Impact of tobacco-related health warning labels across socioeconomic, race and ethnic groups: results from a randomized web-based experiment

Achieving Public Health Impact: Health Communication Research to Inform Tobacco Regulatory Science

Health communication research applies communication science to develop generalizable knowledge capable of improving the health and well-being of individuals and communities. But to what extent does the knowledge generated by the health communication field actually achieve public health impact? To answer this question, we discuss the application of health communication science and research within a tobacco regulatory science framework. We describe three areas in which health communication research funded by the Food and Drug Administration (FDA) Center for Tobacco Products (CTP) contributed to 1) youth tobacco prevention campaigns, 2) cigarette health warnings, and 3) regulation of labeling, advertising, and marketing claims. These examples demonstrate how communication regulatory science achieves public health impact in the real world by informing national policies, regulatory actions, and public health practice.

Differential Responses to Cigarette Package Labeling Alternatives Among Adults Who Smoke: Results From a Randomized Trial

INTRODUCTION

Little experimental research has evaluated whether the effects of cigarette package inserts with efficacy messages and/or pictorial health warning labels (PHWLs) differ across key subgroups of adults who smoke.

AIMS AND METHODS

Adults who reported currently smoking (n = 367) were randomly assigned to one of four groups: Small text-only HWLs on pack sides (control); inserts with efficacy messages and small HWLs (inserts-only); PHWLs showing harms of smoking (PHWLs-only); both (inserts + PHWLs). Participants received a 14-day supply of cigarettes labeled to reflect their group. Every evening over 2 weeks, participants reported forgoing and stubbing out cigarettes before they finished smoking over the prior 24 hours, combined into a binary indicator of either behavior (eg, forgoing/stubbing). Separate mixed-effects logistic models were estimated to evaluate moderation of labeling group contrasts (ie, PHWLs vs not; inserts vs. not; inserts-only vs. inserts + PHWLs; PHWLs-only vs. inserts + PHWLs) by baseline covariates (self-efficacy to quit, intention to quit, education, health literacy, and time discounting), predicting day-level forgoing/stubbing.

RESULTS

Education moderated PHWL effects, with PHWLs predicting more forgoing/stubbing only among those with low education (OR = 4.68, p < .001). Time discounting moderated insert effects, with inserts promoting forgoing/stubbing only among those with low time discounting (ie, lower impulsivity; OR = 4.35, p < .001).

CONCLUSIONS

Inserts with efficacy messages appear effective mostly among people with low time discounting, whereas PHWLs appear most effective among those with low education, suggesting their potential to address education-related disparities. Labeling strategies appeared equally effective across subgroups defined by self-efficacy to quit, quit intention, and health literacy. Combining inserts with PHWLs did not appear to mitigate moderation effects.

IMPLICATIONS

This randomized trial with adults who smoke suggests that cigarette packs with inserts describing cessation benefits and tips can promote cessation-related behaviors (ie, forgoing or stubbing out cigarettes) among those with low-time discounting (ie, low impulsivity). Alternative interventions may be needed for people with high-time discounting, as found in cessation trials. PHWLs appear most effective among those with low education, potentially addressing education-related disparities. No differential effects were found for those with different levels of self-efficacy to quit, quit intentions, or health literacy. Combining inserts and PHWLs may not be more effective than either alone.

Doing more with less: A proposal to advance cigarette packaging regulations in the United States

Cigarette packages are potent marketing tools. Following guidance from the WHO Framework Convention on Tobacco Control, many countries have sought to diminish this marketing power by mandating that (1) large graphic health warnings be affixed to the packages (i.e., text warnings combined with graphic images of the health consequences of smoking) and (2) all packages be fully "plain" in their design (i.e., all packages use the same drab/bland color and font type; no brand logos, other colors, or designs are permitted). Yet, the United States lags other countries in implementing regulations designed to blunt the marketing power of cigarette packages. This is not because of a lack of effort on the part of the Food and Drug Administration, the main governmental body charged with regulating tobacco products in the United States. Rather, it is because the regulatory options that that have been advanced in the country (e.g., graphic health warnings) have not been found - yet - to be legally feasible by its courts. This commentary works through some of the conceptual, practical, and legal issues regarding packaging regulations in the United States. It considers the political and bureaucratic risks involved with issuing new regulations. The overall intent is to prompt our field to think creatively about what is realistic in this regulatory space and to offer a novel perspective that may help move the United States tobacco control community forward in its efforts to reduce the promotional power of cigarette packages.

Youth Exposure and Response to the FDA Health Warning Label on Electronic Cigarettes Packaging: Policy Implications

INTRODUCTION

Youth represent a high-priority group for e-cigarette health communication. This study examined youth exposure to the Food and Drug Administration (FDA) e-cigarette warning label over 4 years and its association with change in youth harm perception and intention.

AIMS AND METHODS

We pooled data from the 2018-2021 National Youth Tobacco Survey (age 10-17; n = 67 159). Participants were divided into four groups: never users (58.5%), susceptible nonusers (16.3%), former users (12.7%), and current users (12.5%). We examined the prevalence, time-trend, correlates, and association of youth exposure to the warning with addictiveness and harm perception, intention to use e-cigarettes, and intention to quit all tobacco products.

RESULTS

Only 24.5% of youth were exposed to the warning. Exposure increased from 14.9% in 2018 to 30.8% in 2019, then declined to 25.2% in 2021. Hispanic (adjusted odds ratio (aOR) = 0.76 [95% CI = 0.641 to 0.89]) and non-Hispanic black current users (0.53 [0.40 to 0.69]) were less likely to be exposed to the warning than white current users. Youth exposure was positively associated with a higher perception of e-cigarette addictiveness (1.12 [1.04 to 1.19]) and intention to quit all tobacco products (1.28 [1.13 to 1.46]). However, exposure was negatively associated with harm perception (0.91 [0.85 to 0.96]) and the intention to use e-cigarettes among e-cigarette nonusers (2.38 [1.99 to 2.84]).

CONCLUSIONS

The decline in youth exposure to the warning indicates wear-out effects. Strengthening the label by using compelling designs, adding themes on e-cigarette harm to youth, periodically rotating warning content, and using culturally tailored messaging may improve its impact on youth and address racial/ethnic disparities.

IMPLICATIONS

The FDA e-cigarette label reached only 24.5% of youth, and exposure to the warning declined to indicate wear-out effects. Exposure was significantly lower among minorities. Exposure was associated with a higher perception of e-cigarette addictiveness and intention to quit all tobacco products. Still, it did not increase harm perception or reduce intention to use e-cigarettes among nonusers. Strengthening the label by using more compelling designs, including diverse themes focusing on e-cigarette harm relevant to youth, and periodically rotating warning content may improve its impact on youth. Continued surveillance of the implementation of e-cigarette policies is needed to ensure that they equally affect youth across racial/ethnic subpopulations.

Inconsistency Between Pictures on Baby Diaper Packaging in Europe and Safe Infant Sleep Recommendations

OBJECTIVE

To describe the level of inconsistency between pictures on baby diaper packaging and safe infant sleep recommendations (SISRs) in Europe.

STUDY DESIGN

We attempted to identify all packaging of baby diapers sold in 11 European countries for infants weighing less than 5 kg through internet searches from July 2022 through February 2023. For each type of package, we extracted whether there was a picture depicting a baby, whether the baby was sleeping, and whether the picture of the sleeping baby was inconsistent with ≥1 of 3 SISRs: (i) nonsupine sleeping position, (ii) soft objects or loose bedding, or (iii) sharing a sleep surface with another person. Data were aggregated at the country level, and a random-effects meta-analysis of proportions was used to obtain summary estimates. The outcome was the summary estimate of the proportion of pictures that were inconsistent with SISRs.

RESULTS

We identified 631 baby diaper packaging types of which 49% (95% CI: 42-57; n = 311) displayed a picture of a sleeping baby. Among those 311 packages, 79% (95% CI 73-84) were inconsistent with ≥1 SISR, including a nonsupine sleeping position, 45% (95% CI 39-51), soft objects or loose bedding such as pillows or blankets, 51% (95% CI 46-57), and sharing a sleep surface with another person, 10% (95% CI 4-18).

