Identifying Persuasive Visual Features within Tobacco Pictorial Warnings: Effects on Anticipated Loss of Face, Gifting, and Refrain Intentions Among Chinese Men Who Smoke

The effect of pictorial warnings on cigarette packages on attentional bias of smokers

Social interactions are a key mechanism through which health communication efforts, including pictorial cigarette pack warnings, may exert their effects. We sought to better understand social interactions elicited by pictorial cigarette pack warnings. A controlled trial randomly assigned US adult smokers (n = 2149) to have their cigarette packs labeled with pictorial or text-only warnings for 4 weeks. Smokers completed surveys during the baseline visit and each of the subsequent 4 weekly visits. Smokers with pictorial warnings on their packs had more conversations throughout the trial compared to those with text-only warnings (8.2 conversations vs 5.0, p<.01). The highest number of conversations occurred during the first week. Smokers with pictorial warnings were more likely than those with text-only warnings to discuss the health effects of smoking, whether the warnings would make them want to quit and whether the warnings would make others want to quit (all p < .05). Smokers were more likely to describe pictorial warnings as scary, gross, or depressing and gloomy during conversations than text-only warnings (all p < .05). Pictorial warnings sparked more conversations about the warnings, the health effects of smoking, and quitting smoking than text-only warnings. These social interactions may extend the reach of pictorial warnings beyond the targeted smoker and may be one of the processes by which pictorial warnings have impact. Health communication can influence behavior by changing social interactions. Our trial characterized social interactions about pictorial cigarette pack warnings with a large longitudinal sample in a real-world setting. Understanding these conversations can inform the United States and other countries as they improve existing warnings and help tobacco control policy makers and health communication theorists understand how social interactions triggered by warnings affect smoking.

Worldwide, around 8 million people die yearly due to tobacco usage. Cigarette smoking is the most popular form of tobacco usage. Smoking has linked to many detrimental health effects among adults and adolescents. Recognising the burden of smoking, World Health Organization have implemented various tobacco control strategies under the Framework Convention of Tobacco Control and mPOWER. This includes implementation of plain packaging and pictorial warning. In Asia, only Thailand, Singapore, Turkey, Saudi Arabia, and Israel have implemented plain cigarette pack. However, some countries have made progress to implement plain cigarette pack. Although some countries have not implemented plain pack, implementation of larger pictorial warning serve as a pathway for implementation of plain packaging. Countries with pictorial warning on cigarette pack should ensure it covers at least 50% of pack. Timor Leste has the largest pictorial warning on cigarette pack in the world. In conclusion, only 5 countries in Asia have implemented plain pack and some countries in this region are yet to implement size of pictorial warning according to requirement of World Health Organization. All countries should target to implement standardized pack to denormalise tobacco usage.

The Message Impact Framework suggests that social interactions may offer smokers the opportunity to process pictorial warnings on cigarette packs more deeply. We aimed to describe adult smokers’ social interactions about pictorial cigarette pack warnings in two longitudinal pilot studies. In Pilot Study 1, 30 smokers used cigarette packs with one of nine pictorial warnings for two weeks. In Pilot Study 2, 46 smokers used cigarette packs with one of five pictorial warnings for four weeks. Nearly all smokers (97%/96% in Pilot Study 1/2) talked about the warnings with other people, with the most common people being friends (67%/87%) and spouses/significant others (34%/42%). Pilot Study 2 found that 26% of smokers talked about the warnings with strangers. Discussions about the health effects of smoking and quitting smoking were more frequent during the first week of exposure to pictorial warnings than in the week prior to beginning the study (both p < 0.05). Pictorial warnings sparked social interactions about the warnings, the health effects of smoking, and quitting smoking, indicating that pictorial warnings may act as a social intervention reaching beyond the individual. Future research should examine social interactions as a potential mediator of the impact of pictorial warnings on smoking behavior.

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

Understanding factors that influence public support for "nudging" policies, like pictorial cigarette pack warnings, may offer insight about how to increase such support. We sought to examine factors that influence smokers' support for requiring pictorial warnings on cigarette packs. In 2014 and 2015, we randomly assigned 2149 adult US smokers to receive either pictorial warnings or text-only warnings on their cigarette packs for 4weeks. The outcome examined in the current study was support for a policy requiring pictorial warnings on cigarette packs in the US. Support for pictorial warnings was high at baseline (mean: 3.2 out of 4). Exposure to pictorial warnings increased policy support at week 4 (β=.05, p=.03). This effect was explained by increases in perceived message effectiveness (p<.001) and reported conversations about policy support (p<.001). Message reactance (i.e., an oppositional reaction to the warning) partially diminished the impact of pictorial warnings on policy support (p<.001). Exposing people to a new policy through implementation could increase public support for that policy by increasing perceived effectiveness and by prompting conversations about the policy. Reactance may partially weaken the effect of policy exposure on public support.

BACKGROUND AND AIM: In this study, we aimed to investigate the effectiveness of pictorial health warnings on cigarette packages on the application of the smoking cessation clinic. METHODS: 356 patients were conducted from Malatya.Fagerstrom test for nicotin dependence was used. The best known pictorial warnings were evaluated by showing 14 pictorial health warnings on cigarette packages RESULTS: The two well known pictorial warning were the same in men and women. The third best known pictorial warning for women was picture included 9Smokers die younger 9and the warning for men was picture included 9Smoking may reduce blood flow and causes impotence9. Men were effected mostly from picture showed in accordingly to women and women were affected from the picture showed in mostly accoding to men (p CONCLUSIONS: Pictorial health warnings are most important in informing, training and telling the risks of smoking to the smokers.

Objectives This study aimed to evaluate Japanese smokers' perceptions of health warnings on tobacco packaging by comparing text-only and pictorial warnings.Methods Data were sourced from the Japan Society and New Tobacco Internet Survey (JASTIS), an online, self-reported study conducted in February and March 2020. Participants included current smokers aged 15-74 years in Japan (n＝2,372). Perceptions regarding five packaging samples were assessed: the old package (text-only warning covering 30% of the pack's front and back before April 2020), the current package (text-only warning covering 50% of the pack's front and back), and three packages with pictorial warnings covering 50% of the front and back. Respondents were asked four questions on a 5-point Likert scale regarding the effectiveness of these warnings in terms of discouraging young people from starting to smoke, encouraging them to quit, communicating the dangers of smoking, and comfort level with the warnings. A t-test was conducted to compare each pair of packages.Results There were no significant differences observed between the "text only 30%" and "text only 50%" packages in terms of preventing young individuals from starting to smoke, encouraging quitting, or communicating the dangers of smoking (P＝0.740-0.987). Conversely, packages with pictorial warnings were perceived as more effective than text-only packages (P＜0.01) in all aspects. A significant difference was observed in the respondents' perceptions of comfort levels with the packages, with the pictorial ones deemed more uncomfortable (P＜0.01).Conclusion The findings indicated that pictorial health warnings are significantly associated with increased awareness of smoking risks, motivation to quit smoking, and prevention of smoking initiation among young people. Accordingly, Japan should consider adopting pictorial health warnings in accordance with the Framework Convention on Tobacco Control.

Introduction Although tobacco is the leading preventable cause of the death among adults in India, the general public including tobacco users has little awareness about possible consequences of tobacco use. One way of bringing more awareness is to place more information on tobacco products in the form of pictorial warnings. Strong pictorial warnings were mandated by the Indian government but were diluted later on. The question that needs to be investigated whether general public in India needs pictorial warnings on tobacco products and how the warnings would look like? Material and Method A survey of 712 individuals was conducted in Mumbai and Thane. A structured questionnaire was designed and data were collected by trained field investigators. The questionnaire contains several questions on awareness of health warnings on tobacco products, opinion on strength of the warnings and on delays in implementing warnings. Results Among 712 respondents, 89.9% were aware about health warning messages on cigarettes pack. 88.5% of people were strongly agreed for strengthening the pictorial health warnings. Strong pictorial health warnings would make 23.2% male tobacco users thinking to quit smoking and 33.1% never tobacco users will think twice before starting smoking. Conclusion Positive response was shown by general population for implementation of pictorial warnings on tobacco products. Majority of the people were strongly agreed for strong pictorial warnings which were diluted by government notifications in year 2008.

BackgroundPictorial health warnings are more effective than text warnings in enhancing motivation to quit and not to start smoking among youth. In Lebanon, packs still have only a very small...

BackgroundScience to determine the impact of pictorial cigarette warning labels can inform decisions about warning label implementation and adjustments to their contents to maximize impact. This pilot study builds from earlier research on plain cigarette packaging to examine the feasibility of a method for determining the impact of pictorial warnings among smokers.FindingsThe study was a prospective, within-subjects pilot trial where smokers ages 18–30 (n = 10) were exposed to pictorial warnings on their cigarette packs. On day one, participants completed a baseline interview with an expired carbon monoxide reading and affixed pictorial warning labels to their cigarette pack(s) they would use the next day. On day two, participants completed mobile phone text message assessments of smoking behaviors and protocol adherence. On day three, participants completed a follow-up interview similar to baseline. We achieved 100% sample retention and adherence with procedures. Compared with baseline assessments of perceptions and behaviors related to existing text-only warnings, at follow-up participants were more likely to report that pictorial warnings used during the study were noticeable (M 4.1, SD 1.3 vs. M 2.7, SD 1.2, p = .013), stopped them from smoking (M 1.6, SD 0.8 vs. M 1.1, SD 0.3, p = .052), and conveyed health risks of smoking (M 3.5 SD 1.3 vs. M 2.2, SD 1.1, p = .006). At follow-up, participants also reported the protocol was acceptable.ConclusionsThese findings suggest this is a feasible method that with further validation could provide evidence that can inform decisions regarding implementation of pictorial cigarette warnings.

Pictorial warnings on cigarette packs are a cost-effective policy-level intervention for smoking cessation; however, little research has examined changes in the impact of warnings over time, especially shortly following the first exposure to pictorial warnings. We sought to characterize the trajectories of responses to pictorial cigarette pack warnings soon after first exposure. Participants were 2149 adult smokers in North Carolina and California, United States. In 2014-2015, we randomized smokers to have pictorial (intervention) or text-only (control) warnings on their cigarette packs for 4 weeks. Weekly surveys assessed psychosocial and behavioral outcomes. After 1 week, smokers in the intervention arm reported higher levels of most outcomes, compared with the control arm. Over subsequent weeks, smokers in both trial arms had decreases in thinking about the harms of smoking (β = -0.046), positive (β = -0.036), and negative (β = -0.042) smoking reinforcement attitudes, and increases in quit intentions (β = 0.070) and cigarette forgoing (β = 0.137) (all p < .05). Only negative affective reactions decreased more in the intervention versus control condition (pinteraction < .01). The impact of pictorial cigarette pack warnings on emotions and cognitions may wane over time. In contrast, quit intentions and cigarette forgoing may continue to increase, at least during the initial period after introduction. Rotation of pictorial warnings may help prevent warning wear-out. Cigarette smoking is the leading cause of preventable morbidity and mortality and warnings on cigarette packs are a cost-effective policy-level intervention. Prior studies reporting on cigarette pack warning "wear out" have been limited by being short-term single-session experimental studies. Ours are the first study to experimentally examine the trajectories of several outcomes after first exposure and report that the impact of pictorial cigarette pack warnings on emotions and cognitions may wane over time while quit intentions and cigarette forgoing may continue to increase. ClinicalTrials.gov identifier: NCT02247908; https://clinicaltrials.gov/ct2/show/NCT02247908.

“Villagers are not afraid to die”: a qualitative study of community cohesion on pictorial warning on cigarette packaging with grounded theory approach in YogyakartaPurposeThe purpose of this study was to explore community's coping with a pictorial health warning on cigarette packaging. MethodsA qualitative study was conducted using grounded theory design. The study was conducted in the rural area of Sambirejo, Prambanan sub-district, Sleman, Yogyakarta. Data were collected by in-depth interviews and focus group discussions (FGD). Subjects were selected purposively with a maximum variation technique. ResultsThe perceptions, beliefs, coping, adaptation period, and smoking behavior remained mostly unchanged after seeing pictorial warnings on cigarette packaging. ConclusionsCoping was influenced by perceptions, beliefs, and the period of adaptation to pictorial health warnings. The period of adaptation changed some feelings and coping prior to the pictorial health warning, while pictorial health warning on cigarette packs appeared to make non-smokers increasingly want to smoke.

Background: Pictorial warnings are effective in promoting smoking cessation as shown by researches in the developed countries. The Government of India has also introduced pictorial warnings as one of the strategies among different tobacco control strategies. Objective: The objective of this study was to find the awareness of pictorial warnings present on cigarette packets and its impact on smoking cessation among cigarette smokers in Shimla, Himachal Pradesh. Materials and Methods: The study was conducted among 200 patients attending the outpatient department in the Department of Oral Medicine and Diagnosis from May 1, 2010 to August 31, 2010. Structured questionnaire consisted of demographic details, health-related issues of smoking, awareness about pictorial warning, and impact to quit smoking. Results: Among the study patients, maximum number of patients who were using any form of tobacco products were 35-44-year-old, and higher consumption was seen among the people from lower socioeconomic status. Younger age group, i.e., ≤25 years, those with higher socioeconomic status, urban residence, and literate were more aware about pictorial warning on cigarette packs and majority of them were about to quit smoking. Conclusion: Pictorial warning is an effective method to improve the awareness among smokers on the deleterious effects of smoking. The present study has shown significant results as the youngsters are less involved in the habit of smoking, aware about pictorial warning on the cigarette pack depicts, and motivated to quit smoking after knowing the harmful effects which the warning on packs reveals.

To evaluate the knowledge, attitude and practice of medical students towards pictorial warnings on cigarette packets. The cross-sectional study was conducted from October 2017 to December 2018 at King Saud bin Abdulaziz University for Health Sciences Riyadh, Saudi Arabia, Riyadh, Saudi Arabia, and comprised medical students from third to sixth year. Data was collected using a self-administered structured questionnaire which was validated through pilot-testing. A five-point Likert scale was used to access each item, with 1 as strongly disagree and 5 as strongly agree. Data was analysed using SPSS 22. Of the 335 subjects, 181(54%) were males. The overall mean age was 23±2.2 years and 307(92%) were non-smokers. The overall knowledge, attitude and practice was low with a total median score of 3.3 (interquartile range: 3.1-3.6). However, knowledge was better 4 (interquartile range: 3.7-4.7). Males had significantly more knowledge about the pictorial health warnings compared to females (p<0.001). Having a smoker friend had significantly better effect on the overall knowledge and attitude with (p<0.05). The study concludes that pictorial warnings are not helpful in persuading the current smokers to give up smoking. The knowledge about who take the decision of printing these warnings is not known to majority of the participants. Those who had a friend smoker had considerably better knowledge about pictorial warnings. Display of pictorial warnings might not be enough to serve the purpose of discouraging future smokers. Innovative strategies involving the non-smokers (peers and friends) should also be considered in the new era for cessation of smoking.