A qualitative content analysis of cigarette health warning labels in Australia, Canada, the United Kingdom, and the United States

Factors related to COVID-19 vaccine intention in Latino communities

OBJECTIVE

To examine the effects of the COVID-19 pandemic among Latino communities, with an emphasis on understanding barriers and facilitators to vaccine intention prior to the development of the vaccine.

METHODS

Qualitative data were collected between April and June 2020 from 3 focus groups with Latino adults (n = 21) and interviews with administrators of community-based organizations serving Latino communities (n = 12) in urban (Los Angeles) and rural (Fresno) California, supplemented by Community Advisory Board input in May 2021to elucidate the findings. Data were analyzed with deductive content analysis.

RESULTS

We have identified four main themes that are barriers to vaccinating against COVID-19: 1) concerns about accessing appropriate healthcare services, 2) financial issues and 3) immigration matters, as well as 4) misinformation.

CONCLUSIONS

Findings illustrate the pervasive role of addressable social determinants of health in the intention of rural and urban Latino communities in being vaccinated, which is a pressing public health issue. Policy implications: Findings provide evidence for a systemic shift to prioritize equitable access to COVID-19 vaccines to Latino communities.

Potential effect of real-world junk food and sugar-sweetened beverage taxes on population health, health system costs and greenhouse gas emissions in New Zealand: a modelling study

Poor diet is a major risk factor for excess weight gain and obesity-related diseases, including cardiovascular diseases, type 2 diabetes mellitus, osteoarthritis and several cancers. This paper aims to assess the potential impacts of real-world food and beverage taxes on change in dietary risk factors, health gains (in quality-adjusted life years (QALYs)), health system costs and greenhouse gas (GHG) emissions as if they had all been implemented in New Zealand (NZ). Ten taxes or tax packages were modelled. A proportional multistate life table model was used to predict resultant QALYs and costs over the remaining lifespan of the NZ population alive in 2011, as well as GHG emissions. QALYs ranged from 12.5 (95% uncertainty interval (UI) 10.2 to 15.0; 3% discount rate) per 1000 population for the import tax on sugar-sweetened beverages (SSB) in Palau to 143 (95% UI 118 to 171) per 1000 population for the excise duties on saturated fat, chocolate and sweets in Denmark, while health expenditure savings ranged from 2011 NZ$245 (95% UI 188 to 310; 2020 US$185) per capita to NZ$2770 (95% UI 2140 to 3480; US$2100) per capita, respectively. The modelled taxes resulted in decreases in GHG emissions from baseline diets, ranging from −0.2% for the tax on SSB in Barbados to −2.8% for Denmark’s tax package. There is strong evidence for the implementation of food and beverage tax packages in NZ or similar high-income settings.

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.

A Qualitative Study on Chinese Canadian Male Immigrants' Perspectives on Stopping Smoking: Implications for Tobacco Control in China

China has the largest number of smokers in the world; more than half of adult men smoke. Chinese immigrants smoke at lower rates than the mainstream population and other immigrant groups do. This qualitative study was to explore the influence of denormalization in Canada on male Chinese immigrant smoking after migration. Semistructured interviews were conducted with 22 male Chinese Canadian immigrants who were currently smoking or had quit smoking in the past 5 years. The study identified that, while becoming a prospective/father prompted the Chinese smokers to quit or reduce their smoking due to concern of the impacts of their smoking on the health of their young children, changes in smoking were also associated with the smoking environment. Four facilitators were identified which were related to the denomormalized smoking environment in Canada: (a) the stigma related to being a smoker in Canada, (b) conformity with Canadian smoking bans in public places, (c) the reduced social function of smoking in Canadian culture, and (d) the impact of graphic health messages on cigarette packs. Denormalization of tobacco in Canada in combination with collectivist values among Chinese smokers appeared to contribute to participants' reducing and quitting smoking. Although findings of the study cannot be claimed as generalizable to the wider population of Chinese Canadian immigrants due to the small number of the participants, this study provides lessons for the development of tobacco control measures in China to reverse the current prosmoking social environment.

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

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

Smoking portrayal in Ethiopian movies: a theory-based content analysis

Considerable research from high-income countries has characterized the amount, nature and effects of movie smoking depiction. However, in low- and middle-income countries (LMICs) where tobacco use and tobacco-related diseases are growing, little research has investigated smoking imagery in movies. This study examined the extent and nature of smoking portrayal in locally produced Ethiopian movies, and estimated the number of tobacco impressions movies delivered. Sample movies were taken from YouTube. Keyword searches were conducted using ‘Ethiopian movies’ and ‘Ethiopian drama’ on 18 September 2016. In each search, the first 100 most viewed movies were examined. Excluding repeated results, a total of 123 movies were selected for content analysis. Three coders participated. Results indicated that 86 (69.9%, 95% CI 63–78%) of the 123 most viewed movies contain at least one tobacco incident (TI). The movies depict a total of 403 TIs, with an average of 4.7 (95% CI 3.7–5.6) TIs in each movie. The average length of TIs is 1 min and 11 s. On average, the movies were viewed more than half a million times by September 2016, and received more ‘likes’ than ‘dislikes’, z = −8.05, p = 0.00. They delivered over 194 million tobacco impressions via YouTube alone from July 2012 through September 2016. Most TIs portray smoking as a socially acceptable behavior with no negative health consequences. The findings suggest that as with transnational Western movies, locally produced movies in LMICs should be scrutinized for compliance with national and international regulatory efforts.