CONCLUSIONS

Pictures on baby diaper packaging in Europe are often inconsistent with SISRs. The prevention of sudden unexpected death in infancy requires action from manufacturers and legislators to stop parents' exposure to misleading images that may lead to dangerous practices.

A mixed-method study of perceptions of cigarette pack inserts among adult smokers from New York and South Carolina exposed as part of a randomized controlled trial

While many countries require prominent pictorial health warning labels (PHWLs) on the outside of cigarette packs to communicate the harms of smoking, there is evidence that cigarette pack inserts that contain efficacy messages may enhance the effectiveness of PHWLs. The US Food and Drug Administration (FDA) has regulatory authority to communicate with smokers through inserts. While current labeling regulations do not require inclusion of inserts, the FDA could implement them in the future. This study assesses US smokers' perceptions of cigarette package inserts at the conclusion of a two-week randomized trial on cigarette labeling where half of participants were exposed to insert messages (two response-efficacy messages and two self-efficacy messages) in their packs. Participants (n = 359) completed a 30- to 60-min interview with both quantitative and qualitative assessments, including measures of recall and perceived message effectiveness (PME) for specific inserts. Correlates of recall and PME were estimated using mixed-effects regression models. Qualitative responses to PME items were analyzed using thematic analysis. Response-efficacy messages had higher PME and recall than self-efficacy messages. People had diverse responses to the inserts, including that they were positive, thought-provoking, and helpful. Reactions to and perceptions of the inserts indicate potential benefits of integrating efficacy messages into labeling policies.

Tobacco-control policy support among people from low socioeconomic positions in Massachusetts

People from low socioeconomic positions (SEP) are at a higher risk of smoking, face greater barriers to smoking cessation, and have lower access to health information. To improve tobacco-related health outcomes, policies requiring altering labeling on cigarette packs could be implemented. However, public support is needed to influence the policymaking process. We assessed factors associated with supporting tobacco-control communication policies. We analyzed data from Project CLEAR, a study conducted in Massachusetts. The analytic sample included participants who answered questions on their support for three policies: 1) graphic health warnings (GHWs), 2) Quitline number, and 3) smoking cessation information on cigarette packs (n = 357). Binomial logistic regression modeling was conducted by policy. Independent variables included demographic characteristics and smoking status. We found that younger vs. older individuals (aOR = 0.41, 95 %CI:0.23-0.72), males vs. females (aOR = 0.58, 95 %CI:0.35-0.96), and people who smoke vs. those who don't smoke (aOR = 0.41, 95 %CI:0.24-0.70) were less likely to support a law requiring GHWs. Participants with a low vs. higher level of education (aOR = 0.55, 95 %CI:0.32-0.95) were less likely to support a law requiring a Quitline number. Younger (18-39) vs. older individuals (aOR = 0.53, 95 %CI:0.29-0.94), males vs. females (aOR = 0.57, 95 %CI:0.34-0.96), and participants with a low vs. higher level of education (aOR = 0.56, 95 %CI:0.32-0.98) were less likely to support a law requiring cessation information on cigarette packs. Findings suggest that targeted theory-based public health and communication strategies should be developed to increase awareness and support towards policies that would help reduce cigarette smoking among people from low SEP to eliminate tobacco-related health inequities in the US.

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.

Estimating the Effectiveness of Health Warnings on Cigarette Packaging in Nigeria: A Modeling Study

INTRODUCTION

Tobacco consumption is associated with nearly 30 000 deaths annually in Nigeria alongside other adverse health and economic effects. Our objective was to estimate the health and economic implications of the current cigarette labeling policies (text-only HWs); new health warnings policies in the country (adding graphic health warnings with up to 60% coverage), and plain packaging policy as recommended by the World Health Organization.

AIMS AND METHODS

We used a probabilistic state-transition individual microsimulation model, considering natural history, healthcare costs, and quality-of-life losses associated with main tobacco-attributable diseases; and the potential effects of packaging and labeling policies. We used three scenarios: (1) text-only health warnings (HWs) covering 50% of the pack, (2) introduction of graphic HWs of 50% (and later increasing to 80%) of the pack, and (3) plain packaging with HWs covering 80% of the pack.

RESULTS

A total of 748 deaths are averted in the current situation; 7478 and 14 208 deaths can be averted with the new policy and with plain packaging, respectively. The number of cardiac, cerebrovascular, and cancer events that could be averted by adopting text and graphic HWs are 3093, 5093, and 1346, respectively; increasing to 5876, 9676, and 2557, respectively, with plain packaging. Up to 251 794 years were lost because of early deaths and disability, and ₦144.6 billion (USD 469 million) in health costs could be saved with HWs covering 50% to 80% of the pack over 10 years. With plain packaging and graphic HWs covering 80% of the package 478,408 years and ₦274.7 billion (USD 895 million) would be saved.

CONCLUSIONS

The new cigarette labeling policy in Nigeria may yield significant health and economic benefits over 10 years. Moving the current policy to plain packaging can significantly improve these benefits.

IMPLICATIONS

The new cigarette labeling policy that Nigeria is implementing should aim to achieve 100% compliance with its current regulation and the logical next step: Plain packaging with large warnings. The present study adds evidence of the potential health effects and cost savings of these levels of implementation, which is valuable for local policymakers.

The association between viewing cigarette health warning labels and intention to quit smoking among Chinese adult smokers: support for including health outcome content and culturally specific messages

BACKGROUND

Tailored themes of pictorial health warning labels (HWLs) that considers specific cultural dimensions and within a specific policy/historical context can motivate behavior change, such as provoking smokers to think about quitting. Currently in China, the HWLs on cigarettes are text-only. This study designed pictorial HWLs using different themes to explore and examine the association between viewing pictorial HWLs and participants' intention to quit smoking. The themes included: (1) Self-harm from using cigarettes, (2) Harming family or children with secondhand smoke, (3) Complying with existing smoke-free policies, and (4) Cigarette gift giving practices.

METHODS

A cross-sectional randomized experimental survey was conducted among 1,625 smokers in Beijing (n = 545), Shanghai (n = 541), and Shenzhen (n = 539) during 2017. Before and after viewing eight pictorial HWLs of one theme, participants were asked if they had plans to quit smoking within the next month, within the next 6 months, beyond the next 6 months, or not at all. Ordinal logistic regression, Wilcoxon and Chi-square tests were used to analyze the data.

RESULTS

After viewing the HWLs, 434 participants (26.9%) reported an intention to quit smoking sooner, 987 (61.2%) reported the same intention to quit, and 191 (11.8%) reported an intention to quit later. The pre-post change in intention to quit was statistically significant among all participants and participants under each theme (p > 0.05). Participants who rated the effectiveness of the HWL communicating how secondhand smoke harms children had 1.13 (95% CI 1.01-1.27) greater odds of reporting an intention to quit sooner compared to those viewing labels from the other themes, adjusting for covariates. Female participants and participants with annual household income more than 100,000RMB had 1.39 (95% CI 1.14-1.69) and 1.29 (95% CI 1.04-1.60) greater odds of reporting an intention to quit sooner compared to their counterparts across the entire sample.

CONCLUSIONS

Findings of this study provide evidence of an association between all four pictorial HWL themes and smokers' intention to quit smoking. These findings can help inform what HWL themes might be appropriate when China implements pictorial health warning labels.

Examining the Effectiveness of the 2012 Canadian Graphic Warning Label Policy Change by Sex, Income, and Education

INTRODUCTION

We examined the differential impact of the 2012 Canadian GWL policy changes on key indicators of warning label impact and quit intentions using national cohorts of Canadian and U.S. adults who smoke.

AIMS AND METHODS

We used data from all waves of the International Tobacco Control surveys (2002-2020) in Canada and the United States. Our key measures were quit intentions and an index of warning label effectiveness (salience, cognitive and behavioral reactions). We estimated overall policy impact by comparing Canada (treatment group) with the United States (control group) using controlled interrupted time series (CITS) regression models, with interactions to examine whether policy impact varied by sex, education, and income.

RESULTS

The CITS model showed a statistically significant increase in the warning label effectiveness in Canada post-policy, compared to the United States (β = 0.84, 95% CI 0.35,1.33). Similarly, the odds of quit intentions were relatively higher among adults who smoked in Canada compared to the United States (OR = 1.89, 95% CI 1.51,2.36) post-policy. The three-way interaction model showed that these associations were greater among adults from low socioeconomic status (SES) groups than in high SES groups.

