Effects of Different Graphic Health Warning Types on the Intention to Quit Smoking

The effects of emotional distress on attentional bias toward cigarette warnings according to smokers' anxiety levels

Anxiety is related with the substance use, including cigarette smoking. Avoidance is one of the strategies smokers with anxiety adopt to manage negative affect, which can be contradictory to a strategy of cigarette warnings that is used to induce negative affect to change smoking behaviors. Therefore, this study examined whether smokers' anxiety levels decrease their attentional biases toward cigarette warnings, especially in response to emotional distress. High-anxiety (n = 60) and low-anxiety (n = 60) smokers were randomly assigned to either a stress condition that utilized the PASAT-C task (Paced Auditory Serial Addition Task-Computer version) or a controlled condition. With the eye-tracking task that involved viewing 8 visual stimuli of cigarette packs composed of warnings and brandings, time to first fixation and fixation duration to warnings compared to brandings were measured both pre and post conditions. The results revealed that high-anxiety smokers detected warnings faster after stress conditions while low-anxiety smokers showed the consistent time to first fixation on warnings. In terms of fixation durations, high-anxiety smokers showed hypervigilance toward warnings that are considered to be a threat, but low-anxiety smokers showed avoidance under stress conditions, particularly toward social-focused warnings. These results indicate that high-anxiety smokers are more vulnerable to emotional distress and have an attentional bias toward fear appeals. Despite hypervigilance, they had greater psychological reactance toward warnings that the conflict between avoidance and hypervigilance might have contributed to, so the effectiveness of fear appeals may be limited regardless of the increased fixation duration.

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.

Eye tracking applied to tobacco smoking: current directions and future perspectives

Over the years the general awareness of the health costs associated with tobacco smoking has motivated scientists to apply the measurement of eye movements to this form of addiction. On one hand they have investigated whether smokers attend and look preferentially at smoking related scenes and objects. In parallel, on the other hand eye tracking has been used to test how smokers and nonsmokers interact with the different types of health warning that policymakers have mandated in tobacco advertisements and packages. Here we provide an overview of the main findings from the different lines of research, such as the evidence related to the attentional bias for smoking cues in smokers and the evidence that graphic warning labels and plain packages measurably increase the salience of the warning labels. We point to some open questions, such as the conditions that determine whether heavy smokers exhibit a tendency to actively avoid looking at graphic warning labels. Finally we argue that the research applied to gaze exploration of warning labels would benefit from a more widespread use of the more naturalistic testing conditions (e.g. mobile eye tracking or virtual reality) that have been introduced to study the smokers' attentional bias for tobacco-related objects when freely exploring the surrounding environment.

Effects of Pictorial Health Warnings on Cognitive, Affective, and Smoking Behavior: A Mixed Methods Study in Four Cities in Indonesia

While studies have shown the importance of pictorial health warnings (PHW) as a tobacco control strategy, empirical evidence on the efficacy of PHW in prompting smoking behavior remains inconclusive. The study aimed to examine the association between PHW and cognitive reactions, emotional/affective reactions, and smoking behavior. We conducted a mixed-methods study, which included a cross-sectional face-to-face survey of 401 smokers in four cities (Jakarta, Bandung, Semarang, and Yogyakarta) and three focus group discussions among 24 participants in Jakarta. We applied multiple logit regression in STATA for quantitative data analysis and explanatory sequential design for qualitative data analysis. Quantitatively, we found high (63-84% of respondents) understanding about PHW objectives (cognitive reactions), including to remind health risks and encourage smoking cessation. With only 40% PHW, we found relatively low (32%-39%) negative emotional reactions, including feeling scared, annoyed and disgusted and relatively low proportions (33-40%) of respondents that reported quit attempt. Consistent with the quantitative findings, qualitative data provided contexts, including in explaining that the professional worker group was the least affected by PHW, while the student and non-professional groups were the most vulnerable. All this is supportive of governments in Indonesia and other countries to increase the PHW size.