1
|
Rodríguez-Lesmes P, Góngora-Salazar P, Mentzakis E, Buckley N, Gallego JM, Guindon GE, Martínez JP, Paraje G. Would plain packaging and health warning labels reduce smoking in the presence of informal markets? A choice experiment in Colombia. Soc Sci Med 2024; 354:117069. [PMID: 38971045 DOI: 10.1016/j.socscimed.2024.117069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 06/19/2024] [Accepted: 06/21/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Despite progress made by many countries on the adoption of plain tobacco packaging laws over the last years, low- and middle-income countries, with a large supply of loose cigarettes via informal vendors, remain far behind. AIM To study the potential effectiveness of plain tobacco packaging and dissuasive cigarette sticks, via willingness-to-pay estimates, when illicit cigarette options are available. METHODS We conducted a discrete choice experiment (DCE) in which respondents chose licit and illicit products with three attributes: packaging (standard vs. plain packaging), stick design (branded stick vs. stick with warning), and price level. The sample, collected on 12/2021, consisted of 1761 respondents from an internet panel involving smokers and nonsmokers. Conditional logit and latent class models were used to estimate the willingness-to-pay (WTP) to avoid restrictive packaging elements. RESULTS Nonsmokers are willing to pay USD $5.63 for a pack of cigarettes to avoid plain packaging, which is higher than the actual commercial price of illicit cigarettes (USD $2.40). The WTP increases to USD $12.14 in the presence of illicit alternatives. Smokers are also willing to pay to avoid illicit options, which they also deem riskier, and the presence of such options increases the WTP to avoid plain packaging. However, nonsmokers do not perceive the illicit option as riskier. The dissuasive stick (stick with warning) does not affect perceptions of risk and plays a small role in terms of choice for both smokers and nonsmokers. CONCLUSIONS Even in the presence of illicit tobacco alternatives, plain packaging seems to be as effective in reducing the attractiveness of tobacco products in Colombia as in other countries that have already adopted it. Given conflicting results on the case for dissuasive sticks, there is a need for more research.
Collapse
Affiliation(s)
| | - Pamela Góngora-Salazar
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Social Protection and Health Division, Inter-American Development Bank, Washington DC, United States.
| | - Emmanouil Mentzakis
- School of Policy and Global Affairs, City, University of London, London, United Kingdom.
| | - Neil Buckley
- Department of Economics, York University, Toronto, Canada.
| | | | - G Emmanuel Guindon
- Centre for Health Economics and Policy Analysis, McMaster University, Ontario, Canada.
| | | | | |
Collapse
|
2
|
Mashal LA, Buss FM, Thabayneh KM. 210Po and 210Pb radioactivity levels in local and imported tobacco used in Palestine and Jordan. RADIATION AND ENVIRONMENTAL BIOPHYSICS 2024; 63:133-141. [PMID: 38411924 DOI: 10.1007/s00411-024-01062-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 02/07/2024] [Indexed: 02/28/2024]
Abstract
This study aimed to assess the concentrations of 210Po and 210Pb in various tobacco samples from Palestine and Jordan. Cigarette smoking is recognized as a significant contributor to the radiation dose received by individuals, primarily due to the elevated levels of 210Pb and 210Po found in tobacco. The analysis revealed that the average concentrations of 210Po in locally sourced tobacco and cigarette samples in Palestine are 16.8 ± 2.3 mBq/g and 18.5 ± 2.0 mBq/g, with a total average of 17.8 ± 7.4 mBq/g (15.5 mBq/cigarette). Similarly, the average concentrations of 210Pb in these samples are 18.5 ± 2.6 mBq/g and 20.3 ± 2.2 mBq/g, with a total average of 19.6 ± 8.1 mBq/g (17.0 mBq/cigarette). In Jordan, the average concentrations of 210Po in cigarette samples and narghile tobacco are 20.1 ± 2.4 mBq/g and 18.3 ± 4.1 mBq/g, with a total average value of 19.6 ± 9.9 mBq/g (18.0 mBq/cigarette), while the average concentrations of 210Pb are 22.2 ± 2.6 mBq/g and 20.2 ± 4.5 mBq/g, with a total average value of 21.6 ± 10.8 mBq/g (19.9 mBq/cigarette). The annual effective doses resulting from inhalation were calculated for smokers of these samples. The findings revealed that the levels of 210Po and 210Pb radioactivity in certain investigated samples exceeded the results of studies in many countries of the world. The associated effective doses per year from smoking for all brands products in Palestine range from 34.7 μSv/y to 186.5 μSv/y with an average of 109.5 μSv/y, while in Jordan 54.5 μSv/y to 289.1 μSv/y with an average of 130.9 μSv/y.
Collapse
Affiliation(s)
- Lilia A Mashal
- Department of Medical Biophysics, Hebron University, Hebron, Palestine
| | - Fida M Buss
- Department of Medical Biophysics, Hebron University, Hebron, Palestine
| | - Khalil M Thabayneh
- Faculty of Science and Technology, Hebron University, Hebron, Palestine.
| |
Collapse
|
3
|
Mercincavage M, Sidhu AK, Waugh L, Kreider C, Souprountchouk V, Delnevo CD, Villanti AC, Strasser AA. Effects of pictorial warning labels depicting lesser-known and well-known risks of smoking on viewing patterns, recall, and knowledge of smoking harms. Drug Alcohol Depend 2023; 251:110939. [PMID: 37660524 PMCID: PMC10538381 DOI: 10.1016/j.drugalcdep.2023.110939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/20/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND In 2019, the Food and Drug Administration introduced 11 pictorial warning labels (PWLs) for inclusion on cigarette packages, created in compliance with court recommendations and tailored to increase knowledge of smoking harms. Several highlighted lesser-known risks of smoking. No behavioral studies have yet evaluated how risk content in PWLs impacts viewing patterns, recall, and knowledge of smoking harms. METHODS Seventy adults who reported smoking cigarettes daily (62.9% male, 57.1% African American, mean age = 50.3, mean cigarettes per day = 14.4) completed a single-session laboratory study. They were randomized to view a set of four PWLs depicting either lesser-known or well-known risks of smoking while having eye movements recorded, then completed post-exposure recall and knowledge measures. RESULTS Participants exposed to PWLs depicting lesser-known smoking risks viewed the text of the warning sooner and for longer than the image (p's <0.05); those exposed to PWLs depicting well-known risks viewed the image longer than text (p <0.001). PWL condition did not affect recall of text or image (p's >0.1). Those viewing lesser-known (vs. well-known) risks had greater knowledge of smoking causing lesser-known risks of bladder cancer, blindness, bloody urine, cataracts, diabetes, and head and neck cancer (p's <0.001). CONCLUSIONS Individuals viewing PWLs depicting lesser-known (vs. well-known) smoking risks visually engaged with the PWL text more than image, had similarly high recall of PWL content, and had greater knowledge of lesser-known risks of smoking. Findings suggest including lesser-known risk information on PWLs improves overall knowledge of smoking health risks.
Collapse
Affiliation(s)
- Melissa Mercincavage
- Center for Interdisciplinary Research on Nicotine Addiction, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States; University of Pennsylvania-Rutgers University Tobacco Center of Regulatory Science, Philadelphia, PA, United States.
| | - Anupreet K Sidhu
- Center for Interdisciplinary Research on Nicotine Addiction, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States; University of Pennsylvania-Rutgers University Tobacco Center of Regulatory Science, Philadelphia, PA, United States
| | - Lizza Waugh
- Center for Interdisciplinary Research on Nicotine Addiction, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Catherine Kreider
- Center for Interdisciplinary Research on Nicotine Addiction, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Valentina Souprountchouk
- Center for Interdisciplinary Research on Nicotine Addiction, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Cristine D Delnevo
- University of Pennsylvania-Rutgers University Tobacco Center of Regulatory Science, Philadelphia, PA, United States; Rutgers Institute for Nicotine & Tobacco Studies, New Brunswick, NJ, United States
| | - Andrea C Villanti
- University of Pennsylvania-Rutgers University Tobacco Center of Regulatory Science, Philadelphia, PA, United States; Rutgers Institute for Nicotine & Tobacco Studies, New Brunswick, NJ, United States
| | - Andrew A Strasser
- Center for Interdisciplinary Research on Nicotine Addiction, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States; University of Pennsylvania-Rutgers University Tobacco Center of Regulatory Science, Philadelphia, PA, United States; Annenberg School of Communication, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
4
|
Desorgher L, Berthet A, Rossier J, Bochud F, Froidevaux P. Dosimetry in the lungs of α-particles ( 210Po) and β-particles ( 210Pb) present in the tobacco smoke of conventional cigarettes and heated tobacco products. JOURNAL OF ENVIRONMENTAL RADIOACTIVITY 2023; 263:107178. [PMID: 37060833 DOI: 10.1016/j.jenvrad.2023.107178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/31/2023] [Accepted: 04/03/2023] [Indexed: 05/06/2023]
Abstract
Tobacco products contain radioactive 210Pb and 210Po which can be transferred from the filler to the mainstream smoke. When inhaled, they can contribute to the radioactive dose to the lungs and are suspected to significantly contribute to lung cancer from smoking. Currently, no data are available on the radioactive risk of the heated tobacco products (HTP). However, due to the relatively high heat involved in some of these devices, there are concerns about the volatility of polonium particles. Here we used data on the 210Po and 210Pb content in tobacco smoke along with biokinetic and dosimetric models to compute the effective dose induced by conventional smoking and by using an HTP device (PMI IQOS system). Results show that conventional smoking of one pack per day induces a dose to the lung of about 0.3 mSv/year. This dose decreases by a factor of ten (0.03 mSv/year) for the IQOS system. However, this dose reduction is not obtained by specific countermeasures but by the fact that the IQOS system heats only 15% of the tobacco filler to the target temperature of 330 °C. When heated homogeneously to 300 °C, both conventional and Heets (IQOS) cigarettes release about 80% of the 210Po from the tobacco, leading to similar doses to lungs.
Collapse
Affiliation(s)
- Laurent Desorgher
- Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Aurélie Berthet
- University of Lausanne, Ctr Primary Care & Publ Hlth Unisante, Lausanne, Switzerland
| | - Jérémie Rossier
- Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - François Bochud
- Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pascal Froidevaux
- Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| |
Collapse
|
5
|
Cornacchione Ross J, Lazard AJ, King JL, Noar SM, Reboussin BA, Jenson D, Sutfin EL. Responses to pictorial versus text-only cigarillo warnings among a nationally representative sample of US young adults. Tob Control 2023; 32:211-217. [PMID: 34330882 PMCID: PMC8985738 DOI: 10.1136/tobaccocontrol-2020-056288] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 06/29/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The US Food and Drug Administration requires six text-only warnings for cigar products, including cigarillos. Research has demonstrated the superiority of pictorial over text-only cigarette warnings, yet the relative effectiveness of pictorial warnings for cigarillos has not been examined. We examined the impact of pictorial cigarillo warnings compared with text-only warnings. METHODS Data were collected from a nationally representative sample of US young adult (18-29) cigarillo users and susceptible non-users. Participants were randomised to one of three experimental conditions: text-only or one of two pictorial conditions (combined for analyses). For each warning, we assessed negative emotional reactions, cognitive elaboration (ie, thinking about cigarillo risks) and perceived message effectiveness (PME). RESULTS Participants (N=661) were 46.5% female, 64.7% white and 21.9% Hispanic; 34.1% reported past 30-day cigarillo use; 41.4% were lifetime users (excluding past 30-day use); and 24.4% were susceptible non-users. Pictorial warnings elicited more negative emotional reactions and higher PME than text-only warnings (p values<0.01), with interactions showing the largest effects for past 30-day users (emotional reactions: d=0.99, PME: d=0.63). For cognitive elaboration, there was no main effect of warning type, but an interaction revealed effects for past 30-day users (p<0.05, d=0.46). CONCLUSIONS Pictorial cigarillo warnings elicited greater negative emotional reactions and PME compared with text-only warnings. These effects and the effects on cognitive elaboration were strongest for past 30-day users. Our findings extend research on cigarette warnings to cigarillos, demonstrating that pictorial warnings are superior to text-only warnings for cigarillos in eliciting beneficial responses.
Collapse
Affiliation(s)
| | - Allison J Lazard
- Hussman School of Journalism and Media, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jessica L King
- Department of Health & Kinesiology, University of Utah, Salt Lake City, Utah, USA
| | - Seth M Noar
- Hussman School of Journalism and Media, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Beth A Reboussin
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Desmond Jenson
- Public Health Law Center, Mitchell Hamline School of Law, Saint Paul, Minnesota, USA
| | - Erin L Sutfin
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| |
Collapse
|
6
|
Berthet A, Butty A, Rossier J, Sadowski IJ, Froidevaux P. 210Po and 210Pb content in the smoke of Heated Tobacco Products versus Conventional Cigarette smoking. Sci Rep 2022; 12:10314. [PMID: 35725999 PMCID: PMC9207432 DOI: 10.1038/s41598-022-14200-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/02/2022] [Indexed: 11/09/2022] Open
Abstract
210Po is a radioactive component of conventional cigarette tobacco smoke and is a recognized carcinogen. Despite the expanding market of heated tobacco products, no data are available on the activity of 210Po in the smoke of IQOS Heets cigarette. We determined the 210Po activity in the mainstream smoke of thirteen cigarette brands available on the Swiss market using a smoking machine and compared the results to the 210Po activity measured in the mainstream smoke of the IQOS system. In addition, we measured the 210Po and 210Pb loss on heating after uniform heating from 50 to 600 °C for several cigarette brands and the Heets cigarettes. 13.6 ± 4.1% of 210Po activity was found in the mainstream smoke in conventional cigarette smoking (7% for 210Pb). This dropped to 1.8 ± 0.3% in the mainstream smoke of IQOS Heets. Conversely, when the tobacco was heated uniformly at 330 °C, a loss of 210Po of more than 80% was observed for all type of cigarettes. Apparently, IQOS significantly reduced the 210Po and 210Pb activities in the mainstream smoke. However, our results show that only 15% of the Heets tobacco reaches 330 °C with IQOS. While IQOS reduces the 210Po and 210Pb activities in the mainstream smoke compared to conventional cigarettes, it only heats a marginal fraction of the tobacco present in the Heets cigarette. Because smoking is an addiction (mostly due to nicotine), IQOS could possibly deliver an unsatisfactory dose of nicotine to a Heets cigarette smoker, as most of the tobacco is left unaltered.