CONCLUSIONS

The 2012 change in the Canadian GWL policy was associated with stronger cognitive and behavioral responses to GWLs and higher odds of quit intentions among adults who smoked in Canada when compared to the United States, specifically among individuals from low SES groups, suggesting a positive equity impact. Our findings affirm the need for countries to implement or enhance GWLs, in line with the WHO Framework Convention on Tobacco Control (FCTC).

IMPLICATIONS

The evidence on the potential health equity benefit of GWL policies is mixed. To further understand the influence of GWL policies on tobacco use disparities, more systematic research using pre/post-policy designs with control groups is needed. Using a CITS model, we aimed to strengthen the available evidence on the causal influence of this tobacco control approach. Our findings show that the 2012 GWL policy change had a greater impact on adults who smoked from low SES groups than it did on adults who smoked from high SES groups, indicating a potentially positive equity impact and confirming the need for countries to implement or maximize the size of GWLs, as recommended by the WHO FCTC.

How do current tobacco warnings compare to the WHO FCTC guidelines: a content analysis of combustible tobacco warnings worldwide

OBJECTIVE

Many countries have adopted warning labels for combustible tobacco products, yet little research exists describing tobacco warning characteristics globally and to what extent they meet the WHO Framework Convention for Tobacco Control (FCTC) Guidelines. This study evaluates characteristics of combustible tobacco warnings.

DESIGN

We conducted a content analysis to describe the overall landscape of warnings using descriptive statistics and compared to the WHO FCTC Guidelines.

SETTING

We searched existing warning databases for combustible tobacco warnings from English-speaking countries. We compiled warnings meeting inclusion criteria and coded for message and image characteristics using a pre-defined codebook.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Characteristics of combustible tobacco warning text statements and warning images were the primary study outcomes. There were no secondary study outcomes.

RESULTS

We identified a total of 316 warnings from 26 countries or jurisdictions worldwide. Of these warnings, 94% included warning text and an image. Warning text statements most often described health effects to the respiratory (26%), circulatory (19%) and reproductive systems (19%). Cancer was the most frequently mentioned health topic (28%). Fewer than half of warnings included a Quitline resource (41%). Few warnings included messages about secondhand smoke (11%), addiction (6%) or cost (1%). Of warnings with images, most were in colour and showed people (88%), mostly adults (40%). More than 1 in 5 warnings with images included a smoking cue (ie, cigarette).

CONCLUSIONS

While most tobacco warnings followed WHO FCTC guidance on effective tobacco warnings, such as communicating health risks and inclusion of images, many did not include local Quitline or cessation resources. A sizeable minority include smoking cues that could inhibit effectiveness. Full alignment with WHO FCTC guidelines will improve warnings and better achieve the WHO FCTC objectives.

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.

The Differential Impact of the 2000 Canadian Graphic Warning Label Policy on Smoking Prevalence by Sex and Education: A Difference-in-Difference-in-Difference Model

INTRODUCTION

Using a quasiexperimental design, we compared the impact of the 2000 Canadian introduction of graphic warning labels (GWLs) on differences in smoking prevalence by sex and education, to the United States, where no GWLs were introduced.

METHODS

We pooled 1999-2004 data from the Canadian Tobacco Use Monitoring Survey and the U.S. Behavioral Risk Factor Surveillance System. We used a difference-in-difference (DD) model to assess the impact of Canadian policy introduction on smoking prevalence, and a difference-in-difference-in-difference (DDD) model to examine differences in the policy impact by sex and education, comparing Canada (the treatment group) with the United States (the control group).

RESULTS

From 1999 to 2004, smoking prevalence decreased from 23.7% to 18.6% in Canada, and from 21.7% to 20.0% in the United States. Results from the DD regression models showed that Canadian respondents reported lower odds of being a current smoker compared to the U.S. respondents following the 2000 introduction of GWLs (OR = 0.84, 95% CI = 0.74-0.94). The DDD model showed that the impact of the Canadian GWLs versus the United States did not differ by sex or education.

CONCLUSIONS

The 2000 Canadian GWL policy reduced smoking prevalence overall, with similar reductions for males and females and across education levels. The impact of the Canadian GWLs in reducing smoking prevalence did not reduce differences by sex or education. Although beneficial for all smokers, GWLs may not serve to decrease existing disparities, especially those by socioeconomic status.

IMPLICATIONS

Existing evidence shows that GWL implementation is associated with reductions in smoking prevalence. But there is limited evidence from past evaluation studies on whether the impact of GWLs on smoking prevalence differs by sociodemographic subgroup. Our findings confirm existing studies that the 2000 implementation of GWLs in Canada was significantly associated with an overall reduction in smoking prevalence in Canada compared to the United States. However, our study improves existing evidence by showing that the impact of the Canadian GWLs on smoking prevalence did not differ by sex or education, and thus did not reduce existing smoking disparities by educational levels.

COTPA implementation status: An observational study in South Indian city

Background & objectives

The World Health Organization (WHO) document released on the World No Tobacco Day, 2020, mentions that tobacco kills over 22,000 people worldwide every day either from its use or second-hand smoke exposure, which is one person every 4 sec. In 2003, the Cigarettes and Other Tobacco Products Act (COTPA) was enacted by the Indian government to control/regulate use of tobacco and tobacco products. Despite various amendments to this law, there has not been any appreciable decrease in tobacco use. The objective of this study was to assess the compliance level with sections 4-10 of COTPA in urban Puducherry in South India.

Methods

Random sample survey of 13 wards was carried out in selected parts of the city of Puducherry. The estimated sample size was minimum 160 public places and point of sales (PoS) each. A pre-tested checklist was used to obtain information on compliance with COTPA. Statistical and spatial analysis was performed using STATA v12.0 and QGIS v2.14.21, respectively.

Results

Eight per cent of public places, 0 per cent of PoS, 1.7 per cent of educational institutions and 48 per cent of tobacco packages were found compliant with COTPA specifications. The compliance in public places varied from 0 (bus stops) to 55 per cent (religious places).

Interpretation & conclusions

The overall compliance with COTPA was found to be very low in urban Puducherry. In order to ensure proper implementation of the laws, effective enforcement with periodic monitoring of various sections of COTPA are needed.

Front-of-Package Labels on Unhealthy Packaged Foods in India: Evidence from a Randomized Field Experiment

Policies to require front-of-package labels (FOPLs) on packaged foods may help Indian consumers to better identify foods high in nutrients of concern, including sugar, saturated fat, and sodium, and discourage their consumption, which are outcomes that are critical for preventing rises in diet-related non-communicable disease. The objective was to test whether FOPLs helped Indian consumers identify “high-in” packaged foods and reduce intentions to purchase them. We conducted an in-person randomized experiment (n = 2869 adults between ages 18 and 60 years old) in six states of India in 2022. Participants were randomized to one of five FOPLs: a control label (barcode), warning label (octagon with “High in [nutrient]”), Health Star Rating (HSR), Guideline Daily Amount (GDA), or traffic light label. Participants then viewed a series of packaged foods high in sugar, saturated fat, or sodium with the assigned FOPL, and rated product perceptions and label reactions. Fewer than half of participants in the control group (39.1%) correctly identified all products high in nutrient(s) of concern. All FOPLs led to an increase in this outcome, with the biggest differences observed for the warning label (60.8%, p < 0.001), followed by the traffic light label (54.8%, p < 0.001), GDA (55.0%, p < 0.001), and HSR (45.0%, p < 0.01). While no FOPLs led to a reduction in intentions to purchase the packaged foods, the overall pattern of results suggested that warning labels are the most effective FOPL to help Indian consumers identify unhealthy foods.

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

Background

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

Aims

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

Methods

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

Results

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

Conclusion

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

Healthy, nudged, and wise: Experimental evidence on the role of information salience in reducing tobacco intake

We evaluate the performance of two behavioral interventions aimed at reducing tobacco consumption in an ultra-poor rural region of Bangladesh, where conventional methods like taxes and warning labels are infeasible. The first intervention asked participants to daily log their tobacco consumption expenditure. The second intervention placed two graphic posters with warnings about the harmful effects of tobacco consumption on tobacco users and their children in the sleeping quarters of the participating households. While both interventions reduced household tobacco consumption expenditure, male participants who logged their expenditure substituted cigarettes with cheaper smokeless tobacco. The reduction in tobacco intake is larger among males with a non-tobacco consuming spouse. Exploratory analysis reveals that risk-averse males who spent relatively more on tobacco responded more to the logbook intervention. More educated, patient males with children below age five responded better to the poster intervention. The findings suggest that in countries with multi-tiered tobacco excise tax structures, which incentivize downward substitution, extending complementary demand-side policies that worked elsewhere to the rural poor might be unwise. Instead, policies may leverage something as universal as parental concern for their children's health to promote better health decision-making.

