Influences of Self-Efficacy, Response Efficacy, and Reactance on Responses to Cigarette Health Warnings: A Longitudinal Study of Adult Smokers in Australia and Canada

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

Although pictorial warning labels (PWLs) now dominate tobacco packages sold in many countries, few studies have probed how people who smoke respond to the threats presented several years post-plain packaging and larger PWLs. Understanding how people manage the fear and dissonance PWLs arouse, and the strategies they use to rationalize, diminish, and reject risk messages, could inform future PWL design.

AIMS AND METHODS

We undertook 27 in-depth interviews with people aged 18 and over (16 female, 8 Māori, and 13 aged ≤35) who smoked roll-your-own tobacco and lived in Aotearoa New Zealand. We probed participants' views on current PWLs and how they responded to these, then asked them to use alternative images and headlines to create new PWLs. We drew on the extended parallel processing model to interpret the data, which we analyzed using a reflexive thematic analysis approach.

RESULTS

People who smoke dislike PWLs, which they think reduce them to diseased body parts. While a minority thought existing PWLs were believable and effective, most reported avoiding PWLs by hiding or cognitively blocking them. Participants used diverse counterarguments to diminish PWLs' relevance and impact, and a minority displayed strong reactance. Several suggested developing PWLs that recognized them as whole people rather than patients in waiting, and recommended greater use of testimonials, particularly from people who had successfully become smoke free.

CONCLUSIONS

PWLs using more holistic and diverse messages could elicit greater engagement and responsiveness, and motivate cessation more effectively than existing health-oriented warnings.

IMPLICATIONS

Our findings suggest existing PWLs, which aim to arouse fear of ill health, could be complemented by warnings that emphasize the benefits of quitting. Continuing to use threat-based PWLs could stimulate greater rationalization and reactance. By contrast, PWLs that aim to illustrate how cessation could benefit people who smoke and their families, rather than instill a fear of disease, could avoid message rejection and counter-argument, and may prove a more powerful way of motivating cessation.

Smoking Dependence, Time-Discounting, and Sustained Cessation Behavior: A Longitudinal Study of Predominantly Light Smokers

INTRODUCTION

This study aimed to assess whether two established psychosocial predictors of smoking abstinence, nicotine dependence and time-discounting, also apply to a population of predominantly cigarette light smokers, which is the dominant pattern of smoking in countries like Mexico. Relatively infrequent smoking is increasingly prevalent, yet still harmful, making it important to understand the predictors of cessation in this population.

AIMS AND METHODS

Mexican adult smokers recruited from an online consumer panel were surveyed every 4 months between November 2018 and July 2020. We considered respondents who reported a quit attempt in between surveys (n = 1288). Dependence was measured with a 10-item version of the Wisconsin Inventory of Smoking Dependence Motives (WISDM). Time-discounting was assessed with five branching questions about hypothetical reward scenarios. Logistic models regressed sustained quit attempts (≥30 days of abstinence) at time t + 1 on study variables at time t.

RESULTS

We found strong interitem reliability (α = 0.92) and intraindividual consistency of our brief WISDM (ρ = 0.68), but moderate intraindividual consistency of the time-discounting measure (ρ = 0.48). Forty-eight percent of the sample reported sustained quit attempts, and 79% were non-daily or light daily smokers (≤5 cigarettes per day). Smokers with higher WISDM-10 had lower odds of sustained quitting and this result remained when controlling for smoking frequency and the Heaviness of Smoking Index (adjusted odds ratio [AOR] = 0.768). Time-discounting was unassociated with sustained quitting.

CONCLUSIONS

Our findings suggest that a brief, 10-item multidimensional measure of dependence is useful for predicting sustained quitting in a context of relatively light smoking; time-discounting appears less relevant, although our results are not conclusive because of the low test-retest reliability of our measure.

IMPLICATIONS

Given the increase in non-daily and light daily cigarette smoking in many countries, including in Mexico, and the health risks this still poses, it is important to understand the predictors of cessation among relatively light smokers. The WISDM-10 multidimensional measure seems to be a good instrument to assess dependence and predict successful quitting in this population, and possibly more appropriate than physical dependence measures. As such, it could help design and target more suitable cessation treatments for non-daily and daily light cigarette smokers. While this study did not find time-discounting to be a relevant predictor of smoking abstinence, future studies should explore other measures.

Boil water notices as health-risk communication: risk perceptions, efficacy, and compliance during winter storm Uri

Winter Storm Uri was a disaster that impacted much of the United States during February of 2021. During and after the storm, Texas and Oklahoma experienced massive power grid failures. This led to cascading impacts, including water system disruptions and many boil water notices (BWNs). The breakdown of some communication channels and the inability to enact protective actions due to power outages, as well as travel limitations on public roads, complicated the dissemination and implementation of notifications. This research examined individuals' perceptions of risk, water quality, and BWNs during Uri. Additionally, this study sought to understand if previous experience with a BWN influenced compliance during Uri and how perceived efficacy impacted these variables. Surveying 893 Texans and Oklahomans revealed that most Uri-affected respondents believed the risks associated with BWNs were severe. Income and race were two factors that influenced BWN compliance. Age, gender, and level of education did not influence compliance. Previous experience with BWNs did not increase risk perceptions. Higher levels of perceived efficacy correlated to higher levels of compliance, perceptions of risk, and water quality, much of which support propositions of the Extended Parallel Process Model. Results suggest that pre-disaster planning and communication are imperative to helping reduce risk(s) and enhancing efficacy during a disaster, especially for novel disasters that have cascading risks, like Winter Storm Uri.

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

BACKGROUND

Cigarette pack inserts with messages on cessation benefits and advice are a promising labeling policy that may help promote smoking cessation.

PURPOSE

To assess insert effects, with and without accompanying pictorial health warning labels(HWLs), on hypothesized psychosocial and behavioral outcomes.

METHODS

We conducted a 2 × 2 between-subject randomized trial (inserts with efficacy messages vs. no inserts; large pictorial HWLs vs. small text HWLs), with 367 adults who smoked at least 10 cigarettes a day. Participants received a 14-day supply of their preferred cigarettes with packs modified to reflect their experimental condition. Over 2 weeks, we surveyed participants approximately 4-5 times a day during their smoking sessions, querying feelings about smoking, level of worry about harms from smoking, self-efficacy to cut down on cigarettes, self-efficacy to quit, hopefulness about quitting, and motivation to quit. Each evening, participants reported their perceived susceptibility to smoking harms and, for the last 24 hr, their frequency of thinking about smoking harms and cessation benefits, conversations about smoking cessation or harms, and foregoing or stubbing out cigarettes before they finished smoking. Mixed-effects ordinal and logistic models were estimated to evaluate differences between groups.

RESULTS

Participants whose packs included inserts were more likely than those whose packs did not include inserts to report foregoing or stubbing out of cigarettes (OR = 2.39, 95% CI = 1.36, 4.20). Otherwise, no statistically significant associations were found between labeling conditions and outcomes.

