The influence of graphic warning labels on efficacy beliefs and risk perceptions: a qualitative study with low-income, urban smokers

Cigarette packaging as a commercial determinant of smoking: A thematic analysis of Filipinos' perception of graphic health warnings and plain packaging in the Philippines

In line with recommendations of Article 11 of the WHO Framework Convention on Tobacco Control, the Philippines has implemented graphic health warnings (GHWs) on cigarette packs. While the Graphic Health Warnings Law was passed in 2014, it was only implemented in 2016. Using a commercial determinants of health framework, this study aims to contribute evidence on Filipinos' perceptions of GHWs and the potential plain packaging of tobacco products in the Philippines. We used a dataset based on open-ended questions in online and nationwide household surveys from 2021. Data collectors showed mock-up sets of cigarette packs based on the Philippines' law on GHWs and Thailand's and Singapore's plain packaging to respondents to gather their comments on each pack's features and its GHW. We conducted a thematic analysis to extract themes in respondents' perceptions. We gathered 3,723 responses from online and household surveys. Most respondents commented on the Philippine packs' ineffectiveness and lauded GHWs from Singapore and Thailand for their characteristics and the information in the warnings, remarking that valuable features of Singapore and Thailand's plain packs for making current cigarette packaging more effective were larger GHWs, less brand visibility, and quitline availability. The study supports recent literature assessing local GHWs. Current GHWs are seen as ineffective, highlighting the need for policy reform. Policymakers should consider prohibiting single-stick cigarette sales, adopting plain packaging with larger GHWs to decrease brand visibility, and increasing the visibility and accessibility of quitlines to motivate smokers to quit and discourage Filipinos from smoking.

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.

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

AIMS

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

METHOD

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

RESULTS

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

POLICY IMPLICATIONS

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

A Risk Education Program Decreases Leftover Prescription Opioid Retention: An RCT

INTRODUCTION

Retaining leftover prescription opioids poses the risks of diversion, misuse, overdose, and death for youth and other family members. This study examined whether a new educational program would enhance risk perceptions and disposal intentions among parents and decrease their retention of leftover prescription opioids.

STUDY DESIGN

This study is an RCT (NCT03287622).

SETTING/PARTICIPANTS

A total of 648 parents whose children were prescribed opioid analgesics were recruited from a Midwestern, academic pediatric hospital between 2017 and 2019. Parents were randomized to receive routine information (control) with or without Scenario-Tailored Opioid Messaging Program intervention.

INTERVENTION

The intervention provided opioid risk and mitigation advice using interactive decisional feedback.

MAIN OUTCOME MEASURES

The main outcome measures were parents' perceptions of the riskiness of keeping/sharing opioids and child misuse measured at baseline, Days 3 and 14, their intention to dispose of leftover opioids, and their final retention decisions after the child's use (at or around Day 14).

RESULTS

Perceived riskiness of child misuse and keeping/sharing opioids increased from baseline through Day 14 only for parents in the intervention group (p≤0.006). However, there were no significant differences in risk perceptions between groups and no intervention effect on disposal intentions at either follow-up. Despite these findings, the intervention reduced the likelihood of parents' opioid retention when adjusted for important parent and child covariates (AOR=0.48; 95% CI=0.25, 0.93; p=0.028). Parents who reported past opioid misuse also showed higher retention behavior (AOR=4.78; 95% CI=2.05, 11.10; p<0.001).

CONCLUSIONS

A scenario-specific educational intervention emphasizing the potential risks that leftover opioids pose to children and that provided risk mitigation advice decreased parents' retention of their child's leftover opioid medication. Removing leftover prescription drugs from homes with children may be an important step to reducing diversion, accidental poisoning, and misuse among youth.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT03287622.

A Narrative Review of the Efficacy and Design of Safety Labels on Tobacco Products to Promote the Use of Safety Labels on Alcohol Products in Canada

Alcohol is consumed by approximately three-quarters of Canadians. Alcohol causes acquired liver disease, increases the risk of cancer, has detrimental effects on mental health, and leads to adverse pregnancy outcomes. Alcohol-related morbidity and mortality are high, and urgent public health measures are warranted to prevent and control these. Tobacco safety labels have been shown in numerous studies to reduce tobacco consumption. Much can be learned from the design of tobacco safety labels in creating promising alcohol safety labels that can possibly help reduce alcohol consumption. The aim of this paper is to review the efficacy of tobacco safety labels in reducing tobacco consumption and the design of tobacco safety labels and to propose a promising design for alcohol safety labels based on our findings. English peer-reviewed papers published in western countries since 2000 were searched on PubMed and Google Scholar. Keywords and synonyms were used to search pertinent papers, which were subsequently screened by title and abstract and fully reviewed if relevant. Findings from studies comparing designs of safety labels on alcohol and tobacco products are similar. Graphics, higher emotion content, and greater size are associated with greater attention, awareness, negative emotions, intention to quit, and reduction in consumption. Mixed results are found for testimonials containing safety labels on tobacco products. It is unclear whether testimonials on alcohol safety labels reduce alcohol consumption or not. Safety labels with specific information, such as tobacco-related costs and alcohol-related cancer risks, are more effective in reducing tobacco consumption. In conclusion, preliminary alcohol safety labels show promise. Large safety labels with graphics and high emotional content appear to be most effective and may reduce alcohol consumption.

A Qualitative Study of Pictorial Health Warnings on Malaysian Cigarette Packs: How Do the Adults Understand Them?

The WHO recommended pictorial health warnings (PHWs) on cigarette packs in 2003 to educate and warn the public of smoking effects. Malaysia too has implemented this policy since 2009. This study explored the public’s understanding of the gazetted PHWs depicted on cigarette packs available in Malaysia. A qualitative study using four focus group discussions (FGDs) was conducted among smokers and non-smokers aged 18–40 in Malacca, Peninsular Malaysia. Thematic analyses were performed using the Atlas Ti version 8.0 software. Six themes have emerged reflecting the public’s understanding of the existing PHWs in Malaysia, namely, (i) awareness and exposures, (ii) recall and attention, (iii) perceived goals, (iv) perceived target groups, (v) attitude in understanding, and (vi) knowledge and meaning of PHWs. All participants were aware of the PHWs depicted on legal cigarettes but not seen on most illicit cigarettes. PHWs were perceived to give awareness and warning about the smoking effects targeting smokers and non-smokers. Participants understood the lung and oral health-related images easily than other body parts such as gangrene foot, miscarriages, etc. Besides enforcement on illicit cigarettes without PHWs, policymakers or relevant authorities should emphasize creating relevant and clear pictorial messages in educating the public to avoid confusion affecting the public’s understanding of the PHWs.

New Zealand roll-your-own smokers' reaction to novel roll-your-own tobacco packaging warning labels

INTRODUCTION

Although roll-your-own (RYO) loose tobacco is increasingly popular among smokers, no jurisdictions have used RYO-specific pictorial warning labels (PWL) on tobacco packaging. We explored how New Zealand RYO smokers, a population with over 10 years of exposure to PWLs, reacted to RYO-specific warnings featuring novel themes.

METHODS

We conducted an online survey of 785 RYO smokers in March 2019. Eligible participants were smokers aged 18-70 years who smoked predominantly RYO cigarettes. Participants randomly viewed two of eight RYO-specific PWLs featuring themes of health information (mouth and throat cancer), suffering (male and female), toxins, material hardship, cost, family transmission of smoking and harm to pets and answered items assessing negative emotions and perceived effectiveness.

RESULTS

Compared to a reference health information PWL (most similar in content and tone to New Zealand's existing PWLs), only a male suffering PWL elicited both significantly stronger negative emotion and higher perceived effectiveness. No themes performed significantly worse than the health information PWL, suggesting any of the themes could be at least as effective as existing health warnings among New Zealand RYO smokers. The individual-level factors consistently associated with negative emotion and perceived effectiveness were age, desire to quit smoking, believing quitting could reduce risk of serious disease, a quit attempt within the previous 6 months and ever-planning to quit.

CONCLUSION

Our findings suggest that, in the New Zealand context, a PWL emphasising male suffering could be a useful starting point for assessing RYO-specific PWLs compared to general smoking warnings.

Health science knowledge translation: Critical appraisal of online physical activity promotion material

Limited research exists on how often health behavior theory concepts, principles, and techniques are embedded in the design of material to promote physical activity and exercise, such as persuasive communications disseminated via the Internet. This cross-sectional study examined 139 web articles on physical activity and exercise. We assessed how often article messages targeted recommended motivational determinants of health behavior: that is, outcome expectancy, self-efficacy, and self-regulation. Moreover, exploratory analyses were performed, which compared patterns in article messages by organization type. Results showed the largest categories were other messages and self-efficacy, each representing nearly one-third of article messages. The frequency that article messages targeted motivational determinants of physical activity and exercise differed by organization type. Our results suggest web articles that could promote physical activity and exercise motivation exist; however, they can be better constructed to meet the needs of people. For example, over half of article messages targeted a recommended motivational determinant, but the least targeted determinant was self-regulation. We present steps nurse educators and clinicians may take to improve the design or selection of physical activity and exercise promotion material.

Responses to Graphic Warning Labels among Low-income Smokers

Objective: Graphic warning labels (GWLs) are effective in communicating tobacco-related harms. Methods: In this mixed-methods study, we used purposive sampling to recruit 100 low-income smokers in the San Francisco Bay Area between October 2017 and February 2018 to participate in an intervention promoting smoke-free homes. We presented the 2009 Food and Drug Administration-proposed GWLs and explored perceptions of affect, efficacy, and appeal using questionnaires at baseline, 3- and 6-months follow-up. Because of participants' interest in this topic, we subsequently conducted a qualitative sub-study among 20 participants exploring perceived efficacy of GWLs on smoking cessation. Results: In all, 87.3% and 59.2% agreed that GWLs were useful and would motivate cessation behaviors, respectively, at baseline. We found that the most common responses were shock (61.8%) and disgust (55.3%), whereas anger (29.0%) and annoyance (19.7%) were less common. Participants also reported that GWLs unequivocally illustrating smoking's harmful effects were more appealing than non-specific images, as were images that depicted positive cessation-related effects. Conclusions: GWLs appear to be an important health communication among low-income smokers. Future studies on GWLs should examine the association of negative affect and cessation among this population.

"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.

Testing messages about comparative risk of electronic cigarettes and combusted cigarettes

INTRODUCTION

Health agencies are grappling with communicating risks of electronic cigarettes (e-cigarettes) compared with combusted cigarettes. This study examined smokers' responses to two types of comparative risk messages with one type incorporating more negative antismoking elements in the design.

METHODS

In an online experiment, 1400 US adult (18+ years) current smokers and recent quitters were randomised to view one of three comparative risk messages about e-cigarettes (CR messages), one of three comparative risk messages that included more negative antismoking elements in the design (CR- messages) or a control message. Selection of outcomes was guided by the antismoking message impact framework. Multivariate analyses of covariance and logistic regression models analysed effects of messages on message evaluations, e-cigarette-related and cigarette-related beliefs and behavioural intentions.

RESULTS

Both CR and CR- messages decreased smokers' intentions to smoke cigarettes, increased intentions to switch to e-cigarettes completely and increased perceptions that e-cigarettes are less harmful than combusted cigarettes. Neither message type increased dual use intentions relative to exclusive e-cigarettes use or smoking cessation. CR messages decreased perceived absolute risks of e-cigarettes and self-exempting beliefs about smoking, whereas CR- versus CR messages produced higher self-efficacy to quit smoking.

CONCLUSION

Comparative risk communication might encourage smokers to switch to lower-harm tobacco products. Comparative risk messages with more negative antismoking elements in the design might be particularly effective, because they led to higher self-efficacy to quit smoking. Regulatory agencies may consider using comparative risk messages with more negative antismoking elements to educate the public about lower risk of e-cigarettes.

Perceived effectiveness of pictorial health warnings on changes in smoking behaviour in Asia: a literature review

BACKGROUND

Several Asian countries have implemented pictorial health warnings on cigarette packs as suggested by the World Health Organization with various policies based on countries' systems. The study is aimed to analyse multiple research studies on the perceived effectiveness of Pictorial Health Warnings as a deterrent to smoking intention and as a stimulant of smoking behaviour in smokers and non-smokers in Asian countries.

METHOD

Peer-reviewed articles were identified through multiple science databases indexed by Scopus, MEDLINE or PubMed. The review was limited to articles that reported original research findings, were conducted in Asian countries and were available for review by January 2010. A PRISMA Flow diagram was used to identify the articles through the process of data screening and extractions.

RESULT

A total of 14 original articles which met the criteria were included in the review, consisting of 12 quantitative studies and 2 studies with both quantitative and qualitative methods from 17 jurisdictions. The reviewed studies found that pictorial health warnings were associated with a greater perception of salience (reading and noticing the warning), emotional effects, and cognitive increase. Additionally, in the reviewed studies, pictorial health warnings were perceived as more effective in deterring smoking initiation and encouraging smoking cessation than text-only warnings. Several studies also evaluated the effectiveness of a new pictorial warning compared with the old one. However, the relevance of refreshing the pictures of pictorial health warnings and the length of the effective period of the implementation of pictorial health warnings were less frequently studied.

CONCLUSION

Pictorial health warnings perceived as more effective in deterring smoking initiation among non-smokers and as well as in stimulating smoking cessation among smokers. Future studies on pictorial health warnings should study the relevance of changing or refreshing pictorial health warning on cigarette packages in a period of time.

Does Segmentation Really Work? Effectiveness of Matched Graphic Health Warnings on Cigarette Packaging by Race, Gender and Chronic Disease Conditions on Cognitive Outcomes among Vulnerable Populations

We examined the differential impact of exposure to smoking-related graphic health warnings (GHWs) on risk perceptions and intentions to quit among different audience segments characterized by gender, race/ethnic group, and presence of chronic disease condition. Specifically, we sought to test whether GHWs that portray specific groups (in terms of gender, race, and chronic disease conditions) are associated with differences in risk perception and intention to quit among smokers who match the portrayed group. We used data from Project CLEAR, which oversampled lower SES groups as well as race/ethnic minority groups living in the Greater Boston area (n = 565). We fitted multiple linear regression models to examine the impact of exposure to different GHWs on risk perceptions and quit intentions. After controlling for age, gender, education and household income, we found that women who viewed GHWs portraying females reported increased risk perception as compared to women who viewed GHWs portraying men. However, no other interactions were found between the groups depicted in GHWs and audience characteristics. The findings suggest that audience segmentation of GHWs may have limited impact on risk perceptions and intention to quit smoking among adult smokers.

Does Awareness on Tobacco Control Legislations Pertaining to Tobacco Sellers Lead to Compliance? – A Study from Chennai, India

Background: Tobacco Sellers (TS) are key stake holders in tobacco control and their compliance with the legislation is crucial to achieve the intended outcome. The current study was conducted to assess the awareness of the Cigarette and Other Tobacco Products Act (COTPA) among TS and their response. Methodology: TS (N=527) were randomly chosen from ten zones of Chennai city. A structured self-administered questionnaire was used to assess awareness and compliance regarding sections 4, 5 and 6. Results: Awareness of COTPA sections-4, 5, 6a, 6b among the TS was 42.0%, 31.0%, 69.3% and 57.2%, respectively, and 65.4% were of the opinion that the tobacco menace can be controlled through legislation. One fourth of the sellers reported that they were contemplating stopping selling tobacco and 13.4% had been requested by various people to stop doing so. The overall profit from tobacco sales was less than 10% for 58.1% of the sellers. There was no change in the sale trends of tobacco products and the smoking form of tobacco was reported to be highly sold (56.2%). Only 54.6% had displayed signboards mentioning the prohibition of smoking in public places as directed under section 4, and 90% of the sellers continued to supply accessories to smoker. In contravention of section-5, 85.6% continued to advertise tobacco in some form and total non-compliance with section-6a and 6b was observed. Conclusion: Awareness on tobacco control legislations among TS was found to be moderate. Furthermore, compliance with the COTPA was minimal.