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.

Controlling the obesity pandemic: Geoffrey Rose revisited

The ongoing obesity pandemic threatens the health of hundreds of millions globally. However, to date, no country has had much success in limiting its growth, let alone reversing it. This commentary demonstrates the relevance to the obesity pandemic of the public health conceptual framework of epidemiologist Geoffrey Rose, first published as "Sick Individuals and Sick Populations" in 1985. That framework provides a useful way to analyze the pandemic's prevention and control options, based on the notions of primordial, primary, secondary and tertiary prevention-the full spectrum of "more upstream and more downstream" approaches, each with its pros and cons. Based on an analysis of key studies to date, this commentary argues strongly that only the primordial prevention approach is likely to be successful against the obesity pandemic-but its onerous requirements for society-wide behavioural and cultural change may make that public health struggle a long one.

Why are anti-smoking health-information interventions less effective among low-socioeconomic status groups? A systematic scoping review

ISSUES

This paper identifies and synthesises explanations proposed in the literature for the (in)effectiveness of institutional anti-smoking health-information interventions (HII) among low-socioeconomic status (SES) adults in high-income countries.

APPROACH

We searched eight databases for relevant papers from various disciplines: Studies published in English since 2009, on the effectiveness among low-SES adults of anti-smoking HIIs, aimed at changing knowledge/behaviour, and conducted by official institutions, were included. Through a scoping review, we synthesised: study design, SES indicator, intervention type, intervention source, study population, outcomes, low-SES effects, equity effects, proposed explanations and whether these were studied empirically.

KEY FINDINGS

Thirty-eight studies were included in this scoping review. Seventeen suggested explanations for the (in)effectiveness of the HIIs in low-SES adults, but only nine assessed them empirically. Thematic analysis yielded six themes: message engagement, material conditions, cognition, risk perception, social environment and self-efficacy.

IMPLICATIONS

Explanations for intervention results are not always present, and empirical evidence for explanations is often not provided. Including such explanations and testing their empirical merits in future research can provide the crucial information needed for developing more effective anti-smoking HIIs for low-SES adults.

CONCLUSIONS

To our knowledge, this is the first review to explore the explanations proposed for why anti-smoking HIIs are (in)effective among low-SES adults. It contains insights for future studies aiming to provide empirical evidence on the causes of this (in)effectiveness, and concludes that such research is yet largely missing, but crucial to the quest for more effective and equitable anti-smoking interventions.

Strategies to enhance the effects of pictorial warnings for cigarettes: results from a discrete choice experiment

AIMS

To measure the effects of changing attributes of pictorial health warning labels (HWLs) on cigarette packs in a country that has already implemented pictorial HWLs.

MEASURES

For each choice set, participants were presented with two cigarette packs and asked the following three questions: (1) 'If only these two cigarette packs were available, which would you buy?'; (2) 'Each of these two packs has warnings on the front and back about the health effects of smoking. Which of these warnings best informs you about the dangers from smoking?'; and (3) 'Which warning most makes you think about quitting smoking?'. As recommended for best practices in discrete choice experiments, each of these questions was followed by an 'opt-out' question for participants to indicate whether they really believed there was a difference between the options presented (i.e. 'Would you really choose one of them?'; 'Do you really think that either of these warnings informs you about dangers from smoking?'; or 'Do you really think that either of these warnings would make you think about quitting smoking?', respectively). Each choice set could be viewed for as long as the participant wished. For each choice question (i.e. willingness to buy, informative, motivating to quit), the pack chosen was coded as 1 and the other pack as 0, with both packs being given a value of 0 if the participant 'opted out'.

DESIGN

A within-subject discrete choice experiment that involved systematic manipulation of pictorial HWL size [75 versus 30% (current policy)]; inclusion of imagery on the back of the pack [versus none (current policy)]; and color formatting [black on yellow versus yellow on black (current policy)].

SETTING

Mexico, on-line panel.

PARTICIPANTS

Adult smokers (n = 705).

MEASUREMENTS

For each choice set, participants selected one pack as having the most informative HWL about smoking harms, the one that makes them think the most about quitting and the one they were most willing to buy. We assessed the independent and interactive effects of HWL attributes on choices.

FINDINGS

Larger HWL size on the pack front (75 versus 30%) and inclusion of a pictorial image on the pack back were both independently associated with lower willingness to buy a pack [b = -0.228, standard error (SE) = 0.023 and -0.089, SE = 0.016, respectively] and greater perception of an HWL as informative (b = 0.214, SE = 0.022, and 0.191, SE = 0.017, respectively) and motivating to quit (b = 0.251, SE = 0.023 and 0.194, SE = 0.017, respectively). HWL with black text and yellow background were perceived as less informative (b = -0.037, SE = 0.016) and less motivating to quit (b = -0.032, SE = 0.015) compared with yellow text on a black background.

CONCLUSIONS

Among adult Mexican smokers, pictorial health warning labels on cigarette packages that are larger or cover both sides of the pack appear more effective at lowering purchase intentions and increasing risk perceptions and motivation to quit than smaller health warning labels or health warning labels with imagery only on the pack front.

Demographic characteristics associated with awareness of cigarette health warnings and thinking about quitting among current adult cigarette smokers in Zambia, 2017

INTRODUCTION

Noticing health warnings on cigarette packages has been associated with thinking about quitting. This study examined sociodemographic characteristics associated with awareness of health warnings on cigarette packages and thinking about quitting because of health warning labels among adults who currently smoked tobacco.

METHODS

We analyzed data from the 2017 Zambia WHO STEPS survey (STEPwise approach to surveillance) for noncommunicable disease risk factors. Descriptive analyses and logistic regression were performed to assess the association of select sociodemographic characteristics with awareness of health warnings and thinking about quitting because of health warnings.

RESULTS

Adults who currently smoked tobacco who were aged 30–44 years, of Chewa ethnicity, or with a formal education, were more likely to be aware of health warnings than those aged 18–29 years (adjusted prevalence ratio, APR=1.26; 95% CI: 1.02–1.54), of Bemba ethnicity (APR=1.43; 95% CI: 1.17–1.74), or with no formal education (APR: 2.61–5.95). Among all adults who currently smoked, those of Chewa ethnicity (APR=1.55; 95% CI: 1.03–2.35), or with a formal education (APR:1.80–4.38), were more likely to report thinking about quitting because of health warnings than those who were of Bemba ethnicity or with less than primary school education level. Women who currently smoked were 49% less likely (APR=0.51; 95% CI: 0.23–0.84) to report thinking about quitting than men. Among a subset of adults who currently smoked who were aware of health warning labels, no sociodemographic characteristics were significantly associated with thinking about quitting in unadjusted or adjusted models.

CONCLUSIONS

Sociodemographic characteristics such as sex, ethnicity, and education level were significantly associated with awareness of cigarette health warnings. Among cigarette smokers aware of health warnings, no sociodemographic differences in thinking about quitting were found. Tobacco control campaigns may need to target people of ethnicities with the highest smoking prevalence in the country.

Influence of the San Francisco, CA, Sugar-Sweetened Beverage Health Warning on Consumer Reactions: Implications for Equity from a Randomized Experiment

BACKGROUND

In 2020, San Francisco, CA, amended an ordinance requiring warning labels on advertisements for sugary drinks to update the warning message. No studies have evaluated consumer responses to the revised message.

OBJECTIVES

To evaluate responses to the 2020 San Francisco sugary drink warning label and to assess whether these responses differ by demographic characteristics.

DESIGN

Randomized experiment.

PARTICIPANTS AND SETTING

During 2020, a convenience sample of US parents of children aged 6 months to 5 years (N = 2,160 included in primary analyses) was recruited via an online panel to complete a survey. Oversampling was used to achieve a diverse sample (49% Hispanic/Latino[a], 34% non-Hispanic Black, and 9% non-Hispanic White).

METHODS

Participants were randomly assigned to view a control label ("Always read the Nutrition Facts Panel") or the 2020 San Francisco sugary drink warning label ("SAN FRANCISCO GOVERNMENT WARNING: Drinking beverages with added sugar(s) can cause weight gain, which increases the risk of obesity and type 2 diabetes."). Messages were shown in white text on black rectangular labels.

MAIN OUTCOME MEASURES

Participants rated the labels on thinking about health harms of sugary drink consumption (primary outcome) and perceived discouragement from wanting to consume sugary drinks. The survey was available in English and Spanish.

STATISTICAL ANALYSES PERFORMED

Ordinary least squares regression.

RESULTS

The San Francisco warning label elicited more thinking about health harms (Cohen's d = 0.24; P < 0.001) than the control label. The San Francisco warning label also led to more discouragement from wanting to consume sugary drinks than the control label (d = 0.31; P < 0.001). The warning label's influence on thinking about harms did not differ by any participant characteristics, including age, gender, race/ethnicity, education, income, or language of survey administration (all P values for interactions > 0.12).

CONCLUSIONS

San Francisco's 2020 sugary drink warning label may be a promising policy for informing consumers and encouraging healthier beverage choices across groups with diverse demographic characteristics.

The impact of pictorial health warnings on purchases of sugary drinks for children: A randomized controlled trial

BACKGROUND

Pictorial warnings on tobacco products are promising for motivating behavior change, but few studies have examined pictorial warnings for sugary drinks, especially in naturalistic environments. This study aimed to examine the impact of pictorial warnings on parents' purchases of sugary drinks for their children in a naturalistic store laboratory.

METHODS AND FINDINGS

Parents of children ages 2 to 12 (n = 325, 25% identifying as Black, 20% Hispanic) completed a shopping task in a naturalistic store laboratory in North Carolina. Participants were randomly assigned to a pictorial warnings arm (sugary drinks displayed pictorial health warnings about type 2 diabetes and heart damage) or a control arm (sugary drinks displayed a barcode label). Parents selected 1 beverage and 1 snack for their child, as well as 1 household good; one of these items was selected for them to purchase and take home. The primary outcome was whether parents purchased a sugary drink for their child. Secondary outcomes included reactions to the trial labels, attitudes toward sugary drinks, and intentions to serve their child sugary drinks. Pictorial warnings led to a 17-percentage point reduction in purchases of sugary drinks (95% CI for reduction: 7% to 27%), with 45% of parents in the control arm buying a sugary drink for their child compared to 28% in the pictorial warning arm (p = 0.002). The impact of pictorial warnings on purchases did not differ by any of the 13 participant characteristics examined (e.g., race/ethnicity, income, education, and age of child). Pictorial warnings also led to lower calories (kcal), purchased from sugary drinks (82 kcal in the control arm versus 52 kcal in the pictorial warnings arm, p = 0.003). Moreover, pictorial warnings led to lower intentions to serve sugary drinks to their child, feeling more in control of healthy eating decisions, greater thinking about the harms of sugary drinks, stronger negative emotional reactions, greater anticipated social interactions, lower perceived healthfulness of sugary drinks for their child, and greater injunctive norms to limit sugary drinks for their child (all p < 0.05). There was no evidence of difference between trial arms on noticing of the labels, appeal of sugary drinks, perceived amount of added sugar in sugary drinks, risk perceptions, or perceived tastiness of sugary drinks (all p > 0.05).

CONCLUSIONS

Pictorial warnings reduced parents' purchases of sugary drinks for their children in this naturalistic trial. Warnings on sugary drinks are a promising policy approach to reduce sugary drink purchasing in the US.

TRIAL REGISTRATION

The trial design, measures, power calculation, and analytic plan were registered before data collection at www.clinicaltrials.gov NCT04223687.

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.

Impact of health warning labels on selection and consumption of food and alcohol products: systematic review with meta-analysis

Health warning labels (HWLs) could reduce harmful consumption of food (including non-alcoholic drinks) and alcoholic drinks. A systematic review with meta-analysis using Cochrane methods was conducted to assess the impact on selection (including hypothetical selection) or consumption of food or alcoholic drink products displaying image-and-text (sometimes termed 'pictorial') and text-only HWLs. Fourteen randomised controlled trials were included, three for alcohol, eleven for food. For the primary outcomes, eleven studies measured selection and one measured consumption (two measured only other secondary outcomes). Meta-analysis of twelve comparisons from nine studies (n=12,635) found HWLs reduced selection of the targeted product compared with no HWL (RR=0.74 (95%CI 0.68-0.80)), with participants 26% less likely to choose a product displaying a HWL. A planned subgroup analysis suggested a larger (although not statistically significant) effect on selection of image-and-text HWLs (RR=0.65 (95%CI 0.54-0.80)) than text-only HWLs (RR=0.79 (95%CI 0.74-0.85)). These findings suggest significant potential for HWLs to reduce selection of food and alcoholic drinks, but all experimental studies to date were conducted in laboratory or online settings with outcomes assessed immediately after a single exposure. Studies in field and naturalistic laboratory settings are needed to estimate the potential effects of food and alcohol HWLs.Study registration: PROSPERO 2018 (registration number: CRD42018106522).

Developing Pictorial Cigarillo Warnings: Insights From Focus Groups

INTRODUCTION

The Food and Drug Administration (FDA) selected six text-only warnings for cigarillos to be implemented on packaging and advertising. Pictorial warnings are more effective at discouraging cigarette use than text-only warnings, yet no research exists for cigarillos. We sought to understand what types of images might be most effectively paired with the cigarillo text warnings to inform broad principles for developing pictorial warnings, with a focus on young adults, who have the highest rate of cigarillo use.

METHODS

We conducted five focus groups with a total of N = 30 young adult cigarillo users and susceptible nonusers (53% female, 50% White, and 33% Black). Participants were shown four to eight unique images for each of the six text statements and were asked about visual-verbal congruency, emotional and cognitive reactions, and perceived effectiveness of each image. Sessions were recorded and transcribed; two investigators independently coded transcripts for emergent themes.

RESULTS

Participants reported images that were graphic or "gross" would best grab attention and discourage use of cigarillos. Participants preferred images that were a direct illustration of the information in the warning text, rather than abstract images that required more cognitive effort to understand. Participants also highlighted that including people in the images, especially youth and young adults making eye contact, helped them relate to the warnings, garner their attention, and positively influence their reactions.

CONCLUSIONS

We identified several principles to inform the selection of images to pair with the FDA-required cigarillo text statements. These insights may also apply to pictorial warnings for other tobacco products.

IMPLICATIONS

This focus group study identified principles for selecting images to develop pictorial warnings for the six FDA text-only cigarillo warnings. We found that young adult cigarillo users and susceptible nonusers preferred images that were graphic and gross, believable, congruent to the warning text, and included people. Images that match young adults' visual expectations of a disease and are emotion-provoking may be most effective in pictorial warnings and highlight challenges for developing pictorial warnings for health effects that do not have a visible health consequence.

Effect of magnification and changes in tobacco pictorial warning on asceticism of tobacco use: An exploratory survey

Background:

Tobacco usage-related diseases pose serious threat for not only public health but also for country's economy and warning labels are considered as an effective strategy to spread more awareness on tobacco hazards.

Aim:

The aim of this hospital-based questionnaire survey was to assess the effect of magnified pictorial warning over tobacco products on asceticism of tobacco use and to measure the association of selected tobacco habits variables and asceticism of tobacco use.

Materials and Methods:

Present exploratory survey based on triangulation method of data collection was conducted among conveniently selected 1,008 tobacco users or smokers attending OPD services at tertiary care center during the year 2018–2019. Quantitative survey data was collected through structured questionnaire and two FGDs were conducted for qualitative information. Data was analyzed using descriptive and inferential statistics.

Results:

Magnification of health warnings over tobacco packets had impact on tobacco or cigarette consumption to some extent (415; 41.25%); but insisted only one third (383; 38.0%) participants to quit tobacco use. A significant association was observed between awareness about bad effect of tobacco use and attempt of quit tobacco uses (OR 0.29; CI 95%, 0.223–0.390; P = 0.001). Furthermore, significant effect of magnified warning over tobacco products was seen on reduction in tobacco use (OR 0.39; CI 95%, 0.300–0.531; P = 0.001) and quitting the tobacco (OR 0.38; CI 95%, 0.28620.513; P = 0.001).

Conclusion:

Study results concluded that magnification of pictorial warning is associated with the asceticism of tobacco use to some extent but alone it is not sufficient. Therefore, adjunct intervention of mass public education about bad effect of tobacco use is more essential to augment asceticism of tobacco use.

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.

Communicating risk differences between electronic and combusted cigarettes: the role of the FDA-mandated addiction warning and a nicotine fact sheet

INTRODUCTION

The US Food and Drug Administration requires e-cigarettes to carry a nicotine addiction warning. This research compared the effects of messages communicating comparative risk of electronic and combusted cigarettes (CR messages) with and without the mandated warning and tested the effects of showing a nicotine fact sheet (NFS) before exposure to CR messages with warning.

METHOD

In an online experiment, 1528 US adult smokers were randomised to one of four conditions: (1) three CR messages, (2) three CR messages in condition one with an addiction warning, (3) an NFS followed by the three messages in condition 2 and (4) control messages. Outcomes included message reactions and perceived effectiveness, e-cigarette-related and cigarette-related beliefs and behavioural intentions and nicotine-related beliefs.

RESULTS

CR messages with and without an addiction warning did not differ. The NFS condition produced higher odds of correctly understanding the risk of nicotine and stronger beliefs that switching to e-cigarettes could reduce health risks (response efficacy) than other treatments. Compared with control, all messages made it more likely for people to report e-cigarettes are less harmful than cigarettes and increased response efficacy and switch intentions to e-cigarettes. Only NFS condition increased correct beliefs about the risk of nicotine and self-efficacy about switching to e-cigarettes.

CONCLUSION

Including an addiction warning on CR messages did not reduce intentions to switch to e-cigarettes. Communicating accurate risk of nicotine together with CR messages and addiction warning increased smokers' self-efficacy beliefs about switching completely to e-cigarettes, making it a potentially promising antitobacco communication strategy.

Numeracy and memory for risk probabilities and risk outcomes depicted on cigarette warning labels

OBJECTIVE

Greater numeracy is associated with higher likelihood to quit smoking. We examined whether numeracy supports learning of numeric health-risk information and, in turn, greater risk perceptions and quit intentions.

METHOD

Adult smokers (N = 696) viewed text warnings with numeric risk information four times each in one of three warning-label types (text-only, low-emotion pictorial [i.e., with image], high-emotion pictorial). They completed posttest measures immediately or 6 weeks later. Emotional reactions to warnings were reported the second time participants viewed the warnings. Numeracy, memory for risk probabilities and risk outcomes, risk perceptions, and quit intentions were assessed postexposures.

RESULTS

Memory for risk probabilities and risk outcomes depended on warning-label type and posttest timing. Consistent with memory-consolidation theory, memory for high- versus low-emotion labels was lower immediately, but declined less for high-than low-emotion labels. Label memory was similar between conditions at 6 weeks. Numeracy predicted overall superior memory (especially for risk probabilities) controlling for health literacy and education. It also indirectly predicted greater risk perceptions and quit intentions via memory. In exploratory analyses, however, the superior recall of risk probabilities of smoking among those higher in numeracy was associated with lower risk perceptions.

CONCLUSIONS

Numeracy is associated with superior risk memory, which relates to greater risk perceptions and quit intentions. More numerate and educated smokers may be better able to quit due to their superior learning of smoking's risks. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Communicating risks to drinkers: testing alcohol labels with a cancer warning and national drinking guidelines in Canada

OBJECTIVE

To test whether alcohol labels with a cancer warning and national drinking guidelines are an effective tool for supporting more informed and safer alcohol consumption among drinkers.

METHODS

Using a quasi-experimental design, pre-post surveys were conducted with 1647 cohort participants systematically selected in liquor stores in two matched sites in Canada in 2017-2018. Enhanced labels designed according to best practices for effective product labels were applied to alcohol containers in the liquor store in the intervention site for one month, and usual practice continued in the comparison site. Generalized estimating equations tested the differences between sites over time in label salience and processing, and self-reported impact of the labels on drinking behaviours.

RESULTS

After the intervention, recall of the cancer warning label increased to a greater extent in the intervention versus comparison site (adjusted odds ratio (AOR) = 32.2, 95% CI = 5.4, 191.1), but not the national drinking guideline label (AOR = 2.7, 95% CI = 0.2, 31.8). There were significant label effects in the intervention versus comparison site for reading (AOR = 1.8, 95% CI = 1.3, 2.5), thinking about (AOR = 2.0, 95% CI = 1.4, 2.9), and talking with others about (AOR = 2.1, 95% CI = 1.3, 3.6) the labels, as well as self-reported impact to cut down on drinking (AOR = 2.5, 95% CI = 1.3, 4.7) and to drink less (AOR = 2.4, 95% CI = 1.3, 4.3).

CONCLUSIONS

Alcohol labels with a cancer warning and national drinking guidelines do a better job conveying risk information and promoting safer consumption than existing practices. Industry has a legal duty to adequately inform consumers about their products and should be mandated to include key information on alcohol containers.

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.

Cigarette Constituent Health Communications for Smokers: Impact of Chemical, Imagery, and Source

INTRODUCTION

Communication campaigns are incorporating tobacco constituent messaging to reach smokers, yet there is a dearth of research on how such messages should be constructed or will be received by smokers.

METHODS

In a 2 × 2 × 2 experiment, we manipulated three cigarette constituent message components: (1) the toxic constituent of tobacco (arsenic vs. lead) with a corresponding health effect, (2) the presence or absence of an evocative image, and (3) the source of the message (FDA vs. no source). We recruited smokers (N = 1669, 55.4% women) via an online platform and randomized them to one of the eight message conditions. Participants viewed the message and rated its believability and perceived effectiveness, the credibility of the message source, and action expectancies (ie, likelihood of seeking additional information and help with quitting as a result of seeing the message).

RESULTS

We found significant main effects of image, constituent, and source on outcomes. The use of arsenic as the constituent, the presence of an evocative image, and the FDA as the source increased the believability, source credibility, and perceived effectiveness of the tobacco constituent health message.

CONCLUSIONS

Multiple elements of a constituent message, including type of constituent, imagery, and message source, impact their reception among smokers. Specifically, communication campaigns targeting smokers that utilize arsenic as the tobacco constituent, visual imagery, and the FDA logo may be particularly effective in changing key outcomes that are associated with subsequent attitude and behavioral changes.

IMPLICATIONS

This article describes how components of communication campaigns about cigarette constituents are perceived. Multiple elements of a tobacco constituent message, including type of constituent, image, and message source may influence the reception of messages among current smokers. Communication campaigns targeting smokers that utilize arsenic as the tobacco constituent, visual imagery, and the FDA logo may be particularly effective in changing key outcomes among smokers. The effects of such campaigns should be examined, as well as the mechanisms through which such campaigns affect change.

The effectivity of pictorial health warning to motivate smoking cessation in rural area: A study from Losari village, Indonesia

INTRODUCTION

Smoking is a significant health problem among Indonesian adolescents and adults. The Indonesian government had issued several policies to alleviate this problem, including placement of pictorial health warning (PHW) on cigarette package. There had been several evaluation studies regarding the effectivity of PHW in urban areas but none in rural areas. This study aims to evaluate the effectivity of PHW in motivating smoking cessation in a rural area in Indonesia.

MATERIALS AND METHODS

This was a descriptive cross-sectional study conducted in August 2017 in Losari village, Indonesia. Respondents of this study were villagers aged 18-60 years who were active smokers and purchased cigarette with PHW on the package. The research instruments for this study were questionnaire and printout pictures of each PHW approved by the Indonesian government.

RESULTS

There were 94 respondents recruited in this study. Among them, only 26 (27.7%) stated that PHW motivated them to stop smoking. From the five figures of PHW, a picture of lung cancer was the most effective PHW to motivate smoking cessation. Eighty-one of 94 respondents affirm that there are other factors besides PHW that might motivate them to stop smoking. Most of them agreed that an increase in cigarette price will force them to stop smoking.