CONCLUSIONS

This study provides some evidence, albeit limited, that pack inserts with efficacy messages can promote behaviors that predict smoking cessation attempts.

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

OBJECTIVE

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

DESIGN

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

SETTING

Singapore.

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

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

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

Communication inequalities in the COVID-19 pandemic: socioeconomic differences and preventive behaviors in the United States and South Korea

BACKGROUND

Communication inequalities are important mechanisms linking socioeconomic backgrounds to health outcomes. Guided by the structural influence model of communication, this study examined the intermediate role of health communication in the relationship between education, income, and preventive behavioral intentions during the COVID-19 pandemic in the United States and South Korea.

METHODS

The data were collected through two online surveys conducted by two professional research firms in the US (April 1-3, 2020) and South Korea (April 9-16, 2020). To test the mediating role of health communication, as well as the hypothesized relationships in the proposed model, we performed a path analysis using Mplus 6.1.

RESULTS

In analyzing survey data from 1050 American and 1175 Korean adults, we found that one's socioeconomic positions were associated with their intentions to engage in COVID-19 preventive behaviors through affecting their health communication experiences and then efficacious beliefs. Differences in education and income were associated with willingness to engage in preventive behaviors by constraining health communication among people with low levels of education and income. The findings showed notable differences and some similarities between the US and South Korea. For example, while income was positively associated with health communication in both US and South Korea, education was only significantly related to health communication in US but not in South Korea.

CONCLUSIONS

This study suggests health communication strategies such as choice of communication channels and messages to promote intention for COVID-19 prevention behaviors in particular consideration of individual differences in socioeconomic positions in countries with different cultural features. Pubic policies and health campaigns can utilize the suggestions to promote efficacy and preventive behavioral intention during early pandemics.

Why should I vaccinate? The role of mindfulness and health-protective behaviours during the COVID-19 pandemic

Objective

Health maintenance of the general public through vaccination is a significant component of controlling the COVID-19 pandemic. This study aims to examine the perception of Nigerians toward the COVID-19 vaccine. Methods: Informed by the Extended Parallel Process Model (EPPM), 793 Nigerian participants completed a cross-sectional self-administered online survey to assess: (1) their perception of COVID-19 based on fear-mongering information on social media (2) the potential relationship between threat perception, efficacy, and fear associated with the COVID-19 vaccine, vaccine hesitancy, and attitudes toward the decision to uptake the vaccine using structural equation modeling (SEM) analysis, and (3) we further employed the use of the hierarchical regression analysis to test the moderating effect of mindful critical thinking between vaccine hesitancy and attitudes toward vaccines.

Results

Most participants (65.7%) intend to uptake the COVID-19 vaccine. However, many people did not fear the disease (19.2%). Threat perception and efficacy were associated with a decision to uptake the COVID-19 vaccine via the mediation of attitudes toward vaccines. Previous vaccine hesitancy has no relationship with uptake decisions. The hierarchical regression analysis showed that participants exhibiting high critical thinking mindfulness were more interested in taking the vaccine.

Conclusions

The findings of this study demonstrate that EPPM constructs are effective predictors of the public's decision to uptake the COVID-19 vaccine. This research highlights the theoretical and practical implications.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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

The effect of fear and situational motivation on online information avoidance: The case of COVID-19

During the COVID-19 pandemic, a plethora of online sources for information and news dissemination have emerged. Extant research suggests that very quickly, individuals become disinterested and begin avoiding the information. In this study, we investigate how an individual's fear and situational motivation impact Online Information Avoidance. Using the self-determination theory and information avoidance theories, we argue that fear and external regulation are associated with increased Online Information Avoidance. We also argue that intrinsic motivation and identified regulation are associated with a decrease in Online Information Avoidance. Our findings suggest that fear, intrinsic motivation, and external regulation drive Online Information Avoidance, where intrinsic motivation is the most significant driver. We also found that identified regulation is a crucial inhibitor of Online Information Avoidance. While focusing on COVID-19, our study contributes to the broader information systems research literature and specifically to the information avoidance literature during a pandemic or a prolonged crisis. Our study's findings will be useful for governments, health organizations, and communities that utilize online platforms, forums, and related outlets to reach larger audiences for disseminating pertinent information and recommendations during a crisis.

Young adults' beliefs about modern oral nicotine products: Implications for uptake in nonvapers, dual use with e-cigarettes, and use to reduce/quit vaping

Modern oral nicotine products (ONPs; nontherapeutic nicotine pouches, gums, lozenges, and gummies) may be perceived in ways that could promote uptake in nonvapers, dual use with e-cigarettes, or use to quit vaping. In this cross-sectional digital remote survey of 1,460 respondents aged 21-24 from Southern California, we examined beliefs about ONPs among past-30-day e-cigarette nonusers, users unmotivated to quit vaping, and users motivated to quit vaping. Positive beliefs about ONPs were reported by 31.8% of the overall sample and higher in past-30-day e-cigarette users (with or without quit motivation) than nonusers. Perceiving ONPs to be easy to conceal, convenient, and able to be used where vaping/smoking is not allowed were the most common types of beliefs reported. Among e-cigarette users with quit motivation (n = 142), interest in using ONPs to quit/reduce vaping (44.4%) was higher than interest in using medicinal nicotine gum/lozenges (23.4%), nicotine patch (17.6%), or prescription medications (16.6%). Interest in using ONPs to reduce/quit vaping (vs. no interest) was greater among participants who reported vaping ≥ 20 (vs. < 10) days in the past month, vaping ≥ 10 (vs. < 10) times per day, low/moderate (vs. high) quit vaping self-efficacy, and low/moderate (vs. high) desire to quit vaping. These findings suggest that: (a) appreciable subsets of the young adult population may hold positive beliefs about ONPs that could promote ONP uptake, particularly e-cigarette users and (b) some young adult e-cigarette users may be interested in using ONPs to reduce/quit vaping, particularly frequent vapers with relatively lower self-efficacy and desire to quit vaping. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Vulnerability to the Effects of Conflicting Health Information: Testing the Moderating Roles of Trust in News Media and Research Literacy

BACKGROUND

Exposure to conflicting health information can produce negative affective and cognitive responses, including confusion and backlash, and the effects of this exposure can even "carry over" and reduce people's receptivity to subsequent messages about health behaviors for which there is scientific consensus. What is not known is whether certain population subgroups are more vulnerable to such carryover effects.

AIMS

This study investigates whether carryover effects of exposure to conflicting information are moderated by two factors, trust in news media and research literacy, testing the hypothesis that lower trust and higher literacy could protect against such effects.

METHOD

The analysis draws on data from a longitudinal population-based experiment (N = 2,716), in which participants were randomly assigned to view health news stories and social media posts that either did or did not feature conflicting information, and subsequently exposed to ads from existing health campaigns about behaviors for which there is scientific consensus. Structural equation modeling was used to test study hypotheses.

RESULTS

Neither lower trust in news media nor higher research literacy protected against carryover effects, as effects were observed across levels of both trust and literacy. Although level of research literacy did not affect whether carryover effects were observed, it did shape how those effects emerged.

CONCLUSION

The public, regardless of their level of trust in news media or research literacy, is vulnerable to the downstream effects of exposure to conflicting health information. Targeted health communication interventions are needed to improve messaging about evolving science and, in turn, increase receptivity to public health recommendations.

Quasi-experimental evaluation of Kenya's pictorial health warnings versus Zambia's single text-only warning: findings from the International Tobacco Control (ITC) Project

BACKGROUND

Population studies in mostly high-income countries have shown that pictorial health warnings (PHWs) are much more effective than text-only warnings. This is the first quasi-experimental evaluation of the introduction of PHWs in Africa, comparing the change from text-only to PHWs in Kenya to the unchanged text-only health warning in Zambia.

METHODS

Data were from International Tobacco Control (ITC) Surveys in Kenya (n=1495), and Zambia (n=1628), cohort surveys of nationally representative samples of adult smokers in each country. The ITC Kenya Survey was conducted in 2012 and 2018 (2 years after the 2016 introduction of three PHWs). The ITC Zambia Survey was conducted in 2012 and 2014 with no change to the single text-only warning. Validated indicators of health warning effectiveness (HWIs) (salience: noticing, reading; cognitive reactions: thinking about health risks, thinking about quitting; and behavioural reactions: avoiding warnings; forgoing a cigarette because of the warnings), and a summary measure-the Labels Impact Index (LII)-measured changes in warning impact between the two countries.

RESULTS

PHWs implemented in Kenya led to a significant increase in all HWIs and the LII, compared with the text-only warning in Zambia. The failure to implement PHWs in Zambia led to a substantial missed opportunity to increase warning effectiveness (eg, an estimated additional 168 392 smokers in Zambia would have noticed the warnings).

CONCLUSIONS

The introduction of PHWs in Kenya substantially increased the effectiveness of warnings. These results provide strong empirical support for 34 African countries that still have text-only warnings, of which 31 are Parties of the Framework Convention on Tobacco Control and are thus obligated to implement PHWs.

Communicating COVID-19 Risk on Instagram: A Content Analysis of Official Public Health Messaging During the First Year of the Pandemic

Early in the COVID-19 pandemic, social media platform Instagram surged in popularity as a source of health information. Both the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) leveraged Instagram accounts to publicly distribute COVID-related information. The current study investigated whether WHO and CDC messaging strategies on Instagram adhered to best practices defined by two theoretical frameworks: the extended parallel process model and crisis and emergency risk communication. We conducted a quantitative content analysis of COVID-related posts (n = 726) published between January-December 2020 to determine how both agencies (1) communicated the threat of the pandemic (e.g. susceptibility and severity of negative COVID-19 consequences); (2) appealed to self-, response, and collective efficacy; (3) incorporated cues to action (e.g. preventive behaviors, information seeking); and (4) leveraged credibility cues (e.g. scientific evidence, experts). Results showed threat information was limited, whereas efficacy appeals and cues to action were abundant. The CDC relied more heavily on depictions of self- and response efficacy, whereas the WHO appealed more frequently than the CDC to collective efficacy. Neither visually modeled behaviors nor leveraged scientific evidence or experts with great frequency. Implications for future research and official communication efforts via social media are discussed.

An extension of the extended parallel process model to promote heart-healthy exercise behavior: An experimental study

Background: The prevalence of heart disease has increased and is a leading cause of death in the U.S. Despite the importance of physical activity, only one-third of adults in the United States meet the amount of physical activity recommended by the Centers for Disease Control and Prevention (CDC). The purpose of this study was to extend the extended parallel process model (EPPM) by adding a 'barrier' (a construct from Health Belief Model) and exploring the roles of threat, efficacy, and barrier on participants' self-efficacy, attitudes, and intentions toward exercise. Methods: A between-subject experimental design was conducted online in 2018 in the U.S. A total of 446 participants were recruited from the Amazon Mechanical Turk age 18 or above. The participants were first provided with stimuli messages about physical activity behaviors. Then participants' responses to self-efficacy, intention, and attitudes toward exercise were assessed. Results: The results found an interaction between efficacy and barrier to participants' attitudes toward exercise [F(1,435)=4.35, P=0.038, η² _part=0.01]. The results also showed that there was a statistically significant effect of barriers on participants' self-efficacy regarding exercise behavior [F(1,442)=4.21, P=0.04, η² _part=0.009]. However, three-way interactions of threat, efficacy, and barrier were not found in attitudes or intentions to exercise. Conclusion: The findings suggested that addressing an individual's perceived barrier regarding a health behavior may lead to an increase in self-confidence ensuing in higher physical activity. Future studies should further explore how addressing barriers may influence other health behaviors to design unique and effective health messages.

Counselling of non-communicable diseases' patients for COVID-19 vaccine uptake in Jordan: Evaluating the intervention

BACKGROUND

People with noncommunicable diseases (NCDs) are at a significantly higher risk of worst outcomes if infected with COVID-19 and thus amongst the main target population for vaccination. Despite prioritizing them for vaccination, the number of vaccinated patients with comorbidities stalled post vaccine introduction. Despite that the government along with partners ran a national awareness campaign to ramp up vaccination coverage, the coverage remained suboptimal. Thus, a one-to-one health counselling initiative was implemented to explore the acceptance of COVID-19 vaccines by the NCDs patients and address the main issues surrounding vaccine hesitancy. This study evaluates the impact of this intervention by analyzing the change in COVID-19 vaccine acceptance.

METHODS

In this analytical observational study, a random sample of 57,794 people living with NCDs were approached. Out of them, 12,144 received one-to-one counselling by a group of trained health professionals. The counselled group's vaccine acceptance was assessed on a Likert scale from 1 to 5 pre- and post- counselling. Moreover, a random sample was followed up 2 months after initial counselling to measure their vaccine acceptance and update their vaccination status.

RESULTS

44.5% of total respondents were already registered in the vaccination platform. On a scale from 1 to 5, the overall mean confidence significantly increased by 1.63 from 2.48 pre-counselling to 4.11 post-counselling. Two-months post counselling, a random sample was contacted again and had a mean vaccine confidence of 3.71, which is significantly higher than pre-counselling confidence level despite a significant decrease to post-counselling results.

DISCUSSION

Implementing an intervention that targets all key factors impacting health decisions, such as health literacy, risk appraisal and response efficacy, helps reach an adaptive response and increase vaccine confidence. Scholars should be cautious when implementing an intervention since it could lead to maladaptive defensive responses. One-to-one interventions are more effective in population when addressing new interventions and vaccines.

Red media, blue media, and misperceptions: examining a moderated serial mediation model of partisan media use and COVID-19 misperceptions

Misinformation and misperceptions about COVID-19 have undermined democratic system. Partisan media are regarded as one of the culprits for facilitating the spread of misinformation. Grounded in the extended communication mediation model, this study analyzes a U.S. survey sample and examines the conditional indirect effects of partisan media use on COVID-19 related misperceptions. Findings show that using conservative and liberal media both have positive effects on misperceptions and message derogation. Conservative media use has a negative impact on perceived response efficacy, whereas liberal media use positively influenced it. Furthermore, the effect of liberal media use on misperceptions became negative when serially mediated by perceived response efficacy and message derogation. Lastly, discussion network heterogeneity was a significant moderator, such that the indirect effects of partisan media use on misperceptions became weaker among those with a more heterogeneous discussion network. Theoretical and practical implications are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12144-022-03772-x.

Effect of fear appeal mobile phone messaging on health behaviors of caregivers with children under-five in Ghana

Social and Behavior Change Communication is a vital strategy in the control of malaria. However, the effectiveness of fear appeal tactic as a preventive strategy remains uncertain. This study examined the influence of a fear appeal mobile phone-based intervention, guided by Witte's Extended Parallel Process model, on malaria prevention among caregivers with children under-five. We conducted a quasi-experimental study of a 12-month intervention using a sample of 324 caregivers from two rural districts, assigned to either an intervention or control group. The intervention group received fear appeal voice Short Message Service (SMS), once a week for twelve (12) months, while caregivers in the control group received none. The results showed that exposure to the messages was associated with an increased odds of positive attitude [adjusted Odds ratio (aOR) = 2.58; 95% CI 1.61-4.15] and behavioral changes (aOR = 2.03, 95% CI 1.29-3.19). The intervention group exhibited lower odds of defensive avoidance (aOR = 0.44, 95% CI 0.29-0.68) and message minimization (aOR = 0.51, 95% CI 0.33-0.78) compared with the control group. These findings highlight the importance of communicating health messages via mobile phones using fear appeal for improving the health behaviors of caregivers. This strategy, however, may not be useful for influencing the intention of caregivers to engage in positive health practices to protect their children from malaria.

A pilot randomised trial of a brief virtual reality scenario in smokers unmotivated to quit: Assessing the feasibility of recruitment

Individual-level interventions for smokers unmotivated to quit remain scarce and have had limited success. Little is known about the potential of virtual reality (VR) for delivering messaging to smokers unmotivated to quit. This pilot trial aimed to assess the feasibility of recruitment and acceptability of a brief, theory-informed VR scenario and estimate proximal quitting outcomes. Unmotivated smokers (recruited between February-August 2021) aged 18+ years who had access to, or were willing to receive via post, a VR headset were randomly assigned (1:1) using block randomisation to view the intervention (i.e., a hospital-based scenario with motivational stop smoking messaging) or a 'sham' VR scenario (i.e., a scenario about the human body without any smoking-specific messaging) with a researcher present via teleconferencing software. The primary outcome was feasibility of recruitment (i.e., achieving the target sample size of 60 participants within 3 months of recruitment). Secondary outcomes included acceptability (i.e., positive affective and cognitive attitudes), quitting self-efficacy and intention to stop smoking (i.e., clicking on a weblink with additional stop smoking information). We report point estimates and 95% confidence intervals (CIs). The study protocol was pre-registered (osf.io/95tus). A total of 60 participants were randomised within 6 months (intervention: n = 30; control: n = 30), 37 of whom were recruited within a 2-month period of active recruitment following an amendment to gift inexpensive (£7) cardboard VR headsets via post. The mean (SD) age of participants was 34.4 (12.1) years, with 46.7% identifying as female. The mean (SD) cigarettes smoked per day was 9.8 (7.2). The intervention (86.7%, 95% CI = 69.3%-96.2%) and control (93.3%, 95% CI = 77.9%-99.2%) scenarios were rated as acceptable. Quitting self-efficacy and intention to stop smoking in the intervention (13.3%, 95% CI = 3.7%-30.7%; 3.3%, 95% CI = 0.1%-17.2%) and control (26.7%, 95% CI = 12.3%-45.9%; 0%, 95% CI = 0%-11.6%) arm were comparable. The target sample size was not achieved within the feasibility window; however, an amendment to gift inexpensive headsets via post appeared feasible. The brief VR scenario appeared acceptable to smokers unmotivated to quit.

A pilot sequential multiple assignment randomized trial (SMART) protocol for developing an adaptive coaching intervention around a mobile application for athletes to improve carbohydrate periodization behavior

Background

It has recently been identified that manipulating carbohydrate availability around exercise activity can enhance training-induced metabolic adaptations. Despite this approach being accepted in the athletic populations, athletes do not systematically follow the guidelines. Digital environments appear to allow nutritionists to deliver this intervention at scale, reducing expensive human coaching time. Yet, digitally delivered dietary behavior change interventions for athletes and the coaching strategy to support them are still novel concepts within sports nutrition.

Methods/design

We aim to recruit 900 athletes across the UK. 500 athletes will be recruited to test the feasibility of a novel menu planner mobile application with coaching for 6 weeks. 250 athletes with pre-existing nutritionist support will also be recruited as control. We will then conduct a 4-week pilot sequential multiple assignment randomized trial (SMART) with an additional 150 athletes. In the SMART, athletes will be given the application and additional coaching according to their engagement responses. The primary outcomes are the mobile application and coach uptake, retention, engagement, and success in attaining carbohydrate periodization behavior. Secondary outcomes are changes in goal, weight, carbohydrate periodization self-efficacy, and beliefs about consequences. Due to the high attrition nature of digital interventions, all quantitative analyses will be carried out based on both the intention-to-treat and per-protocol principles.

Discussion

This study will be the first to investigate improving carbohydrate periodization using a digital approach and tailored coaching strategies under this context. Foundational evidence from this study will provide insights into the feasibility of the digital approach.

Environmental Health Literacy as Knowing, Feeling, and Believing: Analyzing Linkages between Race, Ethnicity, and Socioeconomic Status and Willingness to Engage in Protective Behaviors against Health Threats

This study investigates the relationships between environmental health literacy, the characteristics of people (race, ethnicity, and socioeconomic status) associated with health disparities, and people’s willingness to engage in protective behaviors against environmental health threats. Environmental health literacy is a framework for capturing the continuum between the knowledge of environmental impacts on public health, and the skills and decisions needed to take health-protective actions. We pay particular attention to three dimensions of environmental health literacy: factual knowledge (knowing the facts), knowledge sufficiency (feeling ready to decide what to do), and response efficacy (believing that protective behaviors work). In June 2020, we collected survey data from North Carolina residents on two topics: the viral infection COVID-19 and industrial contaminants called per- and polyfluoroalkyl substances (PFAS). We used their responses to test stepwise regression models with willingness to engage in protective behaviors as a dependent variable and other characteristics as independent variables, including environmental health literacy. For both topics, our results indicated that no disparities emerged according to socioeconomic factors (level of education, household income, or renting one’s residence). We observed disparities in willingness according to race, comparing Black to White participants, but not when comparing White to American Indian, Alaska Native, Asian, Native Hawaiian, or Pacific Islander participants nor Hispanic to non-Hispanic participants. The disparities in willingness between Black and White participants persisted until we introduced the variables of environmental health literacy, when the difference between these groups was no longer significant in the final regression models. The findings suggest that focusing on environmental health literacy could bridge a gap in willingness to protect oneself based on factors such as race/ethnicity and socioeconomic status, which have been identified in the environmental health literature as resulting in health disparities.

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

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

Awareness of the Use of Standard Precautions during Care of People Living with HIV by Ward Attendants in Indian Hospitals

Context:

Standard precautions (SP) are infection prevention practices universally used during patient care to lower infection transmission.

Aims:

The aim of the study was to (1) assess Indian ward attendants' (WAs) knowledge, perceived efficacy, and self-efficacy regarding SP and (2) examine correlates of SP self-efficacy and intent to use unnecessary precautions during care of people living with HIV.

Subjects and Methods:

Data are sourced from a face-to-face baseline survey of a stigma-reduction trial among 1859 WAs from Indian hospitals. Percentages were used to describe categorical variables means and standard deviations for continuous variables. Multiple regressions examined associations between measures.

Results:

WAs who had heard of SP had 44% higher odds of confidently using SP than those who had not heard of them. Those aware of universal SP use were 43% more likely to feel confident in using SP but also reported greater intent to use unnecessary precautions.

Conclusions:

Hospitals could implement SP training for WAs, as their knowledge of universal use was lacking.

Internal and external drivers for compliance with the COVID-19 preventive measures in Slovenia: The view from general deterrence and protection motivation

The emergence of a pandemic is usually accompanied by different measures–economic, social, preventive, and (self)protective. In the case of the COVID-19, several preventive measures were formally enforced by state authorities in the majority of countries worldwide. Thus, during the COVID-19 pandemic, the intertwining of formal and informal social control could be observed. Hence, in this study a cross-sectional design was chosen to explore the issue in Slovenia. To the best of our knowledge, this research is the first in the current literature to empirically test the general deterrence theory in pandemic circumstances (as external factors predicting individuals’ compliance with the COVID-19 preventive measures). The results suggest an important role of informal punishment, with perceived informal severity being the only statistically significant factor from the general deterrence theory. In contrast to external factors, internal factors play a significantly greater role in promoting people’s self-protective behavior in pandemic circumstances. During the unknown, the uncertain and delicate situations with which people have no previous experience, both personal beliefs about the effectiveness of measures and perceived self-efficacy are more important than fear of formal sanctions.

Climate Change Warning Labels on Gas Pumps: The Role of Public Opinion Formation in Climate Change Mitigation Policies

This article analyzes City of Cambridge, Massachusetts legislation that requires all gasoline and diesel pumps to display a consumer warning label outlining the climate change and public health impacts from fuel combustion. This review of empirical and theoretical scholarship on efficacy of carbon label programs and health warning labels suggests government-sponsored "warming labels" may increase self-efficacy beliefs. The analysis reveals warming labels may activate extant climate concern norms and shift public opinion toward long term support of sustainable transportation emissions policies and practices.

Cigarette smokers' perceptions of smoking cessation and associated factors in Karachi, Pakistan

OBJECTIVES

The study explored the perceptions of adult smokers with cardiovascular and respiratory diseases regarding cigarette smoking cessation. We also explored factors that may hinder or facilitate smoking cessation process.

DESIGN

Qualitative descriptive exploratory design SAMPLE: Purposive sample of 13 adult smokers with cardiovascular or respiratory diseases visiting outpatient cardiac and respiratory clinics at a private tertiary care hospital MEASUREMENTS: In-depth, face-to-face, and semi-structured interviews were conducted. The interviews were digitally recorded and transcribed verbatim followed by a six steps process of manual thematic analysis of data.

RESULTS

Meaningful statements were assigned codes and grouped into categories. Categories were clustered under three themes representing individual factors, socio-cultural factors, and institutional factors.

CONCLUSIONS

Smoking cessation is influenced by personal, cultural, as well as social aspects. Institutionally, there is a need to recognize that smoking is a learned behavior; hence, prohibiting public smoking will potentially contribute to non-smoking behaviors. Although the nature of misconceptions varies, this is imperative to ensure consistency in messaging, programming, and supports led by healthcare professionals.

In the Wake of Scandals: How Media Use and Social Trust Influence Risk Perception and Vaccination Intention among Chinese Parents

Recently, repeated childhood vaccine scandals shook public confidence in vaccine safety in China. This study explores whether media attention, online discussion, and social trust influence Chinese parents' risk perception and vaccination intention. Based on data from a Qualtrics panel (N = 354), results indicate that media attention is positively related to social trust and online discussion is positively related to perceived benefits. Additionally, social trust is negatively associated with perceived risk but positively associated with perceived benefits. Social trust is also positively related to general vaccination intention and intention to get domestic vaccines. Further, social trust mediates the relationship between media attention/online discussion and risk perception. Lastly, parents with higher risk perception are less likely to get domestic vaccines, but more likely to get imported vaccines. Perceived benefits also influence vaccination intention.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Strict and Comprehensive Tobacco Control Policy is Needed: A Qualitative Study Exploring How People Responding a New Policy of Pictorial Health Warning on Cigarette Package in Indonesia

BACKGROUND: Little is known about the process on how smoker and nonsmoker responses to a Pictorial Health Warning (PHW) which is important for policy improvement. AIM: We aim to explore the nature of the reaction and the extent of impact of the PHW implementation on smoking habit in Indonesia. METHODS: We collected the data among adult aged 18+ years in Sleman District, Yogyakarta, Indonesia, involving 45 informants in in-depth interviews and 22 informants in four Focus Group Discussions, selected using the maximum variation sampling according to smoking status and area of residence. We discussed with respondents about the meaning of the PHWs, how they felt when seeing the PHWs, how those feelings emerged when seeing the PHWs, and the impact of seeing the PHWs. We analyzed the data using the content analysis. RESULTS: PHWs raised the intended negative emotional response, that wearing out over time. However, for smokers, the disease threat in the message was less obvious than to defeat smoking addiction. Smokers tried to manage their risk of illness themselves. Among non-smokers, they were more confident in being non-smokers. Both smokers and non-smokers thought that Government is half-hearted in controlling the smoking problem. Smokers were grateful, but non-smokers were sorry for this. CONCLUSIONS: The application of PHW threatens smokers but does not make them quit smoking because of the fear of defeating cigarette dependence. For non-smokers, they feel more confident to be a smoker-free. Respondents claim the government is not serious about controlling smoking.

Effects of Prior Exposure to Conflicting Health Information on Responses to Subsequent Unrelated Health Messages: Results from a Population-Based Longitudinal Experiment

BACKGROUND

Accumulating evidence suggests that exposure to conflicting health information can adversely affect public understanding of and trust in health recommendations. What is not known is whether prior exposure to such information renders people less receptive to subsequent unrelated health messages about behaviors for which the evidence is clear and consistent.

PURPOSE

This study tests this "carryover" effects hypothesis, positing that prior exposure to conflict will reduce receptivity to subsequent unrelated health messages, and examines potential affective and cognitive pathways through which such effects might occur.

METHODS

A three-wave, online, population-based survey experiment (N = 2,716) assessed whether participants who were randomly assigned to view a series of health news stories and social media posts featuring conflict at Times 1 and 2 were ultimately less receptive at Time 3 to ads from existing health campaigns about behaviors for which there is scientific consensus, compared to those who saw the same series of stories and posts that did not feature conflict.

RESULTS

Structural equation modeling revealed evidence of carryover effects of exposure to conflict on two dimensions of message receptivity: greater resistance to the unrelated ads and lower perceptions of the health behaviors featured in the ads. Modeling indicated that carryover effects were a function of generalized backlash toward health recommendations and research elicited by prior exposure to conflicting information.

CONCLUSIONS

Findings suggest that the broader public information environment, which is increasingly characterized by messages of conflict and controversy, could undermine the success of large-scale public health messaging strategies.

Effectiveness of Cessation Messages Targeting Pregnant and Nonpregnant Female Smokers in the United States: A Cross-Sectional Analysis into the Impact of Pregnancy, Self-Efficacy, and Risk Perception

OBJECTIVES

Roughly 10% of pregnant women are current smokers. Improving smoking cessation in this population before and during pregnancy is essential to prevent adverse fetal outcomes. This study aimed to examine cessation messages targeting American women.

METHODS

An obstetrics-gynecological clinic-based sample of female, current smokers of reproductive age (18-44 years old) was recruited (n = 135) from January to May 2019; half (51.2%) were currently pregnant. Participants completed a within-subjects study with a randomized set of gain- and loss-framed text-only pregnancy-related cessation messages (5 each). Each individual message was rated on a validated, 10-point scale for perceived effectiveness; responses to the seven items were averaged. Regression analyses examined differences in effectiveness ratings by message framing.

RESULTS

Study participants (female smokers) rated the gain-framed messages as slightly more effective than loss-framed messages (7.9 versus 7.7, p < 0.01). After adjusting for quit intention and pregnancy, the relationship between gain- and loss-framing and effectiveness ratings was modified by both self-efficacy and risk perceptions. Women who perceived high risks of smoking during pregnancy had higher effectiveness ratings of both gain- and loss-framed cessation messages, compared to women who perceived low risks. Lower cessation self-efficacy was significantly associated with lower effectiveness ratings for gain- and loss-framed messages (1.53 and 1.92, respectively; p < 0.05).

CONCLUSIONS FOR PRACTICE

Women with lower self-efficacy and low risk perception of smoking risks had the lowered effectiveness ratings for both frames of cessation messages. Enhancing self-efficacy and risk perceptions through clinical interventions may improve the effectiveness of targeted messages to promote quitting smoking before or during pregnancy.

Self-Efficacy and Other Considerations in Performance of Risk-Reducing Behaviors during a Major Disease Outbreak

This study uses the construct of crisis self-efficacy to examine the importance of different considerations in individuals' decisions to perform recommended safeguarding behaviors during the 2016 Zika virus outbreak. A national survey in the U.S. (n = 370) was administered using a validated crisis self-efficacy scale in late summer 2016, amidst the global crisis. Relationships between crisis self-efficacy and preparedness were assessed. Other considerations such as risk, proximity, and time/money resources required were examined for their importance in decisions to follow safeguarding protocol. Crisis self-efficacy significantly predicted evaluations of preparedness but not of perceived Zika risk. Also, advisories issued from state and federal health agencies influenced individuals' perceptions of preparedness. Results indicate public health information officers should assess publics' levels of crisis self-efficacy in strategic message design. State and federal advisories were important to individual assessments of preparedness. Further, results show the threat needs to be presented to audiences in clear, specific terms.

Effectiveness of warning graphic labels on cigarette packs in enhancing late-teenagers' perceived fear of smoking-related harms in Bangkok, Thailand

Background: This study investigated the level of fear of smoking- related harms for teenagers of different gender, different levels of smoking behaviour, and difference in smoking levels of friends and family members, as influenced by warning graphic images on cigarette packs. The study also compared levels of this fear in categories based on participants' perception (e.g., scarier or less scary images). Design and Methods: The sample group was 353 undergraduate students at King Mongkut's University of Technology Thonburi in Bangkok, Thailand. Questionnaires containing 21 warning graphic images, aimed at measuring levels of fear of smoking-related harms, were conducted. Both descriptive statistics and inferential statistics, such as independent and dependent ttest, were used to analyse the data. Results: The results showed that warning graphic images exhibiting patients suffering from cancers (e.g., lung cancer or laryngeal cancer) and images of damaged body parts were perceived as the scariest warning images. In contrast, images that did not illustrate serious disease suffered by smokers were perceived as the least scary images. The scariest images generated a significant higher level of fear of smoking-related harms than the least scary images. In addition, non-smoking participants were more sensitive to scary warning images than smoking participants. It was also found that the level of fear of smoking-related harms was significantly based on individual cognitive judgment, and it was not affected by the influence of social groups such as friends and family members. Conclusions: Developing effective warning graphic images could directly contribute to individuals' perceived health risks and danger associated with smoking.

Avoidance of tobacco health warnings? An eye-tracking approach

AIMS

Among three eye-tracking studies, we examined how cigarette pack features affected visual attention and self-reported avoidance of and reactance to warnings.

DESIGN

Study 1: smoking status × warning immediacy (short-term versus long-term health consequences) × warning location (top versus bottom of pack). Study 2: smoking status × warning framing (gain-framed versus loss-framed) × warning format (text-only versus pictorial). Study 3: smoking status × warning severity (highly severe versus moderately severe consequences of smoking).

SETTING

University of Bristol, UK, eye-tracking laboratory.

PARTICIPANTS

Study 1: non-smokers (n = 25), weekly smokers (n = 25) and daily smokers (n = 25). Study 2: non-smokers (n = 37), smokers contemplating quitting (n = 37) and smokers not contemplating quitting (n = 43). Study 3: non-smokers (n = 27), weekly smokers (n = 26) and daily smokers (n = 26).

MEASUREMENTS

For all studies: visual attention, measured as the ratio of the number of fixations to the warning versus the branding, self-reported predicted avoidance of and reactance to warnings and for study 3, effect of warning on quitting motivation.

FINDINGS

Study 1: greater self-reported avoidance [mean difference (MD) = 1.14; 95% confidence interval (CI) = 0.94, 1.35, P < 0.001, ηp2  = 0.64] and visual attention (MD = 0.89, 95% CI = 0.09, 1.68, P = 0.03, ηp2  = 0.06) to long-term warnings, but not for reactance (MD = 0.14, 95% CI = -0.04, 0.32, P = 0.12, ηp2  = 0.03). Increased visual attention to warnings on the upper versus lower half of the pack (MD = 1.8; 95% CI = 0.33, 3.26, P = 0.02, ηp2  = 0.08). Study 2: higher self-reported avoidance of (MD = 0.70; 95% CI = 0.59,0.80, P < 0.001, ηp2  = 0.61) and reactance to (MD = 0.37; 95% CI = 0.27, 0.47, P < 0.001, ηp2  = 0.34) loss-framed warnings but little evidence of a difference for visual attention (MD = 0.52; 95% CI = -0.54, 1.58, P = 0.30, ηp2  = 0.01). Greater visual attention, avoidance and reactance to pictorial versus text-only warnings (all Ps < 0.001, ηp2  > 0.25). Study 3: greater self-reported avoidance of (MD = 0.37; 95% CI = 0.25, 0.48, P < 0.001, ηp2  = 0.33) and reactance to (MD = 0.14; 95% CI = 0.05, 0.23, P = 0.003, ηp2  = 0.11) highly severe warnings but findings were inconclusive as to whether there was a difference in visual attention (MD = -0.55; 95% CI = -1.5, 0.41, P = 0.24, ηp2  = 0.02).

CONCLUSIONS

Subjective and objective (eye-tracking) measures of avoidance of health warnings on cigarette packs produce different results, suggesting these measure different constructs. Visual avoidance of warnings indicates low-level disengagement with warnings, while self-reported predicted avoidance reflects higher-level engagement with warnings.

Perceived Knowledge as [Protective] Power: Parents' Protective Efficacy, Information-Seeking, and Scrutiny during COVID-19

During the COVID-19 pandemic, parents were issued numerous, sometimes changing, safeguarding directives including social distancing, mask use, hygiene, and stay-at-home orders. Enacting these behaviors for the parent presented challenges, but the responsibility for children to follow protocol properly was an even more daunting undertaking. Self-efficacy is one of the most power predictors of health behavior and has been adapted to a context-specific crisis self-efficacy scale conducted on March20, 2020, captures real-time perceptions of parents as coronavirus anxieties peaked. The study reveals a relationship between self- and protective efficacy that is mediated by parents' assessments of how informed they are about COVID-19. It also examines the role of perceived knowledge on information-seeking and scrutiny of pandemic information found online. Important directions for future research to develop the protective efficacy construct emerge as well as evidence of the rich applied and theoretical value of a deeper understanding of the perceived ability to perform recommended actions to protect another.

Framing pregnancy-related smoking cessation messages for women of reproductive age

INTRODUCTION

Communicating harms of smoking and benefits of quitting to tobacco users to motivate cessation is critical to reduce the burden of tobacco-related disease. Most messaging strategies focus on health risks of smoking using loss-framing; yet, gain-framed messages to increase confidence in quitting have shown promise for smokers with lower self-efficacy. This study examined the impact of message framing on perceived effectiveness of targeted, pregnancy-related smoking cessation messages among pregnant and not-pregnant smoking women of reproductive age.

METHODS

An obstetrics-gynecological clinic-based sample of female, current smokers of reproductive age (18-44 years old) was recruited during January to May 2019 (n = 135). Participants self-reported ratings for 10 pregnancy-related cessation messages (half gain-framed) on a validated perceived effectiveness scale. Multivariable regression analyses were conducted using generalized estimating equations to account for clustering by message themes.

RESULTS

Gain-framed messages were rated significantly higher (0.20; p < 0.01) compared to loss-framed messages for perceived effectiveness, after accounting for quit intentions, self-efficacy to quit, health literacy, cessation risk perceptions, nicotine dependence, and pregnancy status.

CONCLUSIONS

Gain-framed health messages about cessation were deemed to be more effective than loss-framed messages among adult female smokers. Targeted, positively framed messages to highlight the benefits of quitting to women of reproductive age show promise as a strategy to promote smoking cessation.

Predictors of Staying at Home during the COVID-19 Pandemic and Social Lockdown based on Protection Motivation Theory: A Cross-Sectional Study in Japan

During the COVID-19 pandemic, a social lockdown should be put in place and individuals should stay at home. Behavioral change is the only way to prevent the pandemic and overwhelmed healthcare systems until vaccines are available. We aimed to examine the psychological factors that predict staying at home during the COVID-19 pandemic and social lockdown. A total of 1980 participants in Japan completed a survey for this study from 9 to 11 May 2020, when the state of emergency covered all prefectures in the country. Self-reported behavior in terms of staying at home, the perceived severity of the pandemic, vulnerability to the pandemic, response efficacy, and self-efficacy based on protection motivation theory were assessed. Multiple regression analysis showed that perceived severity (standardized β = 0.11, p < 0.001) and self-efficacy (standardized β = 0.32, p < 0.001) significantly predicted greater levels of staying at home, after controlling for socio-demographics. However, perceived vulnerability and response efficacy did not. To encourage people to stay at home during the pandemic and social lockdown, increasing the perceived severity of infection by COVID-19 and self-efficacy in terms of exercising restraint with respect to going out may consequently encourage people to stay at home.

The psychological typhoon eye effect during the COVID-19 outbreak in China: the role of coping efficacy and perceived threat

Background

The influence of COVID-19 on mental health problems has received considerable attention. However, only a few studies have examined the relationship between exposure to COVID-19 and mental health problems, and no empirical study has tested the mechanisms between them.

Methods

We conducted a survey in 31 provinces of China during 3–13 March 2020 to test the effect of the exposure level on mental health problems. Our sample comprised 2987 participants who reported their perceived threat, coping efficacy, mental health problems and other demographic variables. Multiple mediators path analysis was used in the data analysis.

Results

The results showed that the level of exposure to COVID-19 in China was negatively associated with mental health problems, which confirmed the “Psychological Typhoon Eye” effect. Further analyses indicated that both perceived threat and coping efficacy partially mediated the relationship between them. However, coping efficacy explained the “Psychological Typhoon Eye” effect. Perceived threat mediated the positive relationship between exposure level and mental health problems.

Conclusion

This study detected the psychological typhoon eye effect and demonstrated the mediating role of coping efficacy and perceived threat between exposure to COVID-19 and mental health problems. Our findings suggest that policy makers and psychological workers should provide enough psychological services to low-risk areas as the high-risk areas. An important means of alleviating mental health problems is to improve coping efficacy.

Exploring smoking cessation behaviors of outpatients in outpatient clinics: Application of the transtheoretical model

To examine the knowledge, attitudes, and behaviors of smokers towards smoking prevention and provide high-quality smoking cessation services and education on tobacco prevention and establish a smoke-free care network.This study is a cross-sectional survey. The research tool is a questionnaire composed of 4 sub-scales, namely, "tobacco harm awareness," "tobacco prevention attitude," "quitting smoking self-efficacy scale," and "intentional behavior to quit smoking."A positive correlation was identified between cessation-specific knowledge, attitude to quit smoking, and intentional behavior to quit smoking among outpatients. Following the regression analysis, 2 factors (cessation-specific knowledge and attitude toward quitting the smoking habit) were considered in the model and its total variance explained reached 53.2%.Regular smoking cessation classes should be conducted to increase the awareness of smoking hazards and improve the positive attitude toward smoking cessation to avoid smoking hazards.

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

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

Text2Connect: a health system approach to engage tobacco users in quitline cessation services via text messaging

Mobile technology has created the opportunity for health systems to provide low cost tobacco cessation assistance to patients. The goal of the present study was to examine the feasibility and effectiveness of an intervention (Text2Connect) that uses text messages to offer proactive connection to the New York State Smokers' Quitline. The electronic health record at two urban health systems was queried for patients who were current smokers and who had an outpatient visit between March 2015 and February 2016. Smokers (N = 4000) were sent an informational letter. Those who did not opt out (N = 3719) were randomized to one of 6 message sequences in order to examine the effect of theoretically informed message frames on response rates. Participants were sent a series of text messages at baseline and at 1 month and were asked to reply in order to be contacted by the state quitline (QL). After removing 1403 nonworking numbers, texts were sent to 2316 patients, and 10.0% (205/2060) responded with a QL request. Almost one quarter (23.6%, 486/2060) replied STOP and 66.4% (1369/2060) never responded. QL request rates were significantly higher when response efficacy messages were not used (p < .001). There were no differences by message framing on STOP requests (p > .05). The Text2Connect intervention was well accepted with a minority opting out. A 10% QL response rate is noteworthy given that only 5-7 brief outreach text messages were used. Results indicate that simple self-efficacy-focused messaging is most effective at supporting response rates.

Quasi-experimentally examining the impact of introducing tobacco pictorial health warnings: Findings from the International Tobacco Control (ITC) 4C and Netherlands surveys in the Netherlands, Australia, Canada, United Kingdom, and the United States

BACKGROUND

Our study evaluated the short-term impact of introducing European Union's tobacco pictorial health warnings (PHWs).

METHODS

Longitudinal data were collected at two time-points from adult smokers, participating in the International Tobacco Control (ITC) surveys, conducted in the Netherlands, Australia, Canada, the United Kingdom and the United States. In the Netherlands, textual health warnings (THWs) were replaced by PHWs between both time-points. Health warning policies did not change in the other countries. Data from continuing smokers were used (N = 3,487) and analyzed using Generalized Estimating Equations.

RESULTS

Between both time-points, only Dutch smokers showed increases in noticing health warnings (β = 0.712, p < 0.001), self-reports of health warnings leading to a cognitive response such as thinking about smoking health-risks (SHRs) (OR = 1.834, p < 0.001), knowledge about SHRs (β = 0.369, p < 0.001), and avoiding health warnings (OR = 9.869, p < 0.001). However, Dutch smokers showed no changes in attitude towards smoking (β = 0.035, p = 0.518), intention to quit smoking (OR = 0.791, p = 0.157), self-efficacy to quit smoking (β=-0.072, p = 0.286), or reporting that health warnings helped them to resist having a cigarette (OR = 1.091, p = 0.714).

CONCLUSIONS

Results suggest that introducing the European PHWs was effective in provoking changes closely related to health warnings, but there was no direct impact on variables more closely related to smoking cessation.

Social cognitions and smoking behaviour: Temporal resolution matters

Objectives Health behaviour theories outline how cognitions predict behaviours, but rarely specify the temporal relation between cognitions and behaviours. It is not known whether these predictive relationships vary depending on temporal resolution or whether the relative influence of cognitions varies with measurement schedules. The current exploratory study therefore investigates whether the associations between behavioural cognitions (self-efficacy, intention, and risk perception) and smoking vary when measured momentarily, at day level, or using the more common baseline-follow-up design. Design EMA study involving 36 continuing smokers over 17 days. Participants logged cigarettes and reported their cognitions at baseline, daily (evening), and in response to momentary surveys. Methods Random-effects models were used to compare the effects of cognitions measured at different time points on (1) the number of cigarettes smoked daily and (2) the time interval until the next cigarette smoked. Results Self-efficacy and risk perception measured at baseline significantly predicted cigarettes smoked each day, but this effect became non-significant when daily measurements of cognitions were included in the model. Momentary smoking behaviour was predicted by momentary measurements of risk perception, with no significant effects of social cognitions at baseline. Conclusions Relationships between cognitions and behaviours vary according to the temporal resolution of the measurement schedule. Ensuring that the temporal resolution of assessment is appropriate for the temporal dynamics of the behaviour being assessed is important. Future research is needed to investigate the potential for leveraging specific cognitive processes depending on temporal importance in order to increase health-promoting behaviours. Statement of contribution What is already known on this subject? Social cognitions including intentions, risk perception, and self-efficacy have been observed to predict smoking. Little is known about the role of time in the cognition-behaviour relationship. Cognitions have been observed to fluctuate, but instability is typically not considered in research design. What does this study add? Daily measurement of social cognitions predicts behaviour better than measurements taken at baseline. Momentary smoking behaviour is predicted by momentary cognitions at the intra-individual level. Temporal resolution of measurement should be considered when investigating cognition-behaviour relationships.

Fear or Humour in anti-smoking campaigns? Impact on perceived effectiveness and support for tobacco control Policies

Several anti-smoking campaigns have been used for decades to reduce smoking consumption. However, so far, there is no consensus regarding the effectiveness of inducing distinct emotions in reducing smoke consumption. This study tested the effects of two types of anti-smoking ads, inducing fear or humor, on emotions, perceived effectiveness, support for tobacco control policies, urges to smoke, and susceptibility to smoke. Participants (N = 108; 54 smokers) of both genders were randomly assigned to one of the two following emotion ads condition: fear (N = 52) or humor (N = 56). During exposure, the continuous flow of their emotions by self-report and physiologically was collected. Measures of ads impact on emotions, perceived effectiveness, urges and susceptibility to smoking, and support for tobacco policies were applied after exposure. The results have shown that fear ads were perceived as more effective and reduced the urges to smoke in smokers. Non-smokers were more supportive of tobacco control policies. In conclusion, this study showed that fear campaigns can reduce the urge to smoke among smokers and are perceived to be more effective. This perceived effectiveness can be partially explained by feelings of fear, regardless the other emotions it also triggers, and of the smoking status.

Designing Effective Testimonial Pictorial Warning Labels for Tobacco Products

Warning labels on tobacco products sometimes feature images and stories of real people whose health has been affected by smoking. We examined effects of some of the design elements that may contribute to the effectiveness of these testimonial pictorial warning labels (PWLs). Beginning with a testimonial PWL that contained an image of a person and a basic warning statement (e.g., "Smoking can kill you"), we examined the impact of adding: (a) text detailing the person's name, age and health status (identifiers); and (b) explanatory statements that elaborated on the basic warning using a testimonial or non-testimonial message. In an online experiment, 1255 adult smokers in the United States were randomly assigned to one of six experimental conditions (2 [identifier: none/identifier] × 3 [explanatory statement: none/non-testimonial/testimonial]), or a control condition (text only warning labels that currently appear on packs in the United States). In each condition, participants were exposed to multiple labels each focused on a different health effect. Effectiveness was assessed using emotional responses, engagement and behavioral intentions measured immediately post-exposure, and quit attempts measured at five-week follow up. Testimonial PWLs were more effective than the text only labels. However, there was little evidence that adding identifiers or the explanatory statements enhanced effectiveness; rather, there was some evidence that testimonial explanatory statements reduced effectiveness. These findings suggest that the most effective design for testimonial PWLs may be to combine a basic warning statement with an image of a real person, without any additional textual components.

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.