Challenging key assumptions embedded in Health Canada's cigarette packaging legislation: Findings from in situ interviews with smokers in Vancouver

OBJECTIVES

The main objective of this study was to utilize qualitative research methods in order to explore variations in how smokers respond to the government-mandated graphic health warnings and messages on their cigarette packets.

METHODS

Sixty in situ interviews were carried out with people while they were smoking in public settings across the city of Vancouver, British Columbia. During the interviews, participants were asked to recall the warning label on their cigarette packet, and general questions about the effects the imagery and text have had on their smoking.

RESULTS

The analysis of findings pointed to several ways that participants overlooked, dismissed or otherwise failed to accurately recall health messages and images on their cigarette packaging. In particular, a significant minority questioned the veracity of the content of the labels and highlighted their exaggerated nature. With regard to the health information inserts, participants identified them as rubbish to be discarded rather than messages to be read. Few smokers could remember the warning label on their packet and some described warning labels that do not currently exist. Finally, a substantial proportion of participants were not smoking cigarettes from a standard packet, raising questions about how universal exposure to the labels actually is.

CONCLUSION

Prevailing assumptions about how cigarette packaging legislation works as a population-level tobacco control intervention appear to be based on flawed assumptions about how people interact with cigarette packets as they are used in their everyday lives. As such, continued efforts on the part of tobacco control to redevelop "bolder" or more "graphic" labels on tobacco packaging may require consideration.

Repeated exposure to whole cigarette smoke promotes primary human gingival epithelial cell growth and modulates keratin expression

BACKGROUND AND OBJECTIVE

The gingiva is the first oral tissue directly exposed to cigarette smoke (CS). Exposure to CS compromises the structure and function of gingival tissue. Damaging or altering the gingival epithelium leads to a compromised protective barrier of the periodontium, resulting in several diseases. The aim of this study was to assess the effect of repeated exposure to CS on gingival epithelial cell growth and on expression of apoptotic protein and keratin.

MATERIAL AND METHODS

Primary human gingival epithelial cells were seeded on a collagen scaffold for 5 d to allow growth and stratification. The cells were then exposed for 5 min to whole CS for 3, 6 and 9 d. At the end of each exposure period, cell proliferation [using (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide) (MTT) and 5-bromo-2'-deoxyuridine (BrdU) assays], gene expression [by quantitative reverse transcription polymerase chain reaction (qRT-PCR)] and protein production (by western blot analysis) were investigated.

RESULTS

Higher metabolic activity was found in the CS-exposed cells than in the nonexposed cells, specifically after 3 and 6 d of exposure to CS. At 9 d there was no significant difference between CS-exposed and nonexposed cells. Metabolic activity was supported by the BrdU cell-proliferation analyses, which showed increased cell growth at 3 d compared with the control. However, at 6 and 9 d, cell proliferation in the CS-exposed culture was comparable to that in the nonexposed culture. Interestingly, the Bax/Bcl-2 protein ratios decreased with increased CS exposure, suggesting cell resistance. Moreover, protein analyses showed that CS decreased expression of keratin(K) 5 at 3, 6 and 9 d, and increased expression of K14 at 6 and 9 d. Finally, mRNA analyses showed significant decreases of K1, K6, K10 and K16 in CS-exposed cultures, correlating, at times, with a decrease of protein production.

CONCLUSION

CS was shown to increase epithelial cell proliferation, which may involve cell resistance to apoptosis. This is supported by the modulation of expression of different keratin genes and proteins. Altogether, these data may explain the hyperplasia reported in gingival tissue, as well as periodontal disease, in smokers.

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

Background

Health communication theories indicate that messages depicting efficacy and threat might promote behavior change by enhancing individuals’ efficacy beliefs and risk perceptions, but this has received little attention in graphic warning label research. We explored low socioeconomic status (SES) smokers’ perceptions of theory-based graphic warning labels to inform the development of labels to promote smoking cessation.

Methods

Twelve graphic warning labels were developed with self-efficacy and response efficacy messages paired with messages portraying high, low, or no threat from smoking. Self-efficacy messages were designed to promote confidence in ability to quit, while response efficacy messages were designed to promote confidence in the ability of the Quitline to aid cessation. From January – February 2014, we conducted in-depth interviews with 25 low SES adult men and women smokers in Baltimore, Maryland, U.S. Participants discussed the labels’ role in their self-efficacy beliefs, response efficacy beliefs about the Quitline, and risk perceptions (including perceived severity of and susceptibility to disease). Data were analyzed through framework analysis, a type of thematic analysis.

Results

Efficacy messages in which participants vicariously experienced the characters’ quit successes were reported as most influential to self-efficacy beliefs. Labels portraying a high threat were reported as most influential to participants’ perceived severity of and susceptibility to smoking risks. Self-efficacy messages alone and paired with high threat were seen as most influential on self-efficacy beliefs. Labels portraying the threat from smoking were most motivational for calling the Quitline, followed by labels showing healthy role models who had successfully quit using the Quitline.

Conclusions

Role model-based efficacy messages might enhance the effectiveness of labels by making smokers’ self-efficacy beliefs about quitting most salient and enhancing the perceived efficacy of the Quitline. Threatening messages play an important role in enhancing risk perceptions, but findings suggest that efficacy messages are also important in the impact of labels on beliefs and motivation. Our findings could aid in the development of labels to address smoking disparities among low SES populations in the U.S.