CONCLUSIONS

Current PHW used on cigarette package might be ineffective in motivating smoking cessation at Losari village. Further study with larger samples needs to be done to confirm this finding.

Effects of strengthening alcohol labels on attention, message processing, and perceived effectiveness: A quasi-experimental study in Yukon, Canada

Alcohol labels are one strategy for raising consumer awareness about the negative consequences of alcohol, but evidence to inform labels is limited. This quasi-experimental study sought to test the real-world impact of strengthening health messages on alcohol container labels on consumer attention, message processing (reading, thinking, and talking with others about labels), and self-reported drinking. Alcohol labels with a cancer warning, national drinking guidelines, and standard drink information were implemented in the intervention site, and usual labelling practices continued in the comparison site. Changes in key indicators of label effectiveness were assessed among a cohort of adult drinkers in both the intervention and comparison sites using three waves of surveys conducted before and at two time-points after the alcohol label intervention. Generalized Estimating Equations with difference-in-difference terms were used to examine the impact of the label intervention on changes in outcomes. Strengthening health messages on alcohol container labels significantly increased consumer attention to [Adjusted Odds Ratio (AOR)=17.2, 95%CI:8.2,36.2] and processing of labels (e.g., reading labels: AOR=2.6, 95%CI:1.8,3.7), and consumer reports of drinking less due to the labels (AOR=3.7, 95%CI: 2.0,7.0). Strengthening health messages on alcohol containers can achieve their goal of attracting attention, deepening engagement, and enhancing motivation to reduce alcohol use. Strengthening alcohol labelling policies should be a priority for alcohol control globally.

Over-Time Impacts of Pictorial Health Warning Labels and their Differences across Smoker Subgroups: Results from Adult Smokers in Canada and Australia

Introduction

This study examines patterns of change in different smoker subgroups' responses to new pictorial health warning labels (HWLs) over the initial, two year post-implementation period in Canada, where HWLs include package inserts with cessation messages, and Australia, where "plain" packaging (i.e., prohibition of brand imagery) was also implemented.

Methods

Data were collected from online consumer panels in Canada (nsmokers = 3153; nobservations = 5826) and Australia (nsmokers = 2699; nobservations = 5818) from September 2012 to September 2014, with approximately 1000 adult smokers surveyed in each country every four months, using replenishment to maintain sample size. Data were analyzed using generalized estimating equation models where main effects and interactions among time, country, and socio-demographic factors on HWL responses (i.e., attention to HWLs; cognitive and behavioral responses to HWLs) were examined.

Results

Over time, attention to HWLs declined but cognitive and forgoing responses to HWLs increased, in both Canada and Australia. In both countries, compared to smokers with low income and/or education, smokers with high income and/or education showed an increase over time in attention and cognitive responses to HWLs (p < .05). In Australia only, compared to older smokers, younger smokers showed less decline over time in attention and greater increase in cognitive and forgoing responses to HWLs (p < .001).

Conclusions

Novel HWL policies in Canada and Australia appear effective in staving off "wear out" over the first 2 years after implementation, particularly amongst smokers who are from higher SES groups and, in Australia, who are younger.

Implications

Previous research shows that the effects of health warning label (HWL) on smokers decline over time, but no studies to date have evaluated whether trends differ across socio-demographic groups. This study suggests that innovative policy configurations that combine prominent pictorial HWLs with inserts (Canada) and with "plain" packaging (Australia) may delay wear out over the first 2 years after implementation. While this study found evidence for wear out in attention to HWLs, other HWL responses (cognitive responses, forgoing cigarettes) actually increased over time, with greater increases amongst smokers with higher income and/or education.

Selling tobacco: A comprehensive analysis of the U.S. tobacco advertising landscape

OBJECTIVES

To describe advertising tactics of cigarette, e-cigarette, little cigar/cigarillo and smokeless tobacco manufacturers.

METHODS

We conducted a content analysis of tobacco 827 ads run in the US in 2016. Ads were double coded by trained coders across ten domains: promotions, web/social media presence, use cues, warnings and disclaimers, descriptors, claims, activities, setting, imagery, and themes.

RESULTS

Cigarette ads relied on promotional tactics like discounts and sweepstakes and featured links to websites and mobile apps, all of which can increase brand loyalty and customer engagement. E-cigarette ads used tactics that appear to target new consumers, such as highlighting the product's qualities and modeling product use. Little cigar/cigarillo ads often positioned the product as social and featured music, urban and nightlife settings. Smokeless tobacco ads frequently featured themes, activities and settings stereotypically thought of as masculine.

CONCLUSIONS

The tactics used to advertise tobacco products can help generate new consumers, encourage product/brand switching, and escalate use among current users. Understanding how different products are advertised can inform the Food and Drug Administration's regulatory efforts, and tobacco counter-marketing campaigns.

How effective are pictorial warnings on tobacco products? New evidence on smoking behaviour using Australian panel data

Studies examining the introduction of pictorial warnings on cigarette packages provide inconclusive evidence due to small samples and methodological issues. We use individual-level panel data from Australia to examine the association between pictorial warnings and smoking behaviour - prevalence, quitting, initiating and relapsing. The pictorial warnings were accompanied by a reference to a smoking cessation helpline and supportive television commercials. Applying an event study framework, we show that the reform reduced smoking rates by around 4% within the first year of the policy. The effect decreases with age, is similar for men and women, and is slightly larger for low-educated compared to high-educated individuals. The reform permanently lowered smoking rates primarily due to increased quitting in the year of the reform. Thus, pictorial warnings combined with a reference to a smoking cessation helpline and supportive media campaigns are an important tobacco control measure to reduce the social costs of smoking.

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.

Are the Same Health Warnings Effective Across Different Countries? An Experimental Study in Seven Countries

INTRODUCTION

More than 100 countries have implemented pictorial health warnings on cigarette packages. However, few studies have compared how consumers from different geographic and cultural contexts respond to health warning content. The current study compares perceptions of warnings among adult smokers and youth in seven countries, to examine the efficacy of different health warning themes and images.

METHODS

Between 2010 and 2012, online and face-to-face surveys were conducted with ~500 adult smokers and ~500 youth (age 16-18) smokers and nonsmokers in each of Mexico, United States, China, Germany, India, Bangladesh, and Republic of Korea (total N = 8182). Respondents were randomized to view and rate sets of 5-7 health warnings (each set for a different health effect); each set included a text-only warning and various types (ie, themes) of pictorial warnings, including graphic health effects, "lived experience," symbolic images, and personal testimonials. Mixed-effects models were utilized to examine perceived effectiveness of warning themes, and between-country differences in responses.

RESULTS

Overall, pictorial warnings were rated as more effective than text-only warnings (p < .001). Among pictorial themes, "graphic" health effects were rated as more effective than warnings depicting "lived experience" (p < .001) or "symbolic" images (p < .001). Pictorial warnings with personal testimonials were rated as more effective than the same images with didactic text (p < .001). While the magnitude of differences between warning themes varied across countries, the pattern of findings was generally consistent.

CONCLUSIONS

The findings support the efficacy of graphic pictorial warnings across diverse geographic and cultural contexts, and support sharing health warning images across jurisdictions.

IMPLICATIONS

Although over 100 countries have implemented pictorial health warnings on cigarette packages, there is little research on the most effective types of message content across geographic and cultural contexts. The current study examined perceived effectiveness of text and pictorial health warnings featuring different message content-graphic health effects, "lived experience," personal testimonials, and symbolic imagery-among more than 8000 adults and youth in Mexico, United States, China, Germany, India, Bangladesh, and Korea. Across countries, "graphic" pictorial messages were rated as most effective. Consistencies across countries in rating message content suggests there may be "globally effective" themes and styles for designing effective health warnings.

Who, why, where: an overview of determinants of sunbed use in Europe

Although exposure to indoor tanning has been established as a clear risk factor for skin cancer, sunbeds are still commonly used in Europe. Understanding the determinants of sunbed use in Europe is key to plan educational interventions, behavioural strategies and legislative measures, which should be tailored to subgroups with different risk profiles. Evidences show that the typical sunbed users in Europe are young-adult women, with intermediate skin type, a current employment and a medium/high socio-economic status. Typical users display sun-seeking behaviours and other risky behaviours such as smoking. Indoor tanning seems more common in northern than southern Europe. However, sunbed use remains common in fair-skinned individuals and among adolescents/pre-adolescents. Commonly reported reasons for sunbed use in Europe include aesthetic motives (i.e. looking attractive), the pursue of a prevacation tan, the influence of peers/parents engaging in the same habit, and the treatment of health conditions. The most commonly reported places to get an artificial tan in Europe are tanning studios and beauty salons. However, sunbeds are also available in sport venues, such as swimming pools and gyms, hotels and private houses. All these factors should be taken into account when planning educational, behavioural and legislative interventions to reduce the popularity of artificial tanning in Europe.

Graphic and Arousing? Emotional and Cognitive Reactions to Tobacco Graphic Health Warnings and Associated Quit-Related Outcomes Among Low SEP Population Groups

Research on graphic health warnings (GHWs) indicates that beyond changing cognitions about the health effects of smoking, GHWs evoke emotional reactions that can influence quit-related outcomes. Emotions can be classified based on valence (positive or negative) and arousal (calm or excited). However, although considerable research has examined the differential effectiveness of positive versus negative GHW-evoked emotions, research investigating the role of arousal activation in quit-related behaviors is scarce. This study examined associations between quit-related outcomes (intention and attempt to quit) and GHWs-evoked negative emotions classified as high and low in arousal activation as well as cognitive reactions among smokers of low socioeconomic position (SEP). It also examined whether perceived health risks of smoking moderate the relationship between emotional and cognitive reactions to GHWs and quit-related outcomes. Data were collected from low SEP smokers in three Massachusetts communities. Participants were screened and randomized to view one of the nine GHWs initially proposed for use by the U.S. Food and Drug Administration (FDA) and answered pre- and post-exposure questions. Results showed that GHW-evoked negative emotions high in arousal activation and cognitive reactions were both significantly associated with intention to quit during immediate post-test, controlling for age, warning label difference, and prior quit intention. However, these associations did not hold for quit attempts at follow-up. Perceived health risks of smoking moderated the association between cognitive reactions to GHWs and quit attempts at follow-up. The findings suggest that not all negative emotions evoked by GHWs are effective. Negative emotions high in arousal activation may be more effective in influencing quit-related behavioral intentions in low SEP groups. Additionally, unlike emotional reactions, cognitive reactions to GHWs may have effects that last relatively longer, but only among smokers who had low levels of perceived health risks of smoking at baseline.

Do graphic health warning labels on cigarette packages deter purchases at point-of-sale? An experiment with adult smokers

This experiment tested whether the presence of graphic health warning labels on cigarette packages deterred adult smokers from purchasing cigarettes at retail point-of-sale (POS), and whether individual difference variables moderated this relationship. The study was conducted in the RAND StoreLab (RSL), a life-sized replica of a convenience store that was developed to evaluate how changing POS tobacco advertising influences tobacco use outcomes during simulated shopping experiences. Adult smokers (n = 294; 65% female; 59% African-American; 35% White) were assigned randomly to shop in the RSL under one of two experimental conditions: graphic health warning labels present on cigarette packages versus absent on cigarette packages. Cigarette packages in both conditions were displayed on a tobacco power wall, which was located behind the RSL cashier counter. Results revealed that the presence of graphic health warning labels did not influence participants' purchase of cigarettes as a main effect. However, nicotine dependence acted as a significant moderator of experimental condition. Graphic health warning labels reduced the chances of cigarette purchases for smokers lower in nicotine dependence but had no effect on smokers higher in dependence.

New and Emerging Tobacco Products and the Nicotine Endgame: The Role of Robust Regulation and Comprehensive Tobacco Control and Prevention: A Presidential Advisory From the American Heart Association

The advent of new tobacco products such as electronic cigarettes and the dramatic rise in their use, especially by adolescents and young adults, are significant public health concerns. Electronic cigarettes have become the most popular tobacco products for youth and adolescents in the United States and are attracting youth to new avenues for nicotine addiction. Although these products may have benefit by helping some smokers quit or to move to a less harmful product, the long-term health effects of these products and the net public health effect associated with their use remain unclear and widely debated. There is increasing concern that the use of newer tobacco products may catalyze transition to the use of other tobacco products or recreational drugs, particularly in young adults. Therefore, there is urgent need for robust US Food and Drug Administration regulation of all tobacco products to avoid the significant economic and population health consequences of continued tobacco use. Although the American Heart Association acknowledges that the ultimate endgame would be an end to all tobacco and nicotine addiction in the United States, it supports first minimizing the use of all combustible tobacco products while ensuring that other products do not addict the next generation of youth and adolescents. The endgame strategy needs to be coordinated with the long-standing, evidence-based tobacco control strategies that have significantly reduced tobacco use and initiation in the United States.

Independent or synergistic? Effects of varying size and using pictorial images in tobacco health warning labels

INTRODUCTION

Legal challenges have blocked the implementation of large, pictorial health warning labels (HWLs) in the U.S. In light of future legal questions the U.S. Food and Drug Administration may face in proposing alternative HWLs, we examined whether less restrictive HWL versions on the front of packs-smaller HWLs and/or text-only HWLs that do not include pictorial imagery-may be sufficient to promote cognitive and affective outcomes associated with smoking cessation.

METHODS

We recruited low-income smokers in two separate experiments through field-based recruitment methods (Study 1, N = 497) or Amazon Mechanical Turk (MTurk) (Study 2, N = 495). In both studies, we randomly assigned participants to a no-HWL control condition or one of four HWL conditions in a 2 (pictorial vs. text-only) × 2 (50% vs. 30% size) between-subjects design.

RESULTS

Relative to text-only HWLs, pictorial HWLs increased negative affect but not risk belief acceptance, cognitive elaboration about smoking harms, or quit intentions. The 50% HWLs increased quit intentions relative to the control condition in both studies. The 50% HWLs also outperformed the 30% HWLs in promoting quit intentions in Study 2. Subsequent analyses revealed that this effect in Study 2 may have been driven by the 50% HWLs strengthening the relationship between risk-related thoughts and intentions, although there was no evidence for this pattern in Study 1. We found no evidence for interaction effects between the pictorial and size manipulations.

CONCLUSIONS

Our findings suggest that 50% HWLs, whether pictorial or text-only, can encourage low-income smokers to consider quitting under some conditions.

Communication Regulatory Science: Mapping a New Field

Communication regulatory science is an emerging field that uses validated techniques, tools, and models to inform regulatory actions that promote optimal communication outcomes and benefit the public. In the opening article to this special issue on communication and tobacco regulatory science, we 1) describe Food and Drug Administration (FDA) regulation of tobacco products in the US; 2) introduce communication regulatory science and provide examples in the tobacco regulatory science realm; and 3) describe the special issue process and final set of articles. Communication research on tobacco regulatory science is a burgeoning area of inquiry, and this work advances communication science, informs and potentially guides the FDA, and may help to withstand legal challenges brought by the tobacco industry. This research has the potential to have a major impact on the tobacco epidemic and population health by helping implement the most effective communications to prevent tobacco initiation and increase cessation. This special issue provides an example of 10 studies that exemplify tobacco regulatory science and demonstrate how the health communication field can affect regulation and benefit public health.

Sex Differences in Graphic Warning Label Ratings by Addictions Clients

OBJECTIVES

Research on sex differences in responses to cigarette graphic warning labels (GWLs) has been limited despite tobacco-related, health disparities for women. We examined whether women had stronger responses to certain labels than to others, whether this pattern differed from men's, and whether there were overall sex ratings differences.

METHODS

Smokers (N = 881) in 24, addictions treatment programs rated 3 of 9 Food and Drug Administration-developed labels on credibility, message reactance, quit motivation, and negative emotions. Participants rated one label depicting a woman and/or baby, and 2 depicting tobacco-related disease or male images.

RESULTS

Women's (n = 432) ratings of labels depicting women/babies versus other labels did not differ from men's (n = 449) ratings. Women had higher ratings than men across all labels combined on credibility (p < .001), quit motivation (p = .007), and negative emotions (p < .001). Individual labels were analyzed for sex differences. Women's ratings were higher on credibility for 3 of 9 labels, and on negative emotions for 7 of 9 labels.

CONCLUSIONS

Female smokers in addictions treatment had generally stronger responses to GWLs than men, supporting GWL implementation in the United States to help close the sex gap in smoking cessation.