Collapse
Affiliation(s)
- Aurélie Berthet
- University of Lausanne, Ctr Primary Care & Publ Hlth Unisante, 1010, Lausanne, Switzerland
| | - Audrey Butty
- University of Lausanne, Ctr Primary Care & Publ Hlth Unisante, 1010, Lausanne, Switzerland
| | - Jérémie Rossier
- Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, Grand Pré 1, 1007, Lausanne, Switzerland
| | | | - Pascal Froidevaux
- Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, Grand Pré 1, 1007, Lausanne, Switzerland.
| |
Collapse
|
7
|
Thrasher JF, Islam F, Arillo-Santillán E, Rodriguez-Bolaños R, de Miera Juarez BS, Hardin JW, Barrientos-Gutierrez I. Strategies to enhance the effects of pictorial warnings for cigarettes: results from a discrete choice experiment. Addiction 2022; 117:1095-1104. [PMID: 34697845 PMCID: PMC8904287 DOI: 10.1111/add.15725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 09/28/2021] [Indexed: 11/30/2022]
Abstract
AIMS To measure the effects of changing attributes of pictorial health warning labels (HWLs) on cigarette packs in a country that has already implemented pictorial HWLs. MEASURES For each choice set, participants were presented with two cigarette packs and asked the following three questions: (1) 'If only these two cigarette packs were available, which would you buy?'; (2) 'Each of these two packs has warnings on the front and back about the health effects of smoking. Which of these warnings best informs you about the dangers from smoking?'; and (3) 'Which warning most makes you think about quitting smoking?'. As recommended for best practices in discrete choice experiments, each of these questions was followed by an 'opt-out' question for participants to indicate whether they really believed there was a difference between the options presented (i.e. 'Would you really choose one of them?'; 'Do you really think that either of these warnings informs you about dangers from smoking?'; or 'Do you really think that either of these warnings would make you think about quitting smoking?', respectively). Each choice set could be viewed for as long as the participant wished. For each choice question (i.e. willingness to buy, informative, motivating to quit), the pack chosen was coded as 1 and the other pack as 0, with both packs being given a value of 0 if the participant 'opted out'. DESIGN A within-subject discrete choice experiment that involved systematic manipulation of pictorial HWL size [75 versus 30% (current policy)]; inclusion of imagery on the back of the pack [versus none (current policy)]; and color formatting [black on yellow versus yellow on black (current policy)]. SETTING Mexico, on-line panel. PARTICIPANTS Adult smokers (n = 705). MEASUREMENTS For each choice set, participants selected one pack as having the most informative HWL about smoking harms, the one that makes them think the most about quitting and the one they were most willing to buy. We assessed the independent and interactive effects of HWL attributes on choices. FINDINGS Larger HWL size on the pack front (75 versus 30%) and inclusion of a pictorial image on the pack back were both independently associated with lower willingness to buy a pack [b = -0.228, standard error (SE) = 0.023 and -0.089, SE = 0.016, respectively] and greater perception of an HWL as informative (b = 0.214, SE = 0.022, and 0.191, SE = 0.017, respectively) and motivating to quit (b = 0.251, SE = 0.023 and 0.194, SE = 0.017, respectively). HWL with black text and yellow background were perceived as less informative (b = -0.037, SE = 0.016) and less motivating to quit (b = -0.032, SE = 0.015) compared with yellow text on a black background. CONCLUSIONS Among adult Mexican smokers, pictorial health warning labels on cigarette packages that are larger or cover both sides of the pack appear more effective at lowering purchase intentions and increasing risk perceptions and motivation to quit than smaller health warning labels or health warning labels with imagery only on the pack front.
Collapse
Affiliation(s)
- James F. Thrasher
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.,Department of Tobacco Research, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Farahnaz Islam
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Edna Arillo-Santillán
- Department of Tobacco Research, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Rosibel Rodriguez-Bolaños
- Department of Tobacco Research, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | | | - James W. Hardin
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | | |
Collapse
|
8
|
Phiri MM, Summers AD, Kress AC, de Quevedo IG, Caraballo R, Twentyman E. Demographic characteristics associated with awareness of cigarette health warnings and thinking about quitting among current adult cigarette smokers in Zambia, 2017. Tob Prev Cessat 2022; 8:05. [PMID: 35224314 PMCID: PMC8832506 DOI: 10.18332/tpc/144772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 12/10/2021] [Accepted: 12/12/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Noticing health warnings on cigarette packages has been associated with thinking about quitting. This study examined sociodemographic characteristics associated with awareness of health warnings on cigarette packages and thinking about quitting because of health warning labels among adults who currently smoked tobacco. METHODS We analyzed data from the 2017 Zambia WHO STEPS survey (STEPwise approach to surveillance) for noncommunicable disease risk factors. Descriptive analyses and logistic regression were performed to assess the association of select sociodemographic characteristics with awareness of health warnings and thinking about quitting because of health warnings. RESULTS Adults who currently smoked tobacco who were aged 30–44 years, of Chewa ethnicity, or with a formal education, were more likely to be aware of health warnings than those aged 18–29 years (adjusted prevalence ratio, APR=1.26; 95% CI: 1.02–1.54), of Bemba ethnicity (APR=1.43; 95% CI: 1.17–1.74), or with no formal education (APR: 2.61–5.95). Among all adults who currently smoked, those of Chewa ethnicity (APR=1.55; 95% CI: 1.03–2.35), or with a formal education (APR:1.80–4.38), were more likely to report thinking about quitting because of health warnings than those who were of Bemba ethnicity or with less than primary school education level. Women who currently smoked were 49% less likely (APR=0.51; 95% CI: 0.23–0.84) to report thinking about quitting than men. Among a subset of adults who currently smoked who were aware of health warning labels, no sociodemographic characteristics were significantly associated with thinking about quitting in unadjusted or adjusted models. CONCLUSIONS Sociodemographic characteristics such as sex, ethnicity, and education level were significantly associated with awareness of cigarette health warnings. Among cigarette smokers aware of health warnings, no sociodemographic differences in thinking about quitting were found. Tobacco control campaigns may need to target people of ethnicities with the highest smoking prevalence in the country.
Collapse
Affiliation(s)
- Masauso M. Phiri
- Tobacco Control Scholars Program Fellow Centre for Primary Care Research, School of Medicine, University of Zambia, Ridgeway, Zambia
| | - April D. Summers
- Global Tobacco Control Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, United States
| | - Alissa C. Kress
- Global Tobacco Control Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, United States
| | - Isabel Garcia de Quevedo
- Global Tobacco Control Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, United States
| | - Ralph Caraballo
- Global Tobacco Control Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, United States
| | - Evelyn Twentyman
- Global Tobacco Control Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, United States
| |
Collapse
|
9
|
Sidhu AK, Johnson AC, Souprountchouk V, Wackowski O, Strasser AA, Mercincavage M. Cognitive and emotional responses to pictorial warning labels and their association with quitting measures after continued exposure. Addict Behav 2022; 124:107121. [PMID: 34583271 PMCID: PMC8603253 DOI: 10.1016/j.addbeh.2021.107121] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Previous research has highlighted the role of cognitive and affective mediators in facilitating the effectiveness of pictorial warning labels (PWLs). This study examines smokers' responses towards PWLs after 10 days of use and their associations with changes in quitting attitudes, beliefs, and intentions during this period. METHODS Non-treatment-seeking, daily smokers completed a randomized, parallel design trial. Participants were randomized to either a PWL or control (i.e., text only or no warning label) group and received their preferred brand cigarettes affixed with their assigned label for 10 days. We assessed quitting attitudes, intentions, and beliefs at the onset and end of the study. At study end, smokers rated their PWL on a 5-point scale for 8 cognitive and emotional attributes: memorable, understandable, shocking, informative, offensive, boring, relevant, and interesting. RESULTS Mean ratings of the PWLs were high for memorable, understandable, informative, relevant, and interesting (range = 3.4 to 4.0), moderate for shocking (2.9), and low for offensive (1.7), and boring (1.5). Among the PWLs, quitting-related attitudes, positive beliefs, and intentions increased over the study period (p < .001) and these changes were positively associated with most attributes except offensive and boring (p < .05). For the text-only label group, attitudes and intentions increased significantly but these changes were not associated with any attributes. CONCLUSION Smokers generally have favorable evaluations of PWLs following repeated exposures. Further, these evaluations are associated with increased quitting attitudes and intentions, which may facilitate cessation attempts over longer periods of exposure.
Collapse
Affiliation(s)
- Anupreet K Sidhu
- University of Pennsylvania Tobacco Center of Regulatory Science (UPenn TCORS) and Center for Interdisciplinary Research on Nicotine Addiction (CIRNA), Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
| | - Andrea C Johnson
- University of Pennsylvania Tobacco Center of Regulatory Science (UPenn TCORS) and Center for Interdisciplinary Research on Nicotine Addiction (CIRNA), Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Valentina Souprountchouk
- University of Pennsylvania Tobacco Center of Regulatory Science (UPenn TCORS) and Center for Interdisciplinary Research on Nicotine Addiction (CIRNA), Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Olivia Wackowski
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, and Rutgers Center for Tobacco Studies, Rutgers University, New Brunswick, NJ, United States
| | - Andrew A Strasser
- University of Pennsylvania Tobacco Center of Regulatory Science (UPenn TCORS) and Center for Interdisciplinary Research on Nicotine Addiction (CIRNA), Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Melissa Mercincavage
- University of Pennsylvania Tobacco Center of Regulatory Science (UPenn TCORS) and Center for Interdisciplinary Research on Nicotine Addiction (CIRNA), Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| |
Collapse
|
10
|
Pang B, Saleme P, Seydel T, Kim J, Knox K, Rundle-Thiele S. The effectiveness of graphic health warnings on tobacco products: a systematic review on perceived harm and quit intentions. BMC Public Health 2021; 21:884. [PMID: 34011338 PMCID: PMC8135180 DOI: 10.1186/s12889-021-10810-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 04/12/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Examination of the format and framing of the graphic health warnings (GHWs) on tobacco products and their impact on tobacco cessation has received increasing attention. This review focused on systematically identifying and synthesizing evidence of longitudinal studies that evaluate different GHW formats and specifically considered GHW influence on perceived risk of tobacco use and quit intentions. METHODS Ten databases were systematically searched for relevant records in December 2017 and again in September 2019. Thirty-five longitudinal studies were identified and analyzed in terms of the formatting of GHWs and the outcomes of perceived risk and quit intentions. Quality assessment of all studies was conducted. RESULTS This review found graphics exceeding 50% of packs were the most common ratio for GHWs, and identified an ongoing reliance on negatively framed messages and limited source attribution. Perceived harms and quit intentions were increased by GHWs. However, wear-out effects were observed regardless of GHW format indicating the length of time warnings are present in market warrants ongoing research attention to identify wear out points. Quit intentions and perceived harm were also combined into a cognitive response measure, limiting the evaluation of the effects of each GHW format variables in those cases. In addition, alternative GHW package inserts were found to be a complimentary approach to traditional GHWs. CONCLUSIONS This review demonstrated the role of GHWs on increasing quit intentions and perceptions of health risks by evaluating quality-assessed longitudinal research designs. The findings of this study recommend testing alternate GHW formats that communicate quit benefits and objective methodologies to extend beyond self-report.
Collapse
Affiliation(s)
- Bo Pang
- Social marketing @ Griffith, Department of Marketing, Griffith University, 170 Kessels Road, Nathan, QLD 4111 Australia
| | - Pamela Saleme
- Social marketing @ Griffith, Department of Marketing, Griffith University, 170 Kessels Road, Nathan, QLD 4111 Australia
| | - Tori Seydel
- Social marketing @ Griffith, Department of Marketing, Griffith University, 170 Kessels Road, Nathan, QLD 4111 Australia
| | - Jeawon Kim
- Social marketing @ Griffith, Department of Marketing, Griffith University, 170 Kessels Road, Nathan, QLD 4111 Australia
| | - Kathy Knox
- Social marketing @ Griffith, Department of Marketing, Griffith University, 170 Kessels Road, Nathan, QLD 4111 Australia
| | - Sharyn Rundle-Thiele
- Social marketing @ Griffith, Department of Marketing, Griffith University, 170 Kessels Road, Nathan, QLD 4111 Australia
| |
Collapse
|
11
|
Jeong M, Noar SM, Zhang D, Mendel JR, Agans RP, Boynton MH, Byron MJ, Baig SA, Ranney LM, Ribisl KM, Brewer NT. Public Understanding of Cigarette Smoke Chemicals: Longitudinal Study of US Adults and Adolescents. Nicotine Tob Res 2020; 22:747-755. [PMID: 30852611 DOI: 10.1093/ntr/ntz035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 03/05/2019] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The US Food and Drug Administration has increased communication efforts that aim to raise public awareness of the harmful constituents (ie, chemicals) in cigarette smoke. We sought to investigate whether the public's awareness of these chemicals has increased in light of such efforts. METHODS Participants were national probability samples of 11 322 US adults and adolescents recruited in 2014-2015 (wave 1) and 2016-2017 (wave 2). Cross-sectional telephone surveys assessed awareness of 24 cigarette smoke chemicals at both timepoints. RESULTS The proportion of US adults aware of cigarette smoke chemicals did not differ between waves 1 and 2 (25% and 26%, p = .19). In contrast, awareness of chemicals among adolescents fell from 28% to 22% (p < .001), mostly due to lower awareness of carbon monoxide, arsenic, benzene, and four other chemicals. Belief that most of the harmful chemicals in cigarette smoke come from burning the cigarette also fell from waves 1 to 2 (adults: 31% vs. 26%; adolescents: 47% vs. 41%, both ps < .05). Participants were more likely to be aware of cigarette smoke chemicals if they had been exposed to anti-smoking campaign advertisements (p < .05) or had previously sought chemical information (p < .05). Cigarette smoke chemical awareness did not differ between smokers and nonsmokers. CONCLUSION Awareness of cigarette smoke chemicals remains low and unchanged among adults and decreased somewhat among adolescents. The association of chemical awareness with information exposure via campaigns and information seeking behavior is promising. More concerted communication efforts may be needed to increase public awareness of cigarette smoke chemicals, which could potentially discourage smoking. IMPLICATIONS Awareness of the toxic chemicals in cigarette smoke may contribute to quitting. The US Food and Drug Administration is making efforts to increase public awareness of these chemicals. Two national surveys (2014-2017) found that chemical awareness was low among adults and adolescents. Although awareness did not change among adults, awareness among adolescents dropped over time. In addition, exposure to anti-smoking campaigns and chemical information seeking behavior were associated with higher awareness of chemicals in cigarette smoke. Campaigns and other efforts may be needed to increase awareness of cigarette smoke chemicals.
Collapse
Affiliation(s)
- Michelle Jeong
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC.,Center for Tobacco Studies, Rutgers School of Public Health, New Brunswick, NJ
| | - Seth M Noar
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC.,School of Media and Journalism, University of North Carolina, Chapel Hill, NC
| | - Dongyu Zhang
- Department of Oncology, Georgetown University School of Medicine, Washington, DC
| | - Jennifer R Mendel
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Robert P Agans
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC.,Carolina Survey Research Laboratory, University of North Carolina, Chapel Hill, NC
| | - Marcella H Boynton
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - M Justin Byron
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Sabeeh A Baig
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Leah M Ranney
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| |
Collapse
|
12
|
Owusu D, Massey Z, Popova L. An experimental study of messages communicating potential harms of electronic cigarettes. PLoS One 2020; 15:e0240611. [PMID: 33085686 PMCID: PMC7577451 DOI: 10.1371/journal.pone.0240611] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022] Open
Abstract
There has been an upsurge of e-cigarette use in the United States in recent years. While e-cigarettes may contain lower levels of toxic chemicals than combusted cigarettes, they still pose serious health hazards, including increased risk for heart and respiratory disease. Despite these risks, public awareness of the health harms of e-cigarettes remains low. Thus, it is important to educate the public about the potential harms of e-cigarettes. This study took themes commonly found in antismoking messages and used them to develop messages about harms of e-cigarettes. A national sample of 2801 current smokers and nonsmokers (aged 18+ years) were randomized to view one of four e-cigarette messages (harmful effect of chemicals, uncertainty about ingredients, distrust of big tobacco, or cost of vaping) or a control message (bottled water ad). Participants' reactions to the messages and behavioral intentions were assessed immediately following the exposure. MANOVA examined effects of the messages on blocks of the outcome variables and univariate analyses estimated adjusted means for each experimental condition for each outcome. The message about harmful chemicals was perceived as the most informative and effective and elicited the highest levels of negative emotions (Ps<0.05). However, on measures of actual effectiveness, the other messages performed equally well. Specifically, messages with different themes (harmful chemicals, uncertainty about ingredients, anti-industry, or financial cost) increased perceived risk of e-cigarettes, support for e-cigarette control, and lowered self-exempting beliefs and intentions to use e-cigarettes (Ps<0.05). Themes commonly used in anti-smoking messages may be effective in educating the public about the potential harm of e-cigarettes. The observed differential effects of the messages suggest the need to use multiple themes in a public education campaign about e-cigarettes.
Collapse
Affiliation(s)
- Daniel Owusu
- School of Public Health, Georgia State University, Atlanta, Georgia, United States of America
| | - Zachary Massey
- School of Public Health, Georgia State University, Atlanta, Georgia, United States of America
| | - Lucy Popova
- School of Public Health, Georgia State University, Atlanta, Georgia, United States of America
| |
Collapse
|
13
|
Pepper JK, Zarndt AN, Eggers ME, Nonnemaker JM, Portnoy DB. Impact of Pictorial Cigarette Warnings Compared With Surgeon General's Warnings on Understanding of the Negative Health Consequences of Smoking. Nicotine Tob Res 2020; 22:1795-1804. [PMID: 32202624 PMCID: PMC10557086 DOI: 10.1093/ntr/ntaa032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 02/03/2020] [Indexed: 10/08/2023]
Abstract
INTRODUCTION The Family Smoking Prevention and Tobacco Control Act requires cigarette packages and advertisements to bear health warnings with "color graphics depicting the negative health consequences of smoking." AIMS AND METHODS This study assessed whether new US Food and Drug Administration developed pictorial cigarette warnings (PCW) increased understanding of smoking-related risks relative to the current Surgeon General's (SG) warnings. In March-May 2019, adolescent and adult smokers and nonsmokers participated in an online experiment with three sessions completed over approximately 2 weeks. Participants viewed 1 of 16 PCW (treatment conditions) or an SG warning (control) on mock cigarette packages and advertisements. Measures assessed whether warnings provided new information, induced thinking about risks, changed smoking-related health beliefs, and were accurately recalled, among other outcomes. RESULTS The majority of PCW (≥13 conditions) resulted in greater learning of new information, higher self-reported learning, and greater reports of thinking about smoking risks; they were viewed as more informative, understandable, and attention-drawing compared with the control condition. Most participants believed the warning were factual, although 8 PCW were perceived as less factual than the control. There were changes toward more agreement with health beliefs for 11 PCW between Sessions 1 and 2 and 7 PCW between Sessions 1 and 3. Participants in all treatment conditions were more likely than control condition participants to correctly recall the warning. Across outcomes, PCW related to addiction, death, and quitting did not perform as well as other PCW. CONCLUSIONS Many of the PCW tested increased understanding of the risks associated with cigarette smoking relative to current SG warnings. IMPLICATIONS The Tobacco Control Act requires cigarette packages and advertisements to bear PCW depicting the negative health consequences of smoking. This study tested whether any of 16 newly proposed PCW increased understanding of smoking-related risks relative to existing SG warnings. Results suggest that most PCW tested, particularly those related to less widely known health effects, resulted in greater learning of new information, higher self-reported learning, and greater reports of thinking about smoking risks compared with SG warnings. These results, along with other factors, informed the US Food and Drug Administration's selection of proposed PCW.
Collapse
Affiliation(s)
- Jessica K. Pepper
- Center for Health Policy Science & Tobacco Research, RTI International, Research Triangle Park, NC
| | - Anh Nguyen Zarndt
- US Food and Drug Administration, Center for Tobacco Products, Silver Spring, MD
| | - Matthew E. Eggers
- Center for Health Policy Science & Tobacco Research, RTI International, Research Triangle Park, NC
| | - James M. Nonnemaker
- Center for Health Policy Science & Tobacco Research, RTI International, Research Triangle Park, NC
| | - David B. Portnoy
- US Food and Drug Administration, Center for Tobacco Products, Silver Spring, MD
| |
Collapse
|
14
|
Pepper JK, Zarndt AN, Eggers ME, Nonnemaker JM, Portnoy DB. Influence of Warning Statements on Understanding of the Negative Health Consequences of Smoking. Nicotine Tob Res 2020; 22:1805-1815. [PMID: 32202620 PMCID: PMC10552677 DOI: 10.1093/ntr/ntaa031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 02/03/2020] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Pursuant to the Tobacco Control Act (TCA), the US Food and Drug Administration (FDA) is developing new cigarette health warnings to convey the negative health consequences of cigarette smoking. AIMS AND METHODS This study assessed which of 15 revised warning statements (10 on topics similar to TCA statements and 5 on other topics) promoted greater understanding of cigarette smoking risks relative to TCA statements. In February 2018, adolescent and adult smokers and adolescents susceptible to smoking (n = 2505) completed an online experiment. Control condition participants viewed TCA statements; treatment condition participants viewed combinations of TCA and revised statements. Analyses compared revised statements to TCA statements on the same health topic or to randomly selected TCA statements if there were no statements on the same topic. RESULTS Relative to TCA statements, 12 of 15 revised statements were more likely to be considered new information, and 12 resulted in more self-reported learning. Three revised statements made participants think more about health risks than TCA statements; the reverse was true for one revised statement. Participants rated most TCA and revised statements as moderately believable and informative. Seven revised statements were found to be less believable and factual, and one revised statement more believable and factual. Treatment condition participants correctly selected more smoking-related health conditions than control condition participants (13.79 versus 12.42 of 25). CONCLUSIONS Findings suggest that revised statements can promote greater understanding of cigarette smoking risks. Results informed FDA's selection of warning text that was paired with images for testing in a follow-up study. IMPLICATIONS The US FDA may adjust the text of the cigarette warning statements provided in the TCA if the revised statements promote greater public understanding of the negative health consequences of cigarette smoking. Most of the revised warning statements tested were more likely to be considered new information and resulted in more self-reported learning compared with paired TCA statements, providing support for using revised statements as part of cigarette health warnings. These results informed the development of pictorial cigarette warnings by FDA that were tested in a follow-up study and included in a proposed rule.
Collapse
Affiliation(s)
- Jessica K. Pepper
- Center for Health Policy Science and Tobacco Research, RTI International, Research Triangle Park, NC
| | - Anh Nguyen Zarndt
- US Food and Drug Administration, Center for Tobacco Products, Silver Spring, MD
| | - Matthew E. Eggers
- Center for Health Policy Science and Tobacco Research, RTI International, Research Triangle Park, NC
| | - James M. Nonnemaker
- Center for Health Policy Science and Tobacco Research, RTI International, Research Triangle Park, NC
| | - David B. Portnoy
- US Food and Drug Administration, Center for Tobacco Products, Silver Spring, MD
| |
Collapse
|
15
|
Lazard AJ. Design cues for tobacco communication: Heuristic interpretations and usability of online health information about harmful chemicals. Int J Med Inform 2020; 141:104177. [PMID: 32521448 PMCID: PMC7606338 DOI: 10.1016/j.ijmedinf.2020.104177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/08/2020] [Accepted: 05/11/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Many people have a poor understanding of the numerous chemicals in tobacco products that cause severe health harms. The US government must display a list of these harmful chemicals for the public. Online disclosures are one promising solution, but evidence is needed for effective design strategies to encourage interpretation and use of information as intended. METHOD To examine the impact of website designs for the activation of heuristics and usability perceptions, a national probability sample of US adolescents and adults (n = 1441) was randomized in a 3 (chemical format) × 2 (webpage layout) between-subjects online experiment. Chemicals were displayed as names only, with a visual risk indicator, or with numerical ranges. Layouts displayed health harms at the top of the webpage separate from chemicals or the chemicals grouped by associated health harms. Participants viewed a webpage and reported activated heuristics, usability (perceived ease of use and usefulness), and intentions to use the website. RESULTS Displaying risk indicators increased website usability by encouraging users to rely on colors to interpret the risk of the chemicals (all p < .01). Website designs that grouped chemicals with harms allowed users to link the chemicals to harms they cause and increased perceived usability and intentions to use the website (all p < .001). CONCLUSION Assessing heuristics gives insights for how US adolescents and adults interpret chemical information and the impact of design strategies on usability. Public disclosures of chemicals in tobacco products could be optimized with color-coded risk indicators and layouts placing chemicals near the harms they cause.
Collapse
Affiliation(s)
- Allison J Lazard
- School of Media and Journalism, University of North Carolina at Chapel Hill, NC 27599-3365, United States; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, NC 27599-3365, United States.
| |
Collapse
|
16
|
Noar SM, Rohde JA, Barker JO, Hall MG, Brewer NT. Pictorial Cigarette Pack Warnings Increase Some Risk Appraisals But Not Risk Beliefs: A Meta-Analysis. HUMAN COMMUNICATION RESEARCH 2020; 46:250-272. [PMID: 32565612 PMCID: PMC7291919 DOI: 10.1093/hcr/hqz016] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 10/13/2019] [Accepted: 10/14/2019] [Indexed: 05/28/2023]
Abstract
Pictorial warnings on cigarette packs motivate smokers to quit, and yet the warnings' theoretical mechanisms are not clearly understood. To clarify the role that risk appraisals play in pictorial warnings' impacts, we conducted a meta-analysis of the experimental literature. We meta-analyzed 57 studies, conducted in 13 countries, with a cumulative N of 42,854. Pictorial warnings elicited greater cognitive elaboration (e.g., thinking about the risks of smoking; d = 1.27; p < .001) than text-only warnings. Pictorial warnings also elicited more fear and other negative affect (d = .60; p < .001). In contrast, pictorial warnings had no impact on perceived likelihood of harm (d = .03; p = .064), perceived severity (d = .16; p = .244), or experiential risk (d = .06; p = .449). Thus, while pictorial warnings increase affective and some cognitive risk appraisals, they do not increase beliefs about disease risk. We discuss the role of negative affect in warning effectiveness and the implications for image selection and warning implementation.
Collapse
Affiliation(s)
- Seth M Noar
- Hussman School of Journalism and Media, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Jacob A Rohde
- Hussman School of Journalism and Media, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Joshua O Barker
- Hussman School of Journalism and Media, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Marissa G Hall
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Noel T Brewer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| |
Collapse
|
17
|
Lambert VC, Davis RE, Popova L, Thrasher JF. Cessation Conversations and Quit Attempts: Differences by Ethnicity and Language Preference. Am J Health Behav 2020; 44:473-487. [PMID: 32553028 PMCID: PMC10808996 DOI: 10.5993/ajhb.44.4.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: Conversations about pictorial cigarette health warning labels (HWLs) encourage quit attempts, and prior research suggests prevalence of these conversations varies by ethnicity. We assessed the frequency of conversations about text-only HWLs among Latino and non-Latino white smokers and the relationship between conversations and subsequent quit attempts. Methods: Latino and non-Latino white adult smokers in the United States (N = 4403) were surveyed every 4 months over 2 years. Surveys queried smoking behaviors, recent quit attempts, HWL responses, including HWL conversations, and socio-demographic variables. Negative binomial generalized estimating equation (GEE) models regressed the frequency of HWL conversations on study variables. Logistic GEE models regressed quit attempts at follow-up surveys on responses from the prior wave, including frequency of HWL conversations and their interaction with ethnicity. Results: Spanish preference Latinos reported the most HWL conversations (85%), followed by English preference Latinos (59%), and non-Latino Whites (35%). More frequent HWL conversations predicted subsequent quit attempts (AOR = 1.74, 95% CI = 1.32, 2.30), but ethnicity did not moderate this effect. Conclusions: Latinos appear to talk more frequently about HWLs than non-Latino Whites but are no more likely to quit as a result. Cessation campaigns should use messages that encourage conversations about quitting.
Collapse
Affiliation(s)
- Victoria C Lambert
- Victoria C. Lambert, Doctoral Candidate, Department of Health Promotion, Education, & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC;,
| | - Rachel E Davis
- Rachel E. Davis, Associate Professor, Department of Health Promotion, Education, & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Lucy Popova
- Lucy Popova, Assistant Professor, Second Century Initiative (2CI) Scholar, Department of Health Policy and Behavioral Sciences, School of Public Health, Georgia State University, Atlanta, GA
| | - James F Thrasher
- James F. Thrasher, Professor, Department of Health Promotion, Education, & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC
| |
Collapse
|
18
|
Seidenberg AB, Jo CL, Ribisl KM. Knowledge and Awareness of Added Sugar in Cigarettes. Nicotine Tob Res 2019; 21:1689-1694. [PMID: 30329106 DOI: 10.1093/ntr/nty217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 10/11/2018] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Sugars naturally occur in tobacco leaf but are also commonly added to cigarettes by tobacco companies. Added sugar increases levels of toxic chemicals in cigarette smoke. Little is known about smokers' knowledge of added sugar in cigarettes and awareness of its effects. METHODS Adult cigarette smokers were recruited through Amazon Mechanical Turk to participate in an online experiment on electronic cigarette advertising. After completing the experiment, participants (N = 4351) answered two items assessing knowledge and awareness of added sugar in cigarettes. Participants had the option of providing open-ended comments about the overall study, and two reviewers read and independently coded comments pertaining to the sugar items. RESULTS Only 5.5% of participants responded "yes" to the question: "Is sugar added to cigarettes?", and only 3.8% of participants indicated being aware that added sugar increases toxins in cigarette smoke. Forty-eight participants mentioned the sugar items when asked to comment about the overall questionnaire. Fifty-two percent of these comments expressed an interest in obtaining more information about added sugar, and 23% described the sugar items as interesting or informative. Three participants commented that learning about added sugar motivated them to quit or cut down on smoking. CONCLUSIONS Among a large sample of smokers, few reported knowledge of added sugar in cigarettes and awareness of its effects. Further, several smokers expressed an interest in learning more about added sugar. Messages about added sugar in cigarettes may be a promising new angle for campaigns to discourage smoking. IMPLICATIONS Few American smokers are aware that sugar is added to cigarettes, and some participants expressed a desire to learn more about this additive. Given such low awareness, the interest among smokers, and increased popular concerns about added sugar in foods and beverages, messaging about added sugar in cigarettes should be developed and tested for inclusion in public health media campaigns.
Collapse
Affiliation(s)
- Andrew B Seidenberg
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Catherine L Jo
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
19
|
McDermott MS, Li G, McNeill A, Hammond D, Thrasher JF, O'Connor RJ, Cummings KM, Borland R, Fong GT, Hitchman SC. Exposure to and perceptions of health warning labels on nicotine vaping products: findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. Addiction 2019; 114 Suppl 1:134-143. [PMID: 30618081 PMCID: PMC6612478 DOI: 10.1111/add.14550] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS The presence and content of health warning labels (HWLs) on nicotine vaping products (NVPs), such as electronic cigarettes, varies by country and manufacturer. We compared proportions of people who report (i) noticing HWLs on NVPs and (ii) feeling concerned having noticed HWLs, by country and by smoking or vaping status. We also examined recall of HWL content and whether this varies by country. DESIGN Cross-sectional survey. SETTING Australia (AU), Canada (CA), England (EN) and the United States (US). At the time of data collection, HWLs on NVPs were only mandatory in EN. PARTICIPANTS A total of 11 561 respondents from the following samples in the 2016 International Tobacco Control Four Country Project: (1) re-contacted smokers and quitters who had participated in the previous wave of the project; (2) newly recruited current smokers and recent quitters; and (3) newly recruited current vapers from CA, EN and US. MEASUREMENTS Outcomes included: (1) having noticed HWLs on NVPs, (2) feeling concerned having noticed HWLs, and (3) recall of HWL message content. FINDINGS Compared with respondents in EN, respondents in CA were more likely to report having noticed HWLs [odds ratio (OR) = 1.58, P = 0.02], whereas respondents in AU (OR = 0.76, P = 1.00) and the US (OR = 1.54, P = 0.09) were not significantly more or less likely to report having noticed HWLs. Compared with concurrent smokers and vapers, daily smokers, non-daily smokers and quitters were less likely to report having noticed HWLs (ORs = 0.21, 0.33 and 0.19, respectively, all P < 0.001). There were no significant differences in reports of noticing HWLs when comparing concurrent smokers and vapers with daily (OR = 1.62, P = 0.91) or non-daily (OR = 1.15, P = 1.00) vapers. There were no significant differences by country in reporting that HWLs made them concerned about using NVPs. Daily vapers were less likely to report feeling concerned than concurrent users (OR = 0.11, P = 0.017). Among those who reported reading HWLs (n = 688), there was little evidence of differences in recall of the HWL content. CONCLUSIONS Respondents in England, where health warning labels on nicotine vaping products are mandatory, were not significantly more likely to report having noticed such warnings than those in Australia, Canada and the United States where warnings are not mandatory.
Collapse
Affiliation(s)
- Máirtín S McDermott
- Addictions Department, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Grace Li
- Department of Psychology, University of Waterloo, Waterloo, ON, Canada
| | - Ann McNeill
- Addictions Department, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
- UK Centre for Tobacco and Alcohol Studies, UK
| | - David Hammond
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - James F Thrasher
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
- Tobacco Research Department, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Richard J O'Connor
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - K Michael Cummings
- Department of Psychiatry and Behavioural Sciences, Medical University of South Carolina, Charleston, SC, USA
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, USA
| | - Ron Borland
- Cancer Council Victoria, Melbourne, VIC, Australia
- School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Geoffrey T Fong
- Department of Psychology, University of Waterloo, Waterloo, ON, Canada
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Sara C Hitchman
- Addictions Department, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
- UK Centre for Tobacco and Alcohol Studies, UK
| |
Collapse
|
20
|
Swayampakala K, Thrasher JF, Yong HH, Nagelhout GE, Li L, Borland R, Hammond D, O'Connor RJ, Hardin JW. Over-Time Impacts of Pictorial Health Warning Labels and their Differences across Smoker Subgroups: Results from Adult Smokers in Canada and Australia. Nicotine Tob Res 2019. [PMID: 28637294 DOI: 10.1093/ntr/ntx134] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
Collapse
Affiliation(s)
- Kamala Swayampakala
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, USA
| | - James F Thrasher
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, USA.,Department of Tobacco Research, Centre for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | | | - Gera E Nagelhout
- Department of Health Promotion, Maastricht University (CAPHRI), Maastricht, the Netherlands.,Department of Family Medicine, Maastricht University (CAPHRI), Maastricht, the Netherlands
| | - Lin Li
- Cancer Council Victoria, Melbourne, Australia
| | - Ron Borland
- Cancer Council Victoria, Melbourne, Australia
| | - David Hammond
- School of Public Health & Health Systems, University of Waterloo, Canada
| | - Richard J O'Connor
- Department of Health Behavior, Roswell Park Cancer Institute, New York, USA
| | - James W Hardin
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, USA
| |
Collapse
|
21
|
Green AC, Driezen P, Noar SM, Hammond D, Fong GT. Impact of adding and removing warning label messages from cigarette packages on adult smokers' awareness about the health harms of smoking: findings from the ITC Canada Survey. Tob Control 2019; 28:e56-e63. [PMID: 31253717 PMCID: PMC7495415 DOI: 10.1136/tobaccocontrol-2018-054885] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Adding messages to cigarette health warning labels (HWLs) about the harms of smoking increases awareness of these health facts, but little is known about the impact of removing messages. This is the first study to directly investigate the impact of adding and removing messages from cigarette HWLs on smokers' awareness of harms. METHODS Data were drawn from nine waves of the International Tobacco Control (ITC) Canada Survey, a national representative cohort of adult smokers (n=5863) conducted nearly annually between 2002 and 2013-2014. Two analytical approaches were conducted: generalised estimating equation (GEE) regression models estimated adjusted percentages of correct smoking-related health statements at each wave and segmented regression analyses modelled temporal trends in awareness before and after the revisions by measuring the difference in slopes. RESULTS Adding messages to HWLs significantly increased awareness that smoking causes blindness (OR=3.36 (95% CI 2.71 to 4.18); p<0.001; estimated increase of 1.01 million smokers in Canada) and bladder cancer (OR=2.14 (95% CI 1.71 to 2.66), p<0.001; estimated increase of 1.09 million smokers). Adding the warning that nicotine causes addiction did not significantly impact smokers' awareness. Removing messages was shown to decrease awareness that cigarette smoke contains carbon monoxide (OR=0.53 (95% CI 0.41 to 0.70), p<0.001; estimated decrease of 342 000 smokers) and smoking causes impotence (p=0.007 for the difference in slopes; estimated decrease of 354 000 smokers). CONCLUSIONS Adding messages to HWLs increases smokers' awareness of health facts, but removing messages decreases awareness. These findings demonstrate the importance of carefully considering the implications of adding and especially removing messages from HWLs and the importance of regularly revising warnings.
Collapse
Affiliation(s)
- Annika C Green
- Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
| | - Pete Driezen
- Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
| | - Seth M Noar
- School of Journalism and Mass Communication, University of North Carolina, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - David Hammond
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Geoffrey T Fong
- Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| |
Collapse
|
22
|
Hammond D, Reid JL, Driezen P, Thrasher JF, Gupta PC, Nargis N, Li Q, Yuan J, Boudreau C, Fong GT, Cummings KM, Borland R. Are the Same Health Warnings Effective Across Different Countries? An Experimental Study in Seven Countries. Nicotine Tob Res 2019; 21:887-895. [PMID: 30452728 PMCID: PMC6588394 DOI: 10.1093/ntr/nty248] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 11/13/2018] [Indexed: 11/12/2022]
Abstract
INTRODUCTION More than 100 countries have implemented pictorial health warnings on cigarette packages. However, few studies have compared how consumers from different geographic and cultural contexts respond to health warning content. The current study compares perceptions of warnings among adult smokers and youth in seven countries, to examine the efficacy of different health warning themes and images. METHODS Between 2010 and 2012, online and face-to-face surveys were conducted with ~500 adult smokers and ~500 youth (age 16-18) smokers and nonsmokers in each of Mexico, United States, China, Germany, India, Bangladesh, and Republic of Korea (total N = 8182). Respondents were randomized to view and rate sets of 5-7 health warnings (each set for a different health effect); each set included a text-only warning and various types (ie, themes) of pictorial warnings, including graphic health effects, "lived experience," symbolic images, and personal testimonials. Mixed-effects models were utilized to examine perceived effectiveness of warning themes, and between-country differences in responses. RESULTS Overall, pictorial warnings were rated as more effective than text-only warnings (p < .001). Among pictorial themes, "graphic" health effects were rated as more effective than warnings depicting "lived experience" (p < .001) or "symbolic" images (p < .001). Pictorial warnings with personal testimonials were rated as more effective than the same images with didactic text (p < .001). While the magnitude of differences between warning themes varied across countries, the pattern of findings was generally consistent. CONCLUSIONS The findings support the efficacy of graphic pictorial warnings across diverse geographic and cultural contexts, and support sharing health warning images across jurisdictions. IMPLICATIONS Although over 100 countries have implemented pictorial health warnings on cigarette packages, there is little research on the most effective types of message content across geographic and cultural contexts. The current study examined perceived effectiveness of text and pictorial health warnings featuring different message content-graphic health effects, "lived experience," personal testimonials, and symbolic imagery-among more than 8000 adults and youth in Mexico, United States, China, Germany, India, Bangladesh, and Korea. Across countries, "graphic" pictorial messages were rated as most effective. Consistencies across countries in rating message content suggests there may be "globally effective" themes and styles for designing effective health warnings.
Collapse
Affiliation(s)
- David Hammond
- School of Public Health & Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Jessica L Reid
- School of Public Health & Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Pete Driezen
- Department of Psychology, University of Waterloo, Waterloo, ON, Canada
| | - James F Thrasher
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC
- Departamento de Investigaciones sobre Tabaco, Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Publica (INSP), Cuernavaca, Mexico
| | - Prakash C Gupta
- Healis-Sekhsaria Institute for Public Health, Navi Mumbai, India
| | - Nigar Nargis
- Department of Economics and Bureau of Economic Research, University of Dhaka, Dhaka, Bangladesh
| | - Qiang Li
- China Tobacco Control Office, Chinese Center for Disease Control and Prevention (China CDC), Beijing, China
| | - Jiang Yuan
- China Tobacco Control Office, Chinese Center for Disease Control and Prevention (China CDC), Beijing, China
| | - Christian Boudreau
- Department of Statistics & Actuarial Science, University of Waterloo, Waterloo, ON, Canada
| | - Geoffrey T Fong
- School of Public Health & Health Systems, University of Waterloo, Waterloo, ON, Canada
- Department of Psychology, University of Waterloo, Waterloo, ON, Canada
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - K Michael Cummings
- Department of Psychiatry & Behavorial Sciences, Medical University of South Carolina, Charleston, SC
| | - Ron Borland
- Cancer Council Victoria, Melbourne, Australia
| |
Collapse
|
23
|
Thrasher JF, Brewer NT, Niederdeppe J, Peters E, Strasser AA, Grana R, Kaufman AR. Advancing Tobacco Product Warning Labels Research Methods and Theory: A Summary of a Grantee Meeting Held by the US National Cancer Institute. Nicotine Tob Res 2019; 21:855-862. [PMID: 29444268 PMCID: PMC6775856 DOI: 10.1093/ntr/nty017] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/31/2018] [Indexed: 11/12/2022]
Abstract
BACKGROUND The World Health Organization's Framework Convention on Tobacco Control recommends prominent pictorial health warnings on tobacco products. To advance research methods, theory and understanding of how tobacco product warning labels (TPWLs) work, the US National Cancer Institute convened a grantee meeting. Our article describes the key insights that emerged from the meeting, situated within the context of the scientific literature. RESULTS & RECOMMENDATIONS First, presentations confirmed that large, pictorial TPWLs motivate people to try to quit and encourage smoking cessation. Second, pictorial TPWLs increase attention, knowledge, negative affect, and thinking about the warning. Third, TPWL studies have primarily used brief-exposure laboratory studies and observational studies of sustained exposure through national policy implementation, with a few randomized trials involving several weeks of exposure-with generally consistent results found across study designs. Fourth, novel assessment methods include brain imaging, eye tracking and "best-worst" discrete choice experiments. To make TPWL even more effective, research is needed to confirm the mechanisms of their influence, their impact across vulnerable populations, and their effect on social media posts about tobacco products. Research is also needed on the effect of trial design choices, the predictive validity of new measurement approaches, and warning labels for non-cigarette tobacco products. IMPLICATIONS To improve scientific understanding of TPWL effects, this grantee meeting summary describes emerging research methods, theory and study results. Directions for future research include examination of the mechanisms of how warning labels work across diverse tobacco products and across different populations and contexts.
Collapse
Affiliation(s)
- James F Thrasher
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | | | - Ellen Peters
- Department of Psychology, The Ohio State University, Columbus, OH
| | - Andrew A Strasser
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rachel Grana
- Tobacco Control Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - Annette R Kaufman
- Tobacco Control Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| |
Collapse
|
24
|
Cupertino AP, Cartujano-Barrera F, Ramírez M, Rodríguez-Bolaños R, Thrasher JF, Pérez-Rubio G, Falfán-Valencia R, Ellerbeck EF, Reynales-Shigematsu LM. A Mobile Smoking Cessation Intervention for Mexico (Vive sin Tabaco... ¡Decídete!): Single-Arm Pilot Study. JMIR Mhealth Uhealth 2019; 7:e12482. [PMID: 31021326 PMCID: PMC6658244 DOI: 10.2196/12482] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 02/14/2019] [Accepted: 02/17/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Of the 14.3 million Mexicans who smoke, only a minority take advantage of evidence-based approaches to smoking cessation. Mobile health interventions have the potential to increase the reach of effective cessation interventions in Mexico. OBJECTIVE This study aimed to assess the feasibility and acceptability of an innovative, personalized, and interactive smoking cessation mobile intervention developed for Mexican smokers. METHODS We recruited 40 Mexican smokers to participate in Vive sin Tabaco... ¡Decídete!, a smoking cessation program that uses a tablet-based decision support software to drive a 12-week text messaging smoking cessation program and pharmacotherapy support. Outcome measures included participant text messaging interactivity with the program, participant satisfaction, and 12-week verified abstinence using urinary cotinine testing or exhaled carbon monoxide. RESULTS Average age of the participants was 36 years (SD 10.7), and they were primarily male (65%, 26/40) with at least an undergraduate degree (62%, 25/40). Most participants (95%, 38/40) smoked daily and were interested in quitting in the next 7 days. As an indicator of participant interactivity, participants sent an average of 21 text messages during the 12-week intervention (SD 17.62). Of the 843 messages that participants sent to the program, only 96 messages (11.3%, 96/843) used keywords. At 12 weeks, 40% (16/40) of participants were biochemically verified (87%, 35/40, follow-up rate). The majority of participants (85%, 30/35) reported being very satisfied or extremely satisfied with the program. CONCLUSIONS The Vive sin Tabaco... ¡Decídete! smoking cessation mobile intervention was accepted by participants, generated high satisfaction and high text messaging interactivity, and resulted in a noteworthy cessation rate at the end of treatment. This intervention is a promising strategy for smoking cessation in Mexico. Additional testing as a formal randomized clinical trial appears warranted.
Collapse
Affiliation(s)
- Ana Paula Cupertino
- Department of Cancer Prevention and Control, Hackensack University Medical Center, Hackensack, NJ, United States
| | - Francisco Cartujano-Barrera
- Department of Cancer Prevention and Control, Hackensack University Medical Center, Hackensack, NJ, United States
| | - Mariana Ramírez
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, KS, United States
| | | | - James F Thrasher
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, SC, United States
| | - Gloria Pérez-Rubio
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas, Laboratorio HLA, Mexico City, Mexico
| | - Ramcés Falfán-Valencia
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas, Laboratorio HLA, Mexico City, Mexico
| | - Edward F Ellerbeck
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, KS, United States
| | | |
Collapse
|
25
|
Owusu D, So J, Popova L. Reactions to tobacco warning labels: predictors and outcomes of adaptive and maladaptive responses. ADDICTION RESEARCH & THEORY 2019; 27:383-393. [PMID: 31511769 PMCID: PMC6738943 DOI: 10.1080/16066359.2018.1531127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND The Extended Parallel Process Model (EPPM) responses have not been evaluated from verbal reactions to cigarette warning labels. We identified the EPPM responses in reactions to cigarette warning labels and evaluated their predictors and relationship with warning perceptions. METHODS U.S. adult current smokers, transitioning smokers (quit in the past two years or currently quitting) and never smokers (n=1,838) saw nine of 81 cigarette warning labels. Participants freely wrote their thoughts after viewing the first label and reported perceived informativeness, negative emotions, and denial for this label. Responses were coded for the presence of the EPPM response categories. Multivariable logistic regression models described adaptive and maladaptive respondent characteristics, and linear regression models assessed the relationship between the response categories and label perceptions. RESULTS Participants' responses contained adaptive (65.4%), maladaptive (16.5%), no response (14.7%), and mixed responses (both adaptive and maladaptive; 3.4%). Current smokers had decreased odds of adaptive response compared to never and transitioning smokers. Compared to text warnings, pictorial warnings were associated with increased odds of adaptive and decreased odds of maladaptive responses. Adaptive response was associated with increased odds of intentions to quit smoking. Adaptive respondents reported the highest levels of informativeness and negative emotions among the four response categories. CONCLUSIONS The finding demonstrating predominantly adaptive (and few maladaptive) responses to warning labels supports the continued use of fear appeals in warning label design. The greater adaptive and lower maladaptive responses to pictorial warnings could serve as additional evidence for FDA to implement pictorial warning labels.
Collapse
Affiliation(s)
- Daniel Owusu
- Tobacco Center of Regulatory Science, School of Public Health, Georgia State University, Atlanta, GA, USA
| | - Jiyeon So
- Department of Communication Studies, University of Georgia, Athens, GA, USA
| | - Lucy Popova
- Tobacco Center of Regulatory Science, School of Public Health, Georgia State University, Atlanta, GA, USA
- Corresponding author: P.O. Box 3995, Atlanta, GA 30302.
| |
Collapse
|
26
|
Mostafa A, Mohammed HT, Hussein RS, Hussein WM, Elhabiby M, Safwat W, Labib S, Aboul Fotouh A. Do pictorial health warnings on waterpipe tobacco packs matter? Recall effectiveness among Egyptian waterpipe smokers & non-smokers. PLoS One 2018; 13:e0208590. [PMID: 30562376 PMCID: PMC6298733 DOI: 10.1371/journal.pone.0208590] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 11/20/2018] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Despite the global rise in waterpipe tobacco smoking (WTS), the effectiveness of waterpipe tobacco health warnings remain understudied, especially in countries with high WTS rates. Egypt has been employing waterpipe tobacco labelling for a decade, however, their effectiveness is unknown. Our overall aim was to measure the effectiveness of pictorial health warnings (PHWs) on waterpipe tobacco packs (WTPs) through participant memory recall and to investigate whether they induced behavioural responses in waterpipe smokers and deterred uptake of WTS in non-smokers, examining the differentials of effectiveness among socio-demographic subgroups. SUBJECTS AND METHODS We conducted two surveys including 1490 adult current waterpipe smokers, 73 former waterpipe smokers, and 451 non-smokers in Cairo and a rural village in Egypt between 2015-2017. Participants who noticed PHWs on WTPs were asked questions about salience, communication of health risks, public support, cognitive processing, and self-reported behavioural responses (current waterpipe smokers: reduce consumption, forgo a smoke, quit attempts; former waterpipe smokers: quit; non-smokers: deter WTS initiation). Univariate and multivariable statistical analyses were performed. RESULTS Participants' mean age was 35 years, mostly males (90.4%), waterpipe smokers (74.0%) and rural residents (59.3%). Approximately two-thirds of participants noticed PHWs on WTPs. Salience was significantly less among females, urban residents and participants with high literacy. More than three-quarters of participants reported that WTS health risks were communicated through the warnings. At least half of participants cognitively processed the warnings: 56.3% thought of the warnings when WTPs were out of sight; non-smokers understood the warnings (83.2%) and discussed them with others (90.3%) significantly more than current (76.0% and 72.5%, respectively) and former waterpipe smokers (81.0% and 61.9%, respectively). Participants reported that PHWs on WTPs motivated 58.5% of waterpipe smokers to think about quitting; 64.5% to reduce their consumption; 42.2% to forgo a smoke; 24.5% to attempt to quit; 57.1% of former waterpipe smokers to successfully quit; and 59.3% of non-smokers to remain smoke-free. CONCLUSIONS Findings suggest that inserting PHWs on WTPs is an effective waterpipe tobacco labelling policy. Countries with similarly high rates of WTS should consider adopting WTP PHWs within a comprehensive regulatory framework.
Collapse
Affiliation(s)
- Aya Mostafa
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Heba Tallah Mohammed
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Rasha Saad Hussein
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Wafaa Mohamed Hussein
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mahmoud Elhabiby
- Department of Psychiatry Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Wael Safwat
- Egyptian Tobacco Control Coalition, Cairo, Egypt
- Egypt Health Foundation, Cairo, Egypt
| | - Sahar Labib
- Tobacco Control Unit, Ministry of Health, Cairo, Egypt
| | - Aisha Aboul Fotouh
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| |
Collapse
|
27
|
Berg CJ, Fong GT, Thrasher JF, Cohen JE, Maziak W, Lando H, Drope J, Mejia R, Barnoya J, Nakkash R, Salloum RG, Parascandola M. The impact and relevance of tobacco control research in low-and middle-income countries globally and to the US. Addict Behav 2018; 87:162-168. [PMID: 30041132 DOI: 10.1016/j.addbeh.2018.07.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/11/2018] [Accepted: 07/15/2018] [Indexed: 11/15/2022]
Abstract
International and cross-cultural research is critical for understanding multilevel influences on health, health behaviors, and disease. A particularly relevant area of need for such research is tobacco control. The tobacco epidemic is one of the biggest public health threats globally, killing over 7 million people a year. Research critical to addressing this public health problem has leveraged variability in tobacco use, history, product market, and policies across different countries, settings, and populations, particularly in low- and middle-income countries (LMICs) where the tobacco burden is increasing. These efforts are needed in order to advance the science and inform practice and policy in various settings, including the US. Several funding agencies provide support for international research focused on tobacco control in LMICs because of the importance and implications of such research. This paper provides some concrete examples of how such research has advanced our knowledge-base and informed practice and policy globally, particularly in high-income countries including the US. Some prominent themes emphasized in this manuscript include: the development of knowledge regarding the diverse tobacco products on the market; better understanding of tobacco use and its impact among different populations; generating knowledge about the impacts including unintended consequences of tobacco control policy interventions; and better understanding tobacco industry strategies and informing advocacy efforts. In summary, international tobacco control research, particularly in LMICs, is critical in effectively and efficiently building the evidence base to advance tobacco control research, policy, and practice globally, including the US, with the ultimate goal of curbing the tobacco epidemic.
Collapse
Affiliation(s)
- Carla J Berg
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA 30322, United States.
| | - Geoffrey T Fong
- Department of Psychology and School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L G1 Canada, Ontario Institute for Cancer Research, Toronto, Ontario, Canada.
| | - James F Thrasher
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC 29208, United States; Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico.
| | - Joanna E Cohen
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, 2213 McElderry Street, Baltimore, MD 21205, United States.
| | - Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8h Street, AHC5 505, Miami, FL 33199, United States.
| | - Harry Lando
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 South Second Street, Minneapolis, MN 55454, United States.
| | - Jeffrey Drope
- Department of Economic and Health Policy Research, American Cancer Society, 250 Williams St, Atlanta, GA, 30303, United States.
| | - Raul Mejia
- Centro de Estudios de Estado y Sociedad, Sánchez de Bustamante 27, C1173AAA, Buenos Aires, Argentina.
| | - Joaquin Barnoya
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, 660 South Euclid Ave, St. Louis, MS 63110, United States.
| | - Rima Nakkash
- Department of Health Promotion and Community Health, American University of Beirut, PO, Box 11-0236, Beirut, Lebanon.
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 2004 Mowry Rd, Gainesville, FL 32610, United States.
| | - Mark Parascandola
- Tobacco Control Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD 20892, United States.
| |
Collapse
|
28
|
Elton-Marshall T, Wijesingha R, Kennedy RD, Hammond D. Disparities in knowledge about the health effects of smoking among adolescents following the release of new pictorial health warning labels. Prev Med 2018; 111:358-365. [PMID: 29195760 DOI: 10.1016/j.ypmed.2017.11.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 11/13/2017] [Accepted: 11/26/2017] [Indexed: 11/28/2022]
Abstract
This paper examined knowledge about the health effects of smoking among health equity groups following the 2012 introduction of refreshed pictorial health warning labels (HWLs) in Canada. Data are from the 2012/2013 Youth Smoking Survey a representative school-based survey of 47,203 adolescents in Grades 6-12 in nine provinces. Regression models examined overall knowledge about eight health effects of smoking included in the HWLs. Less than one-third of adolescents (32.2%) knew that smoking causes vision loss/blindness and 33.7% knew that smoking causes bladder cancer. Whereas knowledge was high for lung cancer (93.9%), knowledge about other health effects ranged from 52.9% for chronic bronchitis/emphysema to 77.6% for gum or mouth disease. Non-smoking adolescents who were: susceptible to future smoking, male, ethnic minorities, and who had less spending money were significantly less likely to be knowledgeable of the health effects of smoking. There were fewer disparities in knowledge about the health effects of smoking among smokers. Smokers who bought loose or bagged cigarettes rather than cigarettes in packages or cartons were significantly less likely to be knowledgeable about the health effects of smoking. There are significant disparities in knowledge about the health effects of smoking by health equity groups particularly among non-smoking adolescents. Warning labels have the potential to reduce disparities in knowledge about the health effects of smoking when exposure to the warning labels is universal. Complementary strategies such as mass media campaigns are needed to address disparities in knowledge.
Collapse
Affiliation(s)
- Tara Elton-Marshall
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, London, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Affiliated Scientist, Ontario Tobacco Research Unit, Toronto, Ontario, Canada.
| | - Rochelle Wijesingha
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, London, Ontario, Canada; Department of Sociology, McMaster University, Hamilton, Ontario, Canada
| | - Ryan David Kennedy
- Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - David Hammond
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| |
Collapse
|
29
|
Abstract
Objectives Our aim was to identify message characteristics for cigarette pack inserts that aim to help smokers quit. Methods US adult smokers from an online consumer panel (N = 665) participated in a discrete choice experiment with a 2x2x2x2x4 within-subjects balanced incomplete block design, manipulating: image (vs no image), text type (testimonial vs informational), cessation resource information (vs none), call to action (vs none), and message topic (well-being, financial benefit, cravings, social support). Participants evaluated 9 choice sets, each with 4 inserts, selecting: (1) the most and least helpful for quitting; and (2) the most and least motivating to quit. Linear models regressed choices on insert characteristics, controlling for sociodemographics and smoking-related variables. We assessed interactions between insert characteristics and smoker attributes (ie, education, quit intention, self-efficacy). Results Inserts were most helpful and motivating when they included an image, provided cessation resource information, or referenced well-being and financial benefits. Significant interactions indicated that inserts with cessation resource information were relatively more helpful and motivating among smokers with low self-efficacy, an intention to quit, or lower education. Conclusion Cigarette pack inserts with imagery and cessation resource information may be particularly effective in promoting smoking cessation.
Collapse
|
30
|
Noar SM, Kelley DE, Boynton MH, Morgan JC, Hall MG, Mendel JR, Ribisl KM, Brewer NT. Identifying principles for effective messages about chemicals in cigarette smoke. Prev Med 2018; 106:31-37. [PMID: 28890353 PMCID: PMC5764803 DOI: 10.1016/j.ypmed.2017.09.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/31/2017] [Accepted: 09/04/2017] [Indexed: 10/18/2022]
Abstract
US law requires the Food and Drug Administration (FDA) to disclose information on harmful and potentially harmful chemicals in cigarette smoke (i.e., constituents) to the public. To inform this effort, we sought to identify principles for creating constituent messages that effectively discourage smoking. Participants were an online convenience sample of 1148 US smokers ages 18+. We developed a library of 76 messages about constituents only and constituents plus contextualizing information (i.e., toxic products that also contain the chemical, health effects, or both). We randomized smokers to receive 1 message from each of 7 message panels in a mixed between-/within-subjects experiment. Participants rated each message on perceived message effectiveness. Results indicated that smokers perceived messages about arsenic, formaldehyde, lead, uranium, and ammonia as more effective than messages about nitrosamines. Messages that contained information on toxic products, health effects, or both received higher effectiveness ratings than constituent-only messages. Among constituent-only messages, those that referenced multiple constituents received higher effectiveness ratings than those with fewer constituents. We conclude that chemical messages may have more impact if they pair known constituents with toxic product or health effect information. These message principles can be used to inform studies examining the impact of constituent messages on smoking beliefs and behavior.
Collapse
Affiliation(s)
- Seth M Noar
- School of Media and Journalism, University of North Carolina at Chapel Hill, United States; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States.
| | - Dannielle E Kelley
- School of Media and Journalism, University of North Carolina at Chapel Hill, United States
| | - Marcella H Boynton
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States
| | - Jennifer C Morgan
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States
| | - Marissa G Hall
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States
| | - Jennifer R Mendel
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States
| | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, United States
| |
Collapse
|
31
|
Morgan JC, Byron MJ, Baig SA, Stepanov I, Brewer NT. How people think about the chemicals in cigarette smoke: a systematic review. J Behav Med 2017; 40:553-564. [PMID: 28224264 PMCID: PMC5501992 DOI: 10.1007/s10865-017-9823-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 01/04/2017] [Indexed: 11/24/2022]
Abstract
Laws and treaties compel countries to inform the public about harmful chemicals (constituents) in cigarette smoke. To encourage relevant research by behavioral scientists, we provide a primer on cigarette smoke toxicology and summarize research on how the public thinks about cigarette smoke chemicals. We systematically searched PubMed in July 2016 and reviewed citations from included articles. Four central findings emerged across 46 articles that met inclusion criteria. First, people were familiar with very few chemicals in cigarette smoke. Second, people knew little about cigarette additives, assumed harmful chemicals are added during manufacturing, and perceived cigarettes without additives to be less harmful. Third, people wanted more information about constituents. Finally, well-presented chemical information increased knowledge and awareness and may change behavior. This research area is in urgent need of behavioral science. Future research should investigate whether educating the public about these chemicals increases risk perceptions and quitting.
Collapse
Affiliation(s)
- Jennifer C Morgan
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, 325 Rosenau Hall CB7440, Chapel Hill, NC, 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - M Justin Byron
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, 325 Rosenau Hall CB7440, Chapel Hill, NC, 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Sabeeh A Baig
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, 325 Rosenau Hall CB7440, Chapel Hill, NC, 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Irina Stepanov
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, 325 Rosenau Hall CB7440, Chapel Hill, NC, 27599, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
| |
Collapse
|
32
|
Cho YJ, Thrasher JF, Swayampakala K, Lipkus I, Hammond D, Cummings KM, Borland R, Yong HH, Hardin JW. Does Adding Information on Toxic Constituents to Cigarette Pack Warnings Increase Smokers' Perceptions About the Health Risks of Smoking? A Longitudinal Study in Australia, Canada, Mexico, and the United States. HEALTH EDUCATION & BEHAVIOR 2017; 45:32-42. [PMID: 28715260 DOI: 10.1177/1090198117709884] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Health warning labels (HWLs) on cigarette packs in Australia, Canada, Mexico, and the United States include varying information about toxic cigarette smoke constituents and smoking-related health risks. HWL information changed more recently in Australia, Canada, and Mexico than in the United States. AIMS To investigate whether smokers' knowledge of toxic constituents and perceived smoking-related risks increased after adding this information to HWLs and how knowledge of toxic constituents is associated with perceptions of smoking-related risks. METHODS Data come from a longitudinal, online cohort of 4,621 adult smokers surveyed every 4 months from September 2012 (Wave 1) to January 2014 (Wave 5) in Australia, Canada, and Mexico, with the United States being surveyed from Waves 2 to 5. Generalized estimating equation models estimated the association between perceived smoking-related risk at follow-up and prior wave knowledge of toxic constituents, adjusting for attention to HWLs, sociodemographics, and smoking-related characteristics. RESULTS Between 2012 and 2014, knowledge of toxic constituents increased in Australia, Canada, and Mexico ( p < .001), but not in the United States. Higher levels of both attention to HWLs and knowledge of toxic constituents were associated with a higher perceived risk of smoking-related conditions at follow-up across all countries except for the United States. CONCLUSIONS Our results suggest that information about toxic constituents on prominent HWLs not only increases smoker's knowledge of toxic constituents, but that it may also reinforce the effects of HWL messages about specific, smoking-related health outcomes.
Collapse
Affiliation(s)
- Yoo Jin Cho
- 1 University of South Carolina, Columbia, SC, USA
| | - James F Thrasher
- 1 University of South Carolina, Columbia, SC, USA.,2 National Institute of Public Health, Cuernavaca, Mexico
| | | | | | | | | | - Ron Borland
- 6 Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Hua-Hie Yong
- 6 Cancer Council Victoria, Melbourne, Victoria, Australia
| | | |
Collapse
|
33
|
Salloum RG, Louviere JJ, Getz KR, Islam F, Anshari D, Cho Y, O'Connor RJ, Hammond D, Thrasher JF. Evaluation of strategies to communicate harmful and potentially harmful constituent (HPHC) information through cigarette package inserts: a discrete choice experiment. Tob Control 2017; 27:677-683. [PMID: 28705893 DOI: 10.1136/tobaccocontrol-2016-053579] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 04/28/2017] [Accepted: 05/24/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND The US Food and Drug Administration (FDA) has regulatory authority to use inserts to communicate with consumers about harmful and potentially harmful constituents (HPHCs) in tobacco products; however, little is known about the most effective manner for presenting HPHC information. METHODS In a discrete choice experiment, participants evaluated eight choice sets, each of which showed two cigarette packages from four different brands and tar levels (high vs low), accompanied by an insert that included between-subject manipulations (ie, listing of HPHCs vs grouping by disease outcome and numeric values ascribed to HPHCs vs no numbers) and within-subject manipulations (ie, 1 of 4 warning topics; statement linking an HPHC with disease vs statement with no HPHC link). For each choice set, participants were asked: (1) which package is more harmful and (2) which motivates them to not smoke; each with a 'no difference' option. Alternative-specific logit models regressed choice on attribute levels. RESULTS 1212 participants were recruited from an online consumer panel (725 18-29-year-old smokers and susceptible non-smokers and 487 30-64-year-old smokers). Participants were more likely to endorse high-tar products as more harmful than low-tar products, with a greater effect when numeric HPHC information was present. Compared with a simple warning statement, the statement linking HPHCs with disease encouraged quit motivation. CONCLUSIONS Numeric HPHC information on inserts appears to produce misunderstandings that some cigarettes are less harmful than others. Furthermore, brief narratives that link HPHCs to smoking-related disease may promote cessation versus communications that do not explicitly link HPHCs to disease.
Collapse
Affiliation(s)
- Ramzi G Salloum
- Department of Health Outcomes and Policy and Institute for Child Health Policy, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jordan J Louviere
- Institute for Choice and School of Marketing, University of South Australia, Adelaide, South Australia, Australia
| | - Kayla R Getz
- Department of Health Outcomes and Policy and Institute for Child Health Policy, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Farahnaz Islam
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Dien Anshari
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA.,Department of Health Education and Behavioral Sciences, Faculty of Public Health, Universitas Indonesia, Depok, Jawa Barat, Indonesia
| | - Yoojin Cho
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Richard J O'Connor
- Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - David Hammond
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - James F Thrasher
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| |
Collapse
|
34
|
Francis DB, Noar SM, Kowitt SD, Jarman KL, Goldstein AO. Believability of new diseases reported in the 2014 Surgeon General's Report on smoking: Experimental results from a national survey of US adults. Prev Med 2017; 99:94-98. [PMID: 28189803 PMCID: PMC5687516 DOI: 10.1016/j.ypmed.2017.01.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 01/03/2017] [Accepted: 01/31/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Tobacco use is the leading cause of preventable disease and death globally. The 2014 Surgeon General's Report included new diseases linked to smoking, including liver and colon cancer, diabetes and tuberculosis. As more diseases are linked to smoking, which diseases should we communicate to the public and what message source has the most impact? METHODS Data were collected through a nationally representative phone survey of US adults (N=5014), conducted from September 2014 through May 2015. We experimentally randomized participants to a 2 (new smoking disease messages - liver and colon cancers compared to diabetes and tuberculosis) by 4 (message sources - CDC, FDA, Surgeon General, and none) experiment. The outcome was message believability. RESULTS About half the sample was female (51.5%) and 17.8% were a current smoker. Overall, 56% of participants said the messages were very believable. Cancer messages (liver and colon cancer) were significantly more believable than messages about chronic disease (tuberculosis and diabetes), 61% vs. 52%. Smokers were less likely to report both sets of new disease messages as very believable compared to non-smokers. Significantly more smokers intending to quit (44.5%) found the messages to be very believable compared to smokers not intending to quit (22.6%). Believability did not differ by message source. CONCLUSION Important differences exist in believability of disease messages about new tobacco-related information. Messages emphasizing the causal link between smoking and new diseases should be considered for use in mass media campaigns.
Collapse
Affiliation(s)
- Diane B Francis
- Manship School of Mass Communication, Louisiana State University, Baton Rouge, LA 80803, USA.
| | - Seth M Noar
- School of Media and Journalism, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Sarah D Kowitt
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Kristen L Jarman
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Adam O Goldstein
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| |
Collapse
|
35
|
Baig SA, Byron MJ, Boynton MH, Brewer NT, Ribisl KM. Communicating about cigarette smoke constituents: an experimental comparison of two messaging strategies. J Behav Med 2017; 40:352-359. [PMID: 27663553 PMCID: PMC5334183 DOI: 10.1007/s10865-016-9795-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 09/09/2016] [Indexed: 10/21/2022]
Abstract
Federal law now requires FDA to disseminate information on chemicals in cigarette smoke, but it is unclear how best to do so. In a 2 × 2 between-subjects experiment, participants received a message about chemicals in cigarette smoke (e.g., "Cigarette smoke has benzene.") along with an additional randomly assigned messaging strategy: a "found-in" (e.g., "This is found in gasoline."), a health effect (e.g., "This causes heart disease."), both, or neither. Participants were U.S. probability phone samples of 5000 adults and 1123 adolescents, and an online convenience sample of 4130 adults. Adding a health effect elicited greater discouragement from wanting to smoke cigarettes (all p < .05) as did adding a found-in (all p < .05). However, including both messaging strategies added little or nothing above including just one. These findings can help the FDA and other agencies develop effective and parsimonious messages about cigarette smoke constituents.
Collapse
Affiliation(s)
- Sabeeh A Baig
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, 316 Rosenau Hall CB7440, Chapel Hill, NC, 27599-7440, USA
| | - M Justin Byron
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, 316 Rosenau Hall CB7440, Chapel Hill, NC, 27599-7440, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Marcella H Boynton
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, 316 Rosenau Hall CB7440, Chapel Hill, NC, 27599-7440, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, 316 Rosenau Hall CB7440, Chapel Hill, NC, 27599-7440, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, 316 Rosenau Hall CB7440, Chapel Hill, NC, 27599-7440, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
| |
Collapse
|
36
|
Thrasher JF, Swayampakala K, Borland R, Nagelhout G, Yong HH, Hammond D, Bansal-Travers M, Thompson M, Hardin J. Influences of Self-Efficacy, Response Efficacy, and Reactance on Responses to Cigarette Health Warnings: A Longitudinal Study of Adult Smokers in Australia and Canada. HEALTH COMMUNICATION 2016; 31:1517-26. [PMID: 27135826 PMCID: PMC4972657 DOI: 10.1080/10410236.2015.1089456] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Guided by the extended parallel process model (EPPM) and reactance theory, this study examined the relationship between efficacy beliefs, reactance, and adult smokers' responses to pictorial health warning labels (HWL) on cigarette packaging, including whether efficacy beliefs or reactance modify the relationship between HWL responses and subsequent smoking cessation behavior. Four waves of data were analyzed from prospective cohorts of smokers in Australia and Canada (n = 7,120 observations) over a period of time after implementation of more prominent, pictorial HWLs. Three types of HWL responses were studied: psychological threat responses (i.e., thinking about risks from smoking), forgoing cigarettes due to HWLs, and avoiding HWLs. The results from Generalized Estimating Equation models indicated that stronger efficacy beliefs and lower trait reactance were significantly associated with greater psychological threat responses to HWLs. Similar results were found for models predicting forgoing behavior, although response efficacy was inversely associated with it. Only response efficacy was significantly associated with avoiding HWLs, showing a positive relationship. Higher self-efficacy and stronger responses to HWLs, no matter the type, were associated with attempting to quit in the follow-up period; reactance was unassociated. No statistically significant interactions were found. These results suggest that stronger efficacy beliefs and lower trait reactance are associated with some stronger responses to fear-arousing HWL responses; however, these HWL responses appear no less likely to lead to cessation attempts among smokers with different levels of self-efficacy to quit, of response efficacy beliefs, or of trait reactance against attempts to control their behavior.
Collapse
Affiliation(s)
- James F. Thrasher
- Department of Health Promotion, Education & Behavior, University of South Carolina
- Department of Tobacco Research, National Institute of Public Health, Mexico
- CONTACT James F. Thrasher Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Discovery I Building, 534D, 915 Greene Street, Columbia, SC29208
| | - Kamala Swayampakala
- Department of Health Promotion, Education & Behavior, University of South Carolina
| | | | - Gera Nagelhout
- Health Promotion and Health Communication, Maastricht University
| | | | - David Hammond
- School of Public Health & Health Systems, University of Waterloo
| | | | - Mary Thompson
- Department of Statistics and Actuarial Sciences, University of Waterloo
| | - James Hardin
- Department of Epidemiology & Biostatistics, University of South Carolina
| |
Collapse
|
37
|
Noar SM, Francis DB, Bridges C, Sontag JM, Ribisl KM, Brewer NT. The impact of strengthening cigarette pack warnings: Systematic review of longitudinal observational studies. Soc Sci Med 2016; 164:118-129. [PMID: 27423739 PMCID: PMC5026824 DOI: 10.1016/j.socscimed.2016.06.011] [Citation(s) in RCA: 222] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Cigarette pack warnings are a tobacco control strategy used globally. To understand their impact, we systematically reviewed longitudinal observational studies examining national implementation of strengthened warnings. METHODS We used comprehensive search procedures to identify observational studies examining the impact of strengthening cigarette pack warnings. We report longitudinal changes in knowledge, beliefs, attitudes, intentions, and behavior. RESULTS We identified 32 studies conducted in 20 countries with 812,363 participants. Studies commonly examined changes from text to pictorial warnings (64%); the remainder examined strengthened text or strengthened pictorial warnings. Knowledge increased in all 12 studies that assessed it. Studies of beliefs/attitudes and intentions showed mixed results. Quitline calls increased in four of six studies, while foregoing of cigarettes did not increase. Cigarette consumption decreased in three of eight studies; quit attempts increased in four of seven studies; and short-term cessation increased in two of three studies. Smoking prevalence decreased in six of nine studies. CONCLUSIONS Strengthening warnings was associated with longitudinal increases in knowledge, quitline calls and reductions in smoking behavior. Strengthening warning policies should be a priority for tobacco control globally.
Collapse
Affiliation(s)
- Seth M Noar
- School of Media and Journalism, University of North Carolina at Chapel Hill, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, USA.
| | - Diane B Francis
- School of Media and Journalism, University of North Carolina at Chapel Hill, USA
| | - Christy Bridges
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| | - Jennah M Sontag
- School of Media and Journalism, University of North Carolina at Chapel Hill, USA
| | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, USA
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, USA
| |
Collapse
|
38
|
Brewer NT, Morgan JC, Baig SA, Mendel JR, Boynton MH, Pepper JK, Byron MJ, Noar SM, Agans RP, Ribisl KM. Public understanding of cigarette smoke constituents: three US surveys. Tob Control 2016; 26:592-599. [PMID: 27924009 PMCID: PMC5495614 DOI: 10.1136/tobaccocontrol-2015-052897] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 09/11/2016] [Accepted: 09/23/2016] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The Tobacco Control Act requires public disclosure of information about toxic constituents in cigarette smoke. To inform these efforts, we studied public understanding of cigarette smoke constituents. METHODS We conducted phone surveys with national probability samples of adolescents (n=1125) and adults (n=5014) and an internet survey with a convenience sample of adults (n=4137), all in the USA. We assessed understanding of cigarette smoke constituents in general and of 24 specific constituents. RESULTS Respondents commonly and incorrectly believed that harmful chemicals in cigarette smoke mostly originate in additives introduced by cigarette manufacturers (43-72%). Almost all participants had heard that nicotine is in cigarette smoke, and many had also heard about carbon monoxide, ammonia, arsenic and formaldehyde. Less than one-quarter had heard of most other listed constituents being in cigarette smoke. Constituents most likely to discourage respondents from wanting to smoke were ammonia, arsenic, formaldehyde, hydrogen cyanide, lead and uranium. Respondents more often reported being discouraged by constituents that they had heard are in cigarette smoke (all p<0.05). Constituents with names that started with a number or ended in 'ene' or 'ine' were less likely to discourage people from wanting to smoke (all p<0.05). DISCUSSION Many people were unaware that burning the cigarette is the primary source of toxic constituents in cigarette smoke. Constituents that may most discourage cigarette smoking have familiar names, like arsenic and formaldehyde and do not start with a number or end in ene/ine. Our findings may help campaign designers develop constituent messages that discourage smoking.
Collapse
Affiliation(s)
- Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jennifer C Morgan
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sabeeh A Baig
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jennifer R Mendel
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Marcella H Boynton
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jessica K Pepper
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- RTI International, Research Triangle Park, North Carolina, USA
| | - M Justin Byron
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Seth M Noar
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
- School of Media and Journalism, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Robert P Agans
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| |
Collapse
|
39
|
Educating smokers about the risk of blindness - insights to improve tobacco product health warning labels. Tob Induc Dis 2016; 14:30. [PMID: 27547176 PMCID: PMC4992326 DOI: 10.1186/s12971-016-0094-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/11/2016] [Indexed: 11/24/2022] Open
Abstract
Background Health warning labels (HWL) on tobacco products help educate smokers about the health effects from smoking; however, there is a need to improve HWL content including images and text to increase effectiveness. In Canada, a HWL was created that communicates smoking’s causal association with “blindness” from age-related macular degeneration (AMD). This study surveyed Canadian optometrists about their opinions regarding the image and text used in the “blindness” HWL. Methods An online survey was sent to all 4528 registered Canadian optometrists. Respondents were asked if the HWL conveyed important and believable information, and if the picture was appropriate. Optometrists were invited to make open-ended comments about the label which were analyzed using a qualitative analysis framework suitable for health policy evaluation. Frequency distributions were calculated for closed-ended questions. Results The survey was completed by 850 respondents (19 %). Most respondents (90 %) reported the message was believable/somewhat believable; while 35 % felt the picture was “too graphic”. Some respondents reported in their open-ended comments that they were concerned the HWL was internally inconsistent because it reports there is “no effective treatment in most cases” for AMD but the image depicts someone undergoing surgery. There was concern that this may discourage patients from seeking needed treatment. Conclusion The majority of Canadian optometrist respondents were in agreement that the new, “RISK OF BLINDNESS” pictorial HWL includes important, believable information. Some optometrists had concerns that the HWL included a confusing message or a message that may discourage some patients from pursuing treatment for AMD. Future development of blindness-related HWL should seek practitioner input.
Collapse
|
40
|
McQueen A, Waters EA, Kaphingst KA, Caburnay CA, Thompson VS, Boyum S, Kreuter MW. Examining Interpretations of Graphic Cigarette Warning Labels Among U.S. Youth and Adults. JOURNAL OF HEALTH COMMUNICATION 2016; 21:855-67. [PMID: 27410753 PMCID: PMC8193916 DOI: 10.1080/10810730.2016.1177142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Few studies have examined how diverse populations interpret warning labels. This study examined interpretations of 9 graphic cigarette warning labels (image plus text) proposed by the U.S. Food and Drug Administration among a convenience sample of youth (ages 13-17) and adults (18+) across the United States. Participants (N = 1,571) completed a cross-sectional survey. Participants were asked to select 1 of 3 plausible interpretations (1 preferred vs. 2 alternative) created by the research team about the particular consequence of smoking addressed in each warning label. Participants also rated each label for novelty, counterarguing, perceived effectiveness, and harm. Smokers reported their thoughts of quitting, self-efficacy, and motivation to quit. Although at least 70% of the sample chose the preferred interpretation for 7 of 9 labels, only 13% of participants chose all 9 preferred interpretations. The odds of selecting the preferred interpretation were lower among African Americans, among those with less education, and for labels perceived as being more novel. Smokers reported greater counterarguing and less perceived effectiveness and harms than nonsmokers, but results were not consistent across all labels and interpretations. The alternative interpretations of cigarette warning labels were associated with lower perceived effectiveness and lower perceived harms of smoking, both of which are important for motivating quit attempts.
Collapse
Affiliation(s)
- Amy McQueen
- Division of General Medical Sciences, Washington University, School of Medicine, St. Louis MO
- Health Communication Research Laboratory, Washington University, School of Social Work, St. Louis MO
| | - Erika A. Waters
- Division of Public Health Sciences, Washington University, School of Medicine, St. Louis MO
| | - Kimberly A. Kaphingst
- Department of Communication, University of Utah, Salt Lake City UT
- Huntsman Cancer Institute, Salt Lake City UT
| | - Charlene A. Caburnay
- Health Communication Research Laboratory, Washington University, School of Social Work, St. Louis MO
| | - Vetta S. Thompson
- Health Communication Research Laboratory, Washington University, School of Social Work, St. Louis MO
| | - Sonia Boyum
- Health Communication Research Laboratory, Washington University, School of Social Work, St. Louis MO
| | - Matthew W. Kreuter
- Health Communication Research Laboratory, Washington University, School of Social Work, St. Louis MO
| |
Collapse
|
41
|
Cho YJ, Thrasher JF, Swayampakala K, Yong HH, McKeever R, Hammond D, Anshari D, Cummings KM, Borland R. Does Reactance against Cigarette Warning Labels Matter? Warning Label Responses and Downstream Smoking Cessation amongst Adult Smokers in Australia, Canada, Mexico and the United States. PLoS One 2016; 11:e0159245. [PMID: 27411100 PMCID: PMC4943644 DOI: 10.1371/journal.pone.0159245] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 06/29/2016] [Indexed: 11/19/2022] Open
Abstract
Objective Some researchers have raised concerns that pictorial health warning labels (HWLs) on cigarette packages may lead to message rejection and reduced effectiveness of HWL messages. This study aimed to determine how state reactance (i.e., negative affect due to perceived manipulation) in response to both pictorial and text-only HWLs is associated with other types of HWL responses and with subsequent cessation attempts. Methods Survey data were collected every 4 months between September 2013 and 2014 from online panels of adult smokers in Australia, Canada, Mexico, and the US were analyzed. Participants with at least one wave of follow-up were included in the analysis (n = 4,072 smokers; 7,459 observations). Surveys assessed psychological and behavioral responses to HWLs (i.e., attention to HWLs, cognitive elaboration of risks due to HWLs, avoiding HWLs, and forgoing cigarettes because of HWLs) and cessation attempts. Participants then viewed specific HWLs from their countries and were queried about affective state reactance. Logistic and linear Generalized Estimating Equation (GEE) models regressed each of the psychological and behavioral HWL responses on reactance, while controlling for socio-demographic and smoking-related variables. Logistic GEE models also regressed having attempted to quit by the subsequent survey on reactance, each of the psychological and behavioral HWL responses (analyzed separately), adjustment variables. Data from all countries were initially pooled, with interactions between country and reactance assessed; when interactions were statistically significant, country-stratified models were estimated. Results Interactions between country and reactance were found in all models that regressed psychological and behavioral HWL responses on study variables. In the US, stronger reactance was associated with more frequent reading of HWLs and thinking about health risks. Smokers from all four countries with stronger reactance reported greater likelihood of avoiding warnings and forgoing cigarettes due to warnings, although the association appeared stronger in the US. Both stronger HWLs responses and reactance were positively associated with subsequent cessation attempts, with no significant interaction between country and reactance. Conclusions Reactance towards HWLs does not appear to interfere with quitting, which is consistent with its being an indicator of concern, not a systematic effort to avoid HWL message engagement.
Collapse
Affiliation(s)
- Yoo Jin Cho
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, United States of America
- * E-mail:
| | - James F. Thrasher
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, United States of America
- Department of Tobacco Research, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Kamala Swayampakala
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, United States of America
| | - Hua-Hie Yong
- Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Robert McKeever
- School of Journalism and Mass Communications, University of South Carolina, Columbia, South Carolina, United States of America
| | - David Hammond
- School of Public Health & Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Dien Anshari
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, United States of America
- Department of Health Education & Behavioral Sciences, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia
| | - K. Michael Cummings
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Ron Borland
- Cancer Council Victoria, Melbourne, Victoria, Australia
| |
Collapse
|
42
|
Osman A, Thrasher JF, Cayir E, Hardin JW, Perez-Hernandez R, Froeliger B. Depressive symptoms and responses to cigarette pack warning labels among Mexican smokers. Health Psychol 2016; 35:442-53. [PMID: 26867043 PMCID: PMC4833615 DOI: 10.1037/hea0000298] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We examine whether having depressive symptoms (DS) is associated with different responses to cigarette package health warning labels (HWLs) before and after the implementation of pictorial HWLs in Mexico. METHOD We analyze data from adult smokers from Wave 4 and Wave 5 (n = 1,340) of the International Tobacco Control Policy Evaluation Project in Mexico. Seven Center for Epidemiological Studies Depression Scale (CES-D) items assessed DS, with scores ≥7 indicating elevated DS. Outcomes included: attention to HWLs, cognitive responses to HWLs, tobacco constituents awareness, putting off smoking due to HWLs, avoidance of HWLs, and awareness of telephone support for cessation (i.e., quitlines). Mixed effects models were used to assess main and interactive effects of DS and time (i.e., survey wave) on each outcome. RESULTS All HWL responses increased over time, except putting off smoking. Statistically significant interactions were found between DS and time for models of tobacco constituents awareness (b = -0.36, SE = 0.15, p = .022), putting off smoking (OR = 0.41, 95% CI [0.25, 0.66]), avoidance of HWLs (OR = 1.84, 95% CI [1.03, 3.29]), and quitline awareness (OR = 0.35, 95% CI [0.21, 0.56]). Compared to smokers with low DS, smokers with elevated DS reported stronger HWL responses at baseline; however, HWL responses increased over time among smokers with low DS, whereas HWL responses showed little or no change among smokers with elevated DS. DISCUSSION Population-level increases in HWL responses after pictorial HWLs were introduced in Mexico appeared mostly limited to smokers with low DS. In general, however, smokers with elevated DS reported equivalent or stronger HWL responses than smokers with low DS.
Collapse
Affiliation(s)
- Amira Osman
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina
| | - James F Thrasher
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina
| | - Ebru Cayir
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina
| | - James W Hardin
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina
| | - Rosaura Perez-Hernandez
- National Institute of Public Health, Department of Tobacco Research, Population Health Research Center
| | - Brett Froeliger
- Department of Neuroscience, Hollings Cancer Center, Medical University of South Carolina
| |
Collapse
|
43
|
Thrasher JF, Abad-Vivero EN, Huang L, O'Connor RJ, Hammond D, Bansal-Travers M, Yong HH, Borland R, Markovsky B, Hardin J. Interpersonal communication about pictorial health warnings on cigarette packages: Policy-related influences and relationships with smoking cessation attempts. Soc Sci Med 2015; 164:141-149. [PMID: 26092600 PMCID: PMC4747859 DOI: 10.1016/j.socscimed.2015.05.042] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study evaluated the relationship between interpersonal communication about cigarette health warning labels (HWLs), psychological responses to HWLs, and smoking cessation attempts. Data were analyzed from online consumer panels of adult smokers in Australia, Canada and Mexico, during implementation of new pictorial health warning labels (HWLs) on cigarette packs. Approximately 1000 adult smokers were surveyed in each country every four months (September 2012, January 2013, May 2013, September 2013, January 2014). Only smokers followed for at least two waves were included in the analytic sample. Participants reported the frequency of talking about HWLs in the last month (in general, with family members, and with friends). For each country, poisson generalized estimating equation (GEE) models were estimated to assess the bivariate and adjusted correlates of talking about HWLs. Logistic GEE models regressed having attempted to quit by the subsequent wave on HWL talk, socio-demographics and psychological responses to HWLs. The frequency of HWL talk gradually decreased in Canada (48%–36%) after new HWLs were implemented; an increase (30%–58%) in Australia corresponded with implementation of new HWLs, after which talking stabilized; and the frequency of HWL talk in Mexico was stable over time, where new HWLs are implemented every six months. Talk about HWLs was an independent predictor of subsequent quit attempts in Canada (AOR = 1.50; 95% CI = 1.11 –2.02), Australia (AOR = 1.41; 95% CI = 1.05–1.89), and Mexico (AOR = 1.53; 95% CI = 1.11–2.10), as was cognitive responses to HWLs (Australia AOR = 1.66; 95% CI = 1.22–2.24; Canada AOR = 1.56; 95% CI = 1.15–2.11; Mexico AOR = 1.30; 95% CI = 0.91–1.85). No interaction between talk and cognitive reactions to HWLs were found. These results suggest that interpersonal communication about HWLs influences smoking cessation attempts independent of other established predictors of smoking cessation, including cessation-related HWL responses. Future research should determine ways to catalyze interpersonal communication about HWLs and thereby potentiate HWL effects.
Collapse
Affiliation(s)
- James F Thrasher
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, USA; Department of Tobacco Research, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico.
| | - Erika N Abad-Vivero
- Department of Tobacco Research, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Liling Huang
- Department of Family Medicine, University of North Carolina, Chapel Hill, NC, USA
| | | | - David Hammond
- School of Public Health & Health Systems, University of Waterloo, Canada
| | | | | | - Ron Borland
- Cancer Council Victoria, Melbourne, Australia
| | - Barry Markovsky
- Department of Sociology, University of South Carolina, Columbia, USA
| | - James Hardin
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, USA
| |
Collapse
|
44
|
Chiosi JJ, Andes L, Asma S, Palipudi K, McAfee T. Warning about the harms of tobacco use in 22 countries: findings from a cross-sectional household survey. Tob Control 2015; 25:393-401. [PMID: 25953532 DOI: 10.1136/tobaccocontrol-2014-052047] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 02/20/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Knowledge about the harms of tobacco use deters initiation and is associated with cessation. Most studies on this knowledge in the general population have been in high-income countries, but the tobacco use burden is increasing in low-income and middle-income countries. We sought to estimate levels of knowledge about tobacco-related diseases in 22 countries and determine the factors associated with differences in knowledge. METHODS We used data from the Global Adult Tobacco Survey (GATS), a nationally representative survey of persons aged ≥15 years. GATSs were conducted from 2008 to 2013 in 22 low-income and middle-income countries. Information was gathered on tobacco-related knowledge and noticing of antismoking mass media messages and health warning labels on cigarette packages. We constructed a four-point knowledge scale and performed multivariate regression analyses. RESULTS Median country values for the proportion of adults who believed smoking causes a specific illness were 95.9% for lung cancer, 82.5% for heart attack and 74.0% for stroke. Knowledge scores ranged from 2.1 to 3.8. In multivariate regressions, adults scored significantly higher on the knowledge scale if they noticed antismoking media messages (22 countries) or health warning labels (17 countries). Significantly higher knowledge scores occurred in all 9 countries with pictorial health warning labels compared with only 8 out of 13 countries with text-only warning labels. CONCLUSIONS Antismoking media messages appear effective for warning the public about the harms from tobacco use in all 22 countries, while warning labels are effective in the majority of these countries. Our findings suggest opportunities to motivate smoking cessation globally.
Collapse
Affiliation(s)
- John J Chiosi
- Global Tobacco Control Branch, Office on Smoking and Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georgia, USA Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Linda Andes
- Global Tobacco Control Branch, Office on Smoking and Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Samira Asma
- Global Tobacco Control Branch, Office on Smoking and Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Krishna Palipudi
- Global Tobacco Control Branch, Office on Smoking and Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Tim McAfee
- Global Tobacco Control Branch, Office on Smoking and Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | |
Collapse
|
45
|
Smith CN, Kraemer JD, Johnson AC, Mays D. Plain packaging of cigarettes: do we have sufficient evidence? Risk Manag Healthc Policy 2015; 8:21-30. [PMID: 25897269 PMCID: PMC4396458 DOI: 10.2147/rmhp.s63042] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Tobacco industry marketing is a primary factor influencing cigarette smoking behavior and the cigarette pack has become an important marketing vehicle for tobacco companies. Standardized "plain" cigarette packaging is advocated as a public health policy to prevent and reduce morbidity and mortality caused by smoking by reducing youth smoking initiation and promoting cessation among smokers. Plain packaging was implemented in Australia in December 2012, and several other countries are considering doing so, but each faces foreseeable legal resistance from opponents to such measures. Tobacco companies have challenged these public health policies, citing international trade agreements and intellectual property laws. Decision-making in these court cases will hinge in part on whether the evidence indicates the public health benefits of plain packaging outweigh any potential harm to tobacco manufacturers' interests. We reviewed the available evidence in support of plain packaging, finding evidence from observational, experimental, and population-based studies. Results indicate that plain packaging can reduce positive perceptions of smoking and dissuade tobacco use. Governments deciding to implement plain cigarette packaging measures can rely on this evidence to help make a strong case that plain packaging plays an important role in the context of comprehensive smoking prevention efforts.
Collapse
Affiliation(s)
- Collin N Smith
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - John D Kraemer
- Department of Health Systems Administration, School of Nursing and Health Studies, Georgetown University, Washington, DC, USA
| | - Andrea C Johnson
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Darren Mays
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| |
Collapse
|
46
|
Magnan RE, Cameron LD. Do Young Adults Perceive That Cigarette Graphic Warnings Provide New Knowledge About the Harms of Smoking? Ann Behav Med 2015; 49:594-604. [DOI: 10.1007/s12160-015-9691-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
47
|
Huang LL, Thrasher JF, Abad EN, Cummings KM, Bansal-Travers M, Brown A, Nagelhout GE. The U.S. National Tips From Former Smokers Antismoking Campaign: Promoting Awareness of Smoking-Related Risks, Cessation Resources, and Cessation Behaviors. HEALTH EDUCATION & BEHAVIOR 2015; 42:480-6. [PMID: 25588934 DOI: 10.1177/1090198114564503] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Evaluate the second flight of the U.S. Tips From Former Smokers (Tips) campaign. METHOD Data were analyzed from an online consumer panel of U.S. adult smokers before (n = 1,404) and after (n = 1,401) the 2013 Tips campaign launch. Generalized estimating equation models assessed whether the Tips advertisement recall was associated with knowledge about smoking-related risks in the Tips advertisements, awareness and use of a toll-free quitline and cessation websites, and quit attempts. RESULTS Seventy-one percent of participants at Wave 2 reported that they recalled seeing at least one Tips advertisement. Smokers who recalled seeing a Tips advertisement were more likely to (a) show increases over baseline in knowledge of health risks such as amputation: 65% versus 34%, p < .001; blindness: 27% versus 12%, p < .001; and (b) to be aware of a quitline (41% vs. 30%, p < .001) and cessation website (28% vs. 20%, p < .001). Recall of Tips advertisements was also associated with greater likelihood of reporting having visited cessation websites (odds ratio [OR] = 1.62, 95% confidence interval [CI] = 1.27-2.06), having called a quitline (OR = 2.28, 95% CI = 1.61-3.24), and having made a quit attempt (OR = 1.18, 95% CI = 1.00-1.39), although these results were only statistically significant in the unadjusted models. CONCLUSIONS The 2013 Tips campaign was successful in increasing knowledge of health risks and awareness of tobacco cessation resources.
Collapse
Affiliation(s)
| | - James F Thrasher
- University of South Carolina, Columbia, SC, USA National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | | | | | | | | | | |
Collapse
|