therefore enhance graphic health warnings compared to traditional health warnings (THW). Further, because impulsivity influences smoking behaviors, we also examined whether these affective responses were associated with delay discounting.

METHODS

In a between-subjects design, 240 smokers rated the valence and arousal elicited by tobacco packaging that contained either a C19HW or THW (both referring to death). Participants also completed questionnaires to quantify delay discounting, and attitudes towards COVID-19 and smoking (eg, health risks, motivation to quit).

RESULTS

There were no differences between the two health warning types on either valence or arousal, nor any secondary outcome variables. There was, however, a significant interaction between health warning type and delay discounting on arousal ratings. Specifically, in smokers who exhibit low delay discounting, C19HWs elicited significantly greater subjective arousal rating than did THWs, whereas there was no significant effect of health warning type on arousal in smokers who exhibited high delay discounting.

CONCLUSION

The results suggest that in smokers who exhibit low impulsivity (but not high impulsivity) C19HWs may be more arousing than THWs. Future work is required to explore the long-term utility of C19HWs, and to identify the specific mechanism by which delay discounting moderates the efficacy of tobacco health warnings.

IMPLICATIONS

The study is the first to explore the impact of COVID-19-related health warnings on cigarette packaging. The results suggest that COVID-19-related warnings elicit a similar level of negative emotional arousal, relative to traditional warnings. However, COVID-19 warnings, specifically, elicit especially strong emotional responses in less impulsive smokers, who report low delay discounting. Therefore, there is preliminary evidence supporting COVID-19 related warnings for tobacco products to aid smoking cessation. Additionally, there is novel evidence that, for some warnings, high impulsiveness may be a factor in reduced warning efficacy, which may explain poorer cessation success in this population.

Consumer Reactions to Positive and Negative Front-of-Package Food Labels

INTRODUCTION

The National Academy of Medicine recommends that the U.S. adopt an interpretative front-of-package food labeling system, but uncertainty remains about how this system should be designed. This study examined reactions to front-of-package food labeling systems that use positive labels to identify healthier foods, negative labels to identify unhealthier foods, or both.

METHODS

In August 2021, U.S. adults (N=3,051) completed an online randomized experiment. Participants were randomly assigned to 1 of 4 labeling conditions: control (calorie), positive, negative, or both positive and negative labels. Labels were adapted from designs for a 'healthy' label drafted by the Food and Drug Administration and displayed on the front of product packaging. Participants selected products to purchase, identified healthier products, and reported reactions to the labels. Analyses, conducted in 2022, examined the healthfulness of participants' selections using the Ofcom Nutrient Profiling Model score (0-100, higher scores indicate being healthier).

RESULTS

Participants exposed to only positive labels, only negative labels, or both positive and negative labels had healthier selections than participants in the control arm (differences vs control=1.13 [2%], 2.34 [4%] vs 3.19 [5%], respectively; all p<0.01). The both-positive-and-negative-labels arm outperformed the only-negative-labels (p=0.03) and only-positive-labels (p<0.001) arms. The only-negative-labels arm outperformed the only-positive-labels arm (p=0.005). All the 3 interpretative labeling systems also led to improvements in the identification of healthier products and beneficial psychological reactions (e.g., attention, thinking about health effects; all p<0.05).

CONCLUSIONS

Front-of-package food labeling systems that use both positive and negative labels could encourage healthier purchases and improve understanding more than systems using only positive or only negative labels.

Reactions to Pictorial and Text Cigarette Pack Warning Labels among Chinese Smokers

Objectives. This study aims at examining the impact of graphic pictorial warning labels on inten-tion to quit smoking and perceived harms among Chinese working-age adults (n = 661). Methods. A randomized controlled trial is utilized as the research design by comparing three scenarios: Group 1 as baseline (n = 193) and presented with real market tobacco products with text-only la-bels, Group 2 as price group and with hypothetical scenarios of manipulated prices, and Group 3 as the imaging group and with hypothetical scenarios of graphic pictorial cigarette warning la-bels. Both bivariate and multivariate analyses are utilized to determine the effectiveness of warn-ing labels. Results. Graphic pictorial cigarette warning labels are associated with stronger inten-tion to quit smoking and greater perceived harms. Smokers have a greater number of attempts if they are less nicotine dependent and express greater smoking risk perceptions. Conclusions. This study adds to the evidence that graphic pictorial warning labels are more effective than text-only labels in increasing intention to quit smoking. As China strives to achieve a reduction in smoking to meet the goal of the Healthy China 2030 initiative, this work strengthens the evidence base for policy makers, practitioners, and researchers to design low-cost warning labels on cigarette packs to promote tobacco control.

The Role of Narrative Pictorial Warning Labels in Communicating Alcohol-Related Cancer Risks

This study examined the role of pictorial warning labels (PWLs) featuring narrative content in communicating alcohol-related cancer risks. In an online experiment, 169 adult alcohol consumers were randomly assigned to view two narrative PWLs, two non-narrative PWLs, or control. Results showed that exposure to narrative PWLs significantly increased participants' worry about, feelings of risk of, and perceived severity of harm of getting alcohol-related cancer, but did not affect their comparative likelihood of getting alcohol-related cancer or intentions to reduce alcohol use. Exposure to narrative PWLs also indirectly influenced intentions through increased worry. Moreover, participants' risk perceptions and intentions in non-narrative PWLs condition did not differ from those in narrative PWLs and control conditions. Therefore, these findings suggest that narrative PWLs are a promising strategy in informing consumers about the cancer risks of alcohol.

'It brings light to what you really put into your body': a focus group study of reactions to messages about nicotine reduction in cigarettes

OBJECTIVE

In 2017, the US Food and Drug Administration (FDA) announced a proposed regulation to lower nicotine in cigarettes to minimally addictive levels to help smokers quit. We sought to explore effective message strategies communicating about nicotine reduction in cigarettes across the different key audiences that the regulation is most likely to influence.

METHODS

We designed four types of messages: efficacy messages, risk messages, a message about alternative sources of nicotine and a compensation message. Sixteen virtual focus groups were conducted in Atlanta and San Francisco in April-May 2020. Data were analysed in NVivo 12.0 using a thematic analysis approach.

FINDINGS

Exclusive smokers were receptive to both efficacy messages and risk messages. Dual users were the only group that was open to resorting to alternative sources of nicotine. Former smokers were critical of these messages as promoting the new kinds of cigarettes and potentially encouraging initiation and relapse of smoking. Non-smokers felt that efficacy messages downplayed the risks of smoking and did not scare people away from smoking. Presenting information that very low nicotine cigarettes (VLNCs) still contain harmful chemicals made smokers question continued smoking in the absence of nicotine and view VLNCs as harmful.

CONCLUSIONS

Messages communicating about nicotine reduction in cigarettes might help to motivate smokers to quit and can correct the misperceptions that VLNCs are less harmful. The FDA should consider specific target audiences and use different messages that complement each other in communicating about this regulation.

Impact of Self-Affirmation on Responses to Health Warning Messages: Does Consideration of Future Consequences Matter?

Self-affirmation theory has inspired numerous studies that have tried to understand the effects of self-affirmation on defensive processing of threatening health messages and subsequent behavior. Despite the overall positive effects of self-affirmation, psychological processes through which self-affirmation exerts such impact remain unclear. We examined Consideration of Future Consequences (CFC) as a potential moderator of the effects of self-affirmation on responses to graphic cigarette warning warnings, in an attempt to shed light on the psychological processes. We conducted an experimental study in which 925 African American smokers were instructed to self-affirm (or not) prior to viewing graphic cigarette warning labels. We found that smokers with stronger present time orientation (PTO) experienced higher defensive responses as measured by anger, perceived message manipulation, and message derogation, after viewing graphic cigarette warning labels; whereas smokers with stronger future time orientation (FTO) reported less message derogation. PTO interacted with self-affirmation in predicting defensive processing measures, such that self-affirmation reduced message derogation at lower levels of PTO and increased message derogation and perceived message manipulation at higher levels of PTO. Self-affirmation also had a conditional indirect effect on smoking intentions and intention to quit smoking through measures of defensive processing. We discuss implications of our study.

"You Know Nothing about How Alcohol Might Lead to Cancer!" Effects of Threatening and Hedging Languages on Intentions to Reduce and Stop Drinking

Alcohol causes cancer, but many alcohol consumers are not aware of this risk. Research is needed to identify effective communication strategies to increase risk perceptions and decrease alcohol consumption. This study examined the effects of threatening and hedging languages in communicating the cancer risk associated with alcohol use. Results from a between-subjects experiment (N = 584) revealed a significant interaction effect: Threatening language combined with lexical hedges led to a higher perceived threat to drinker identity competence, which predicted higher intentions to reduce and stop drinking. Moreover, threatening language increased perceived threat to freedom, predicting greater reactance and lower behavioral intentions. Lastly, hedging increased perceived message tentativeness, predicting lower risk perceptions and behavioral intentions. Implications of our study were discussed.

Developing health and environmental warning messages about red meat: An online experiment

INTRODUCTION

The United States has among the highest per capita red meat consumption in the world. Reducing red meat consumption is crucial for minimizing the environmental impact of diets and improving health outcomes. Warning messages are effective for reducing purchases of products like sugary beverages but have not been developed for red meat. This study developed health and environmental warning messages about red meat and explored participants' reactions to these messages.

METHODS

A national convenience sample of US red meat consumers (n = 1,199; mean age 45 years) completed an online survey in 2020 for this exploratory study. Participants were randomized to view a series of either health or environmental warning messages (between-subjects factor) about the risks associated with eating red meat. Messages were presented in random order (within-subjects factor; 8 health messages or 10 environmental messages). Participants rated each warning message on a validated 3-item scale measuring perceived message effectiveness (PME), ranging from 1 (low) to 5 (high). Participants then rated their intentions to reduce their red meat consumption in the next 7 days.

RESULTS

Health warning messages elicited higher PME ratings than environmental messages (mean 2.66 vs. 2.26, p<0.001). Health warning messages also led to stronger intentions to reduce red meat consumption compared to environmental messages (mean 2.45 vs. 2.19, p<0.001). Within category (health and environmental), most pairwise comparisons of harms were not statistically significant.

CONCLUSIONS

Health warning messages were perceived to be more effective than environmental warning messages. Future studies should measure the impact of these messages on behavioral outcomes.

Perceived Message Effectiveness of the Meatless Monday Campaign: An Experiment With US Adults

Given the negative health and environmental impacts of red meat consumption, reducing red meat intake in the United States is important for both human and planetary well-being. To experimentally evaluate the impact of health-focused and environment-focused messages from the Meatless Monday campaign, we conducted an online randomized experiment among US adults aged 18 years or older (n = 1244). Compared with control messages, health-focused and environment-focused Meatless Monday messages led to significantly higher perceived message effectiveness and increased intention to reduce meat consumption. (Am J Public Health. Published online ahead of print March 24, 2022: e1-e4. https://doi.org/10.2105/AJPH.2022.306766).

Gender-Specific Pictorial Health Warnings: Moderation Effects of the Threat Level and Gender

This study examined the effects of gender-specific pictorial health warning labels contingent on their intended gender and threat levels (for females) in forming anti-smoking intentions. We conducted a within-subject design experiment with smokers and nonsmokers in Singapore (N = 100, 50% men). Each participant viewed 10 warning labels-four female-specific (high and low threat), four gender-neutral (high and low threat), and two male-specific (only low threat)-in a random order, evaluating each label on personal relevance, attention, cognitive elaboration, reactance, and intentions to purchase or avoid smoking. The findings showed that females reported greater relevance, attention, elaboration, and intentions to avoid smoking for low threat female-specific warning labels than male-specific or gender-neutral counterparts. Males reported less attention, elaboration, and relevance for low threat male-specific warning labels than female-specific or gender-neutral counterparts. Under high threat conditions, female-specific and gender-neutral warning labels were equally effective for both genders. No differences were observed by smoking status. Overall, gender-specific warning labels are potentially more effective than gender-neutral ones for deterring smoking in women contingent on low threat levels. By providing a deeper understanding of persuasive mechanisms and boundary conditions for the effects of gender specificity, findings can aid health policymakers in developing better gender-responsive interventions.

Longitudinal effects of cigarette pictorial warning labels among young adults

Young adults are influenced by cigarette package marketing. Pictorial warning labels are a recommended intervention. Evidence demonstrates pictorial warnings impact negative emotion, risk perceptions, and motivation to quit smoking, but there is limited research on their effects over time. This study analyzes data from a randomized trial of young adult smokers (N = 229) exposed to a pictorial or text-only cigarette warning. We assessed changes in fear, anger, risk perceptions, and motivation to quit smoking after 4 weeks using latent change score modeling and over 3 months using latent growth modeling. Latent change results showed exposure was associated with increases in fear, anger, and motivation to quit after 4 weeks. Latent growth showed exposure was associated with increases in motivation to quit smoking over 3 months, but not other outcomes. Findings suggest pictorial warning labels produce an emotional response and increase motivation to quit among young adult smokers.

Image Framing, Emoticons, and Sharing Intention for Health-Related Posts on Facebook

In response to calls for greater integration of research on the effects of visual images in the emotional and cognitive processing of health-related posts on Facebook, this study examined the questions of how gain-and-loss framed images, the valence of emoticon responses, and level of personal relevance of health topics contribute toward intentional engagement (e.g., sharing the posts) on Facebook. This study conducted a 2 (visual framing: gain vs. loss) × 2 (personal relevance of health topic: high vs. low) × 2 (emoticon valence: positive vs. negative) mixed-factorial experiment. A total of 187 college students were recruited to assess the impact of visual framing, personal relevance, and emoticon valence on sharing intention. Results showed that negative emoticons led to a higher intention to share health news posts than positive emoticons. Moreover, two parallel mediation models showed that (a) gain-framed images with high-relevance topics positively predicted perceived susceptibility but negatively predicted perceived severity that both positively impacted sharing intention; (b) loss-framed images with low-relevance topics positively predicted perceived severity but negatively predicted perceived susceptibility that both positively impacted the sharing intention. The implications regarding the contribution to the literature of visual framing and emotion on social media engagement and health communication are discussed.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Are smokers scared by COVID-19 risk? How fear and comparative optimism influence smokers' intentions to take measures to quit smoking

Research suggests that smoking may compound the risk of serious health problems to smokers who contract COVID-19. This study examines whether and how exposure to news stories reporting the severe COVID-19 risk to smokers may influence smokers’ emotional responses (fear, anxiety, and sadness) and intentions to take measures to quit smoking. Current smokers in the US participated in an online experiment (N = 495) and were randomized to read smoking risk news stories or news stories reporting the combined risk of smoking and COVID-19. We found that combined risk news stories lead to participants feeling more fearful and sadder than when they viewed smoking risk news stories (M = 5.74; SD = 2.57 vs. M = 5.20; SD = 2.74; p < .05). Fear fully mediated the effect of news exposure on intentions to take measures to quit smoking (ß = .09; SE = 05; 95% CI [.010, .200]). Moreover, moderated-mediation analyses revealed that the mediating effect of fear was conditioned on the levels of comparative optimism, such that the association between fear and intentions to take measures to quit smoking was only significant among smokers whose comparative optimism was at the mean score (ß = .16; SE = 05; 95% CI [.071, .250]), and for those whose comparative optimism was high (ß = .27; SE = .06; 95% CI [.146, .395]). These results suggest that fear of the pandemic and optimism might play important roles in predicting and explaining the association between exposure to news stories and intentions to take measures to quit smoking. Messages about heightened risk of COVID-19 complications for smokers that increase fear might be an effective strategy to motivate smokers to quit. Such messages should be used to turn the adversity of COVID-19 pandemic into an intervention opportunity to reduce tobacco-related disease.

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

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

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

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Warning language may impact warning effectiveness among Spanish speakers.

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

Support for legislative, technological, and organizational strategies to reduce cellphone use while driving: Psychological predictors and influences of language

OBJECTIVE

A large body of research has established that cellphone use while driving (CUWD) is common and dangerous. However, little research has been conducted about how people react psychologically to various distraction-reduction strategies and, ultimately, support or do not support them. Understanding support for reduction is important for predicting use of technological solutions and compliance with laws and for improving communication and education about the risks of CUWD.

METHODS

We measured support for a variety of legislative, technological, and organizational strategies to reduce CUWD in an online sample of American drivers (N = 648). We also developed evidence-based communication techniques, describing strategies in terms of benefits vs. costs or using freedom-invoking vs. freedom-reducing language to assess what would influence support.

RESULTS

Support for CUWD reduction was generally high. It was predicted by driver characteristics and beliefs. For example, drivers who supported reducing CUWD more also had lower CUWD reactance, greater anti-CUWD beliefs, higher personal risk perceptions of CUWD, and greater self-reported distracted driving. Age and perceived ability to drive distracted did not predict overall support. However, two strategies that allow for handsfree phone use were supported more by people who engaged in more CUWD, perceived they had greater ability to CUWD, perceived more benefits to CUWD, had more positive affect to cellphones, and were younger. Communication techniques also influenced support. Specifically, the same strategy was supported more when described using benefits and permissive language instead of costs and restrictive language.

CONCLUSIONS

Most respondents supported strategies to reduce CUWD, and beliefs about risks and benefits predicted this snupport. Reactance to CUWD messaging emerged as a key predictor of lower support (and of greater self-reported distracted driving), indicating that it could be an important variable to consider when designing strategies to reduce CUWD. When targeting people resistant to quitting CUWD entirely, communicators could recommend a switch to handsfree use. Communicators who emphasize benefits and use permissive language also may increase support for CUWD reduction.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Walk in the Park? Examining the Impact of App-Based Weather Warnings on Affective Reactions and the Search for Information in a Virtual City

Background: Warning apps can provide personalized public warnings, but research on their appraisal and impact on compliance is scarce. This study introduces a virtual city framework to examine affective reactions when receiving an app-based warning, and subsequent behavioral intentions. Methods: In an online experiment, 276 participants (M = 41.07, SD = 16.44, 62.0% female) were randomly allocated to one of eight groups (warning vs. no warning, thunderstorm vs. no thunderstorm, video vs. vignette). Participants were guided through a virtual city by a mock-up touristic app (t1). Then, the app issued a warning about an impending thunderstorm (t2), followed by a virtual thunderstorm (t3). The virtual city tour was presented via vignettes or videos. ANCOVAs were used to investigate trajectories of momentary anxiety, hierarchical regressions analyzed the impact of momentary anxiety on information seeking. Results: Participants who received a warning message and were confronted with a thunderstorm showed the highest increase in momentary anxiety, which predicted information seeking intentions. Conclusions: The findings underscore the importance of affective appraisal in processing warning messages. The virtual city framework is able to differentiate the impact of warning versus event in an online context, and thus promising for future warning research in virtual settings.

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.

The effectiveness of graphic health warnings on tobacco products: a systematic review on perceived harm and quit intentions

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.

Descriptive or injunctive: How do restaurant customers react to the guidelines of COVID-19 prevention measures? The role of psychological reactance

In this study, we employed an experimental design to empirically test how restaurant customers react differently to normative appeals (descriptive vs. injunctive) relating to COVID-19 prevention measures through freedom threat and negative cognition. We conducted t-tests, serial mediation, moderation, and moderated serial mediation analysis to test the hypotheses using SPSS 23.0 and PROCESS macro v.3.5 (model 6 and model 85). Injunctive normative appeal causes an increase in freedom and a less favorable attitude than descriptive normative appeals. The findings also demonstrate the serial-mediated effect of freedom threat and negative cognition on attitude. Furthermore, the effectiveness of normative appeals depends on an individual's age. This study contributes to the academic literature on hospitality by applying psychological reactance theory and testing the model within a restaurant context. It also discusses the implications of its findings for consumers and restaurant managers.

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.

Impact of Sugar-Sweetened Beverage Warning Labels on Consumer Behaviors: A Systematic Review and Meta-Analysis

CONTEXT

As a primary source of added sugars, sugar-sweetened beverage consumption contributes to obesity. This study systematically synthesizes the scientific evidence regarding the impact of sugar-sweetened beverage warning labels on consumer behaviors and intentions.

EVIDENCE ACQUISITION

A keyword/reference search was performed in 2019 in Cochrane Library, PubMed, Web of Science, CINAHL, Scopus, and Google Scholar. Meta-analysis was conducted in 2020 to estimate the effect of sugar-sweetened beverage warning labels on consumers' purchase decisions.

EVIDENCE SYNTHESIS

A total of 23 studies (13 RCTs, 9 nonrandomized experiments, and 1 computer simulation study) met the eligibility criteria and were included. Labels were classified into 6 categories: (1) symbol with nutrient profile, (2) symbol with health effect, (3) text of nutrient profile, (4) text of health effect, (5) graphic with health effect, and (6) graphic with nutrient profile. Compared with the no-label control group, sugar-sweetened beverage warning label use was associated with reduced odds of choosing sugar-sweetened beverages (OR=0.49, 95% CI=0.41, 0.56) and a reduced sugar-sweetened beverage purchase intention (Cohen's d= -0.18, 95% CI= -0.31, -0.06). Across alternative label categories, the graphic with health effect (OR=0.34, 95% CI=0.08, 0.61), text of health effect (OR=0.47, 95% CI=0.39, 0.55), graphic with nutrient profile (OR=0.58, 95% CI=0.36, 0.81), and symbol with health effect (OR=0.67, 95% CI=0.39, 0.95) were associated with reduced odds of choosing sugar-sweetened beverages.

CONCLUSIONS

Sugar-sweetened beverage warning labels were effective in dissuading consumers from choosing them. Graphic with health effect labels showed the largest impact. Future studies should delineate the psychosocial pathways linking sugar-sweetened beverage warning labels to purchase decisions, recruit socioeconomically diverse participants, and design experiments in naturalistic settings.

Motivations and Barriers for the Use of Face Coverings during the COVID-19 Pandemic: Messaging Insights from Focus Groups

Widespread use of face coverings is a key public health strategy to prevent the spread of COVID-19. However, few studies have examined why Americans use or do not use face coverings, and little is known about the most effective messaging strategies. This study explored perceptions of face coverings, including motivations and barriers for use, and examined reactions to messaging promoting the use of face coverings. Six virtual focus groups were conducted with 34 North Carolina residents in July 2020. Participants reported high compliance with face covering recommendations but often did not wear them around family, friends, and colleagues. The most prevalent motivation for the use of face coverings was to protect or respect other people, including high-risk populations and individuals. Other motivators were self-protection, responsibility, desire for control, requirements, and expert advice. Barriers included physical and social discomfort, confusion or misinformation, low perceived susceptibility to COVID-19, and perceptions of identity and autonomy. Even among individuals who frequently wear face coverings, there are opportunities to improve compliance. Messaging should highlight how face coverings protect the wearer and others around them, normalize the use of face coverings in social settings, and emphasize requirements. Positive messages that focus on unity, personal experiences and the rationale for face coverings are recommended.

Effects of self-affirmation on responses toward graphic cigarette warning labels: testing the mediating role of perceived susceptibility and self-efficacy

Purpose

The purpose of this study is to examine the effects of self-affirmation on African American smokers' intentions to quit smoking sooner and desire to stop smoking altogether in response to viewing graphic cigarette warning labels. It also tested the mediating role of perceived susceptibility and self-efficacy in explaining the impact of self-affirmation.

Design/methodology/approach

African American smokers (N = 158) were recruited to participate in a controlled experiment. Participants first completed a short questionnaire about their demographic background and smoking-related attitudes and behavior. They were then randomly assigned to engage in either a self-affirmation task or a control task and viewed two graphic cigarette warning labels subsequently. Participants then responded to a questionnaire about their perceived susceptibility to smoking-related diseases, perceived self-efficacy to quit smoking, intentions to quit smoking and desire to stop smoking altogether.

Findings

Results showed that engaging in self-affirmation prior to exposure to graphic cigarette warning labels increased African American smokers' perceived susceptibility to smoking-related diseases, but decreased their perceived self-efficacy to quit smoking. Furthermore, self-affirmation indirectly enhanced smokers' intentions to quit smoking sooner and desire to stop smoking altogether through increased perceived susceptibility. It also had an unexpected negative indirect effect on intentions to quit smoking sooner through decreased self-efficacy.

Originality/value

This study is one of the few studies that investigates the effect of self-affirmation on African American smokers' responses toward graphic cigarette warning labels.

Impact of Graphic Warning Messages on Intentions to Use Alternate Tobacco Products

Graphic cigarette warnings increase quit attempts. Perceived message effectiveness and message avoidance are predictive of later quit attempts. We sought to examine whether randomized exposure to warning messages would inadvertently increase intentions to use alternate tobacco products while enhancing attempts to quit cigarettes. An online survey of 1392 adult smokers in the US asked participants to rate six randomly selected tobacco warnings (from a set of 319) on perceived effectiveness and avoidance intentions. These two indicators of message effectiveness were calculated at the message-level and then at the individual campaign-level to facilitate causal inference. After viewing a message campaign of six warning messages, participants indicated their intentions to use alternate tobacco products. Sixty-eight percent of participants reported some intention to use e-cigarettes and intentions to use other alternate tobacco products ranged from 31% to 40%. Campaigns of messages eliciting higher avoidance increased the odds of intending to use hookah (aOR: 4.32), smokeless tobacco (aOR: 4.88), and snus (aOR: 8.06), but not the intention to use electronic cigarettes. These relationships are mediated by intentions to quit smoking (all p <.05). Viewing campaigns with higher campaign-level perceived effectiveness increased the intentions to quit, which in turn increased intentions to try alternate tobacco products. Our findings increase the tobacco control community's understanding of unintended consequences of graphic tobacco warnings.

Reactions to graphic and text health warnings for cigarettes, sugar-sweetened beverages, and alcohol: An online randomized experiment of US adults

We aimed to examine reactions to graphic versus text-only warnings for cigarettes, SSBs, and alcohol. A convenience sample of US adults completed an online survey in 2018 (n = 1352 in the analytic sample). We randomly assigned participants to view a: 1) text-only warning without efficacy information (i.e., message intended to increase consumers' confidence in their ability to stop using the product), 2) text-only warning with efficacy information, 3) graphic warning without efficacy information, or 4) graphic warning with efficacy information. Participants viewed their assigned warning on cigarettes, SSBs, and alcohol, in a random order. Across product types, graphic warnings were perceived as more effective than text-only warnings (p < .001) and led to lower believability, greater reactance (i.e., resistance), more thinking about harms, and lower product appeal (all p < .05); policy support did not differ. Compared to SSB and alcohol warnings, cigarette warnings led to higher perceived message effectiveness, believability, fear, thinking about harms, policy support, and greater reductions in product appeal (all p < .05). The efficacy information did not influence any outcomes. Graphic warnings out-performed text-only warnings on key predictors of behavior despite causing more reactance.

Pictorial Cigarette Pack Warnings Increase Some Risk Appraisals But Not Risk Beliefs: A Meta-Analysis

Pictorial warnings on cigarette packs motivate smokers to quit, and yet the warnings' theoretical mechanisms are not clearly understood. To clarify the role that risk appraisals play in pictorial warnings' impacts, we conducted a meta-analysis of the experimental literature. We meta-analyzed 57 studies, conducted in 13 countries, with a cumulative N of 42,854. Pictorial warnings elicited greater cognitive elaboration (e.g., thinking about the risks of smoking; d = 1.27; p < .001) than text-only warnings. Pictorial warnings also elicited more fear and other negative affect (d = .60; p < .001). In contrast, pictorial warnings had no impact on perceived likelihood of harm (d = .03; p = .064), perceived severity (d = .16; p = .244), or experiential risk (d = .06; p = .449). Thus, while pictorial warnings increase affective and some cognitive risk appraisals, they do not increase beliefs about disease risk. We discuss the role of negative affect in warning effectiveness and the implications for image selection and warning implementation.

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.

Perspectives to social media usage of depressed patients and caregivers affecting to change the health behavior of patients in terms of information and perceived privacy risks

It has been confirmed that the use of social media (SM) can affect the mental health of users. However, there is no explanation for its impact on health behavior. This study focuses on the perspectives of depressed patients and caregivers on social media usage and how it can change their health behavior. A questionnaire designed according to the framework of the I-Change Model (ICM) is used to collect data from a sample group. This group consists of 214 patients diagnosed with major depressive disorders, and 110 caregivers. The data is used to analyze causal relationships with the help of structural equation modeling. The results showed that from the patient's perspective it is essential to be aware of the content and volume of social media usage. An awareness of the perceived risk to privacy is also essentially a motivating factor in patients' decisions to use social media. The views of caregivers suggest that content valence has an essential role to play in their use of social media. After viewing content on social media patients change their behavior. The perceived privacy risk also plays a critical role in patients' decisions to use social media.

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.

Pictorial Warning Labels and Memory for Cigarette Health-risk Information Over Time

BACKGROUND

Pictorial cigarette warning labels are thought to increase risk knowledge, but experimental research has not examined longer-term effects on memory for health risks named in text.

PURPOSE

To investigate memory-consolidation predictions that high- versus low-emotion warnings would support better long-term memory for named cigarette health risks and to test a mediational model of warning-label effects through memory on risk perceptions and quit intentions.

METHODS

A combined sample of U.S.-representative adult smokers, U.S.-representative teen smokers/vulnerable smokers, and Appalachian-representative adult smokers were randomly assigned to a warning-label condition (High-emotion pictorial, Low-emotion pictorial, Text-only) in which they were exposed four times to nine warning labels and reported emotional reactions and elaboration. Memory of warning-label risk information, smoking risk perceptions, and quit intentions were assessed immediately after exposures or 6 weeks later.

RESULTS

Recall of warning-label text was low across the samples and supported memory-consolidation predictions. Specifically, immediate recall was highest for Low-emotion warnings that elicited the least emotion, but recall also declined the most over time in this condition, leaving its 6-week recall lowest; 6-week recall was similar for High-emotion and Text-only warnings. Greater recall was associated with higher risk perceptions and greater quit intentions and mediated part of warning-label effects on these important smoking outcomes. High-emotion warnings had additional non-memory-related effects on risk perceptions and quit intentions that were superior to text-only warnings.

CONCLUSIONS

High- but not Low-emotion pictorial warning labels may support the Food and Drug Administration's primary goal to "effectively convey the negative health consequences of smoking."

CLINICALTRIALS.GOV IDENTIFIER

NCT03375840.

Ethical Considerations for Food and Beverage Warnings

Several countries have implemented warnings on unhealthy foods and beverages, with similar policies under consideration in the U.S. and around the world. Research demonstrating food warnings' effectiveness is emerging, but limited scholarship has evaluated the ethics of food warning policies. Using a public health ethics framework for evaluating obesity prevention policies, we assessed the ethical strengths and weaknesses of food warnings along multiple dimensions: 1) Health behaviors and physical health, 2) Psychosocial well-being, 3) Social and cultural values, 4) Informed choice, 5) Equality, 6) Attributions of responsibility, 7) Liberty, and 8) Privacy. Our analysis identifies both ethical strengths and weaknesses of food warnings, including that: 1) warnings are likely to generate important benefits including increased consumer understanding and informed choice, healthier purchases, and potential reductions in obesity prevalence; 2) warnings evoke negative emotional reactions, but these reactions are an important mechanism through which food warnings encourage healthier behaviors and promote informed choice; 3) warnings appear unlikely to have ethically unacceptable effects on social and cultural values, attributions of responsibility, liberty, or privacy. Current research suggests we continue to pursue food warnings as a policy option for improving public health while simultaneously conducting additional research on the ethics of these policies. Future research is especially needed to clarify warnings' effects on stigma and to characterize the balance and distribution of costs of and benefits from implementing warning policies.

"I Quit": Testing the Added Value and Sequencing Effects of an Efficacy-focused Message among Cigarette Warning Labels

Many emotional appeal theorists argue that negative affect and efficacy work together to promote adaptive behavioral responses to a threat, yet most research on cigarette warning label messages has not examined the intersection between negative affect, hope, and efficacy. The current study tests effects of exposure, at different points in a sequence, to an efficacy-focused warning label in the context of threat-focused warning labels. We conducted an online, between- and within-subjects experiment with 398 adult smokers, testing the effects of warning label exposure on negative affect, hope, efficacy beliefs, and intentions to quit. Exposure to the efficacy-focused "Quit" label aroused higher levels of reported hope and lower levels of reported negative affect than threat-focused labels. Negative affect increased with each additional exposure to a threat-focused warning label, regardless of the order in which respondents saw the "Quit" label. Exposure to the "Quit" label (within a larger set of three threat-focused labels) led to greater self-efficacy but did not influence response efficacy or intentions to quit. We conclude that "Quit" messaging on warning labels can inspire both hopeful feelings and efficacy beliefs. Future research should identify the optimal balance between threat-focused and hopeful quit messages.

National Tobacco Control Policies from the Perspectives of Singapore Young Male Adults

Between 2016 and 2018, tobacco control legislation has undergone several amendments to further restrict tobacco use in Singapore. This study explored the attitudes toward these policy changes and the perceived effectiveness of legislations from the perspectives of young male adults in Singapore. Twenty-nine semi-structured telephone interviews were conducted among young male adults who have completed their National Service in 2017/18 and self-reported as a smoker at pre-enlistment screening. Young male smoker perspectives on Singapore tobacco policies including taxation, smoke-free environment, point-of-sale display ban on tobacco products, graphic health warnings, and raising the minimum legal age of smoking to 21, were evaluated. Participants held the view that cigarette pricing was a highly effective approach to control their smoking behavior because it has a direct impact on tobacco affordability, and they shared that the least effective approaches were point-of-sale display bans and graphic health warnings. Results demonstrate that participants were well aware of tobacco control policies in Singapore, but they did not always fully accept them or understand the rationale behind them. Tobacco control measures should be implemented along with public education to correct misperceptions and increase public support for tobacco control measures in Singapore.

Online Randomized Controlled Trials of Restaurant Sodium Warning Labels

INTRODUCTION

Policymakers are interested in requiring chain restaurants to display sodium warning labels on menus to reduce sodium consumption. This study examined the influence of label design on consumers' hypothetical choices, meal perceptions, and knowledge.

STUDY DESIGN

Four sequential, randomized, controlled online experiments were conducted.

SETTING/PARTICIPANTS

Across all 4 experiments, 10,412 sociodemographically diverse participants were recruited online through Survey Sampling International and Amazon Mechanical Turk.

INTERVENTION

Participants were randomized to view restaurant menus with either no sodium label (control) or 1 of 13 sodium warning labels that varied the text (e.g., "sodium warning" versus "high sodium"), icons (e.g., stop sign), and colors (red/black) used. Participants placed a hypothetical meal order and rated restaurant meal perceptions. Data were collected and analyzed in 2016-2019.

MAIN OUTCOME MEASURES

The primary outcome was sodium content of hypothetical restaurant choices. Secondary outcomes included restaurant meal perceptions and sodium knowledge.

RESULTS

In Experiments 1-3, all warning labels reduced average sodium ordered across both restaurants (by 19-81 mg) versus controls, with some of the largest reductions from traffic light and stop sign labels, but results were not statistically significant. In a larger, preregistered replication (Experiment 4) testing traffic light and red stop sign labels versus control, traffic light and red stop sign labels significantly reduced average sodium ordered across both restaurants (-68 mg, p=0.002 and -46 mg, p=0.049, respectively). Warnings also significantly increased participants' knowledge of sodium content and perceived health risks associated with high-sodium meals compared with no label.

CONCLUSIONS

Traffic light and red stop sign warning labels significantly reduced sodium ordered compared with a control. Warning labels also increased knowledge about high sodium content in restaurant meals. Designs with warning text are likely to improve consumer understanding.