Graphic Warning Labels Research Articles

Delayed effects of cigarette graphic warning labels on smoking behavior.

Graphic warning labels (GWLs) are widely employed to communicate smoking-related health risks; however, their implementation in the US has been held back by concerns about their efficacy. Most GWLs elicit a high level of emotional reaction (ER). The extent to which ER contributes to GWLs efficacy in improving smoking outcomes is a subject of debate. Our recent study showed poorer efficacy of the high-ER GWLs versus the low-ER ones during a month-long naturalistic exposure. Whether GWL effects persist after discontinuing the exposure remains unclear. We conducted a secondary analysis to investigate the delayed effects of GWLs on smoking severity in adult smokers. The number of cigarettes smoked per day (CPD) was measured immediately as well as 4 weeks after the end of a month-long exposure to high-ER versus low-ER GWLs. Participants indicated their subjective feeling of being relieved from having to see the GWLs. We found a significant reduction in CPD from the immediate to the 4-week post-exposure timepoint. There was no difference in CPD reduction between the high-ER and low-ER groups.Subjective sense of relief from GWL exposure was associated with greater CPD reduction in the high-ER group, but not the low-ER group. Our study suggests lasting impact of GWLs on smoking behavior. The findings may be particularly important to high-arousal GWLs, which appear less effective in reducing smoking during active exposure. Whether GWLs that evoke higher ER are more effective remains inconclusive. We recently showed that high-ER GWLs are less effective than low-ER ones in reducing smoking during continuous exposure. Here, we found evidence of delayed GWL effects such that smoking decreased from immediately to four weeks after the end of GWL exposure. Feeling of relief from GWL exposure was associated greater smoking reduction in the high-ER group. We suggest that continuously exposing smokers to high-ER GWLs that have been well remembered may be unnecessary and counterproductive.

School-based tobacco prevention and cessation program using psycho-education and counselling: a mixed method

Introduction. In Malaysia, tobacco-related causes of death have claimed an estimated 27,400 lives annually, and that number is anticipated to climb in the coming years. Despite laws in Malaysia banning smoking in public areas, restrictions on tobacco sponsorship, promotion, and advertising in all media, as well as Graphic Warning Labels (GWLs) on cigarette packets and restricting the legal smoking age to 18 years, it is well-known that children and teenagers are involved and youth tobacco usage is rising. As there is a rise in the prevalence of tobacco use so is the call for effective school-based tobacco prevention and cessation program for children and teenagers. The study set out to understand the current level of knowledge, attitude, and behaviour of children and teenagers towards tobacco use and possible change through psycho-education and counselling towards prevention and cessation. Study participants and methods. This study adopted a pre and post Mixed Method Triangulation Design: Convergence Model. There was an independent and concurrent collection of quantitative and qualitative data from school children ages 11 to 18 years and 7 to 10 years respectively. A one-day four-module school-based prevention and cessation program was developed and carried out in five approved schools and data were collected before and after the program. The mean age for the quantitative study was 13 years, 66% were males and 34% were females. For the qualitative study, the mean age was 9 years, 54% were male and 46% were female A grand total of 131 students participated in the study. The data was analyzed using descriptive statistics, paired samples t-test thematic analysis. Results. The quantitative analysis showed a significant difference between knowledge test scores before psychoeducation intervention (M=.803; SD=.1793) and Knowledge test scores after the psycho-education intervention (M=.895; SD=.1193); [t (108) = -4.596, p = .000], attitude and behavior were insignificant Results from the thematic analysis on the qualitative results showed that the psychoeducation and counselling intervention had a significant impact only on knowledge. The children report on attitude and behaviour towards tobacco did not significantly change from before to after the program. The timing between the program and postdata may be a contributing factor but irrespective of the data collection method the outcome was similar for both children and teenagers. Practical Significance. Through psycho-education and counselling towards prevention and cessation the study set out to understand the current level of knowledge, attitude, and behaviour of children and teenagers towards tobacco use and possible change through psycho-education and counselling towards prevention and cessation. Therefore, intervention programme should include psychoeducation and counselling to improve the knowledge of students in school-based interventions.

Suicide mortality following the implementation of tobacco packaging and pricing policies in Korea: an interrupted time-series analysis

BackgroundTo prevent tobacco use in Korea, the national quitline number was added to tobacco packages in December 2012, tobacco prices were raised by 80% in January 2015, and graphic health warning labels were placed on tobacco packages in December 2016. This study evaluated the association of these tobacco packaging and pricing policies with suicide mortality in Korea.MethodsMonthly mortality from suicide was obtained from Cause-of-Death Statistics in Korea from December 2007 to December 2019. Interrupted time-series analysis was performed using segmented Poisson regression models. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated adjusted for suicide prevention strategies.ResultsSuicide mortality was 20 per 1,000,000 in December 2007 and showed a downward trend over the study period. After the implementation of tobacco packaging and pricing policies, suicide mortality immediately declined by − 0.09 percent points (95% CI = − 0.19 to 0.01; P > 0.05) for the national quitline number, − 0.22 percent points (95% CI = − 0.35 to − 0.09; P < 0.01) for tobacco prices, and − 0.30 percent points (95% CI = − 0.49 to − 0.11; P < 0.01) for graphic health warning labels. The corresponding RRs for these post-implementation changes compared with the pre-implementation level were 0.91 (95% CI = 0.83 to 1.00), 0.80 (95% CI = 0.70 to 0.91), and 0.74 (95% CI = 0.61 to 0.90), respectively. Significant associations between tobacco control policies and suicide mortality were observed even when stratified by sex and region.ConclusionsThe findings of this study provide new evidence for an association between tobacco control policies and deaths by suicide. An array of effective tobacco control policies should be considered for prevention programs targeting suicide.

Smoking cessation policy and treatments derived from the protective motivation of smokers: a study on graphic health warning labels.

Smoking is a leading public health risk. Many countries are reducing the demand for tobacco through graphic health warning labels (GHWLs). This study aims to explore smokers' perceptions of GHWLs and analyze the effect of GHWLs on their behavioral intentions to quit smoking. A theoretical model is designed by synthesizing protection motivation theory, an extension of the extended parallel process model, and the theory of planned behavior. We collected a cross-sectional sample of 547 anonymous smokers through a stratified random sampling strategy. GHWLs published in 2011 by the US Food and Drug Administration were used in the survey to assess smokers' responses to them, and then the hypotheses are validated through structural equation models. The results suggest that perceived severity, perceived vulnerability, response efficacy, and health anxiety have a significant impact on smokers' protection motivation. Furthermore, smokers' protection motivation directly impacts the behavioral intention to quit smoking and indirectly influences intention to quit through attitudes. These findings have practical implications for the implementation and improvement of GHWLs policies. Meanwhile, this study enriches the literature on public health protection measures (i.e., GHWLs) and smokers' behavioral intention to quit smoking.

Effects of cigarette package colors and warning labels on marlboro smokers’ risk beliefs, product appraisals, and smoking behavior: a randomized trial

ObjectivePlain packaging and graphic warning labels are two regulatory strategies that may impact cigarette risk beliefs and reduce consumption, but data are needed to better understand how smokers respond to such regulations.MethodsAdult, daily, Marlboro non-menthol smokers (Red [n = 141] or Gold [n = 43]) completed a mixed factorial randomized trial. Participants smoked their usual cigarettes during baseline (5-days) and were randomized to receive cigarette packs with a warning label manipulation (graphic vs. text-only). Within each warning label condition, participants completed three within-subjects pack color manipulations (red, gold, plain), each lasting 15 days. Participants were blinded to the fact that all packs contained their usual cigarettes. Mixed-effects models examined between- and within-subject differences on risk beliefs, product perceptions, and smoking behavior.ResultsWarning type and package color did not impact cigarette consumption or subjective ratings. However, use increased in all conditions (2.59–3.59 cigarettes per day) relative to baseline. While smokers largely held correct risk beliefs at baseline (Mean = 6.02, SE = 0.17, Range:0–8), the cumulative number of incorrect or uncertain cigarette risk beliefs increased from baseline in all pack color manipulations in the text (IRR range = 1.70–2.16) and graphic (IRR range = 1.31–1.70) warning conditions. Across all pack color periods, those in the graphic (vs. text) warning condition had reduced odds of reporting their study cigarettes as ‘safer’ than regular cigarettes (OR range = 0.22–0.32).ConclusionsPack color modification may increase uncertainty about several key cigarette risk beliefs, though graphic warnings may attenuate these effects. Regulatory agencies could consider supporting policy changes with information campaigns to maximize public knowledge.Trial registrationNovember 25, 2014; Registration number: NCT02301351.

HIV/AIDS in Afghanistan: A Review of Prevalence, Perspectives, and Associated Factors

AIDS, considered one of the leading causes of death worldwide, is not exempt in Afghanistan. This virus targets the human immune system, paving the way for various infections. The first AIDS case was reported in Afghanistan in 1989, and over time, due to increased migration and drug usage, the rate of HIV/AIDS prevalence increased dramatically. Although the prevalence of this disease in our country is relatively low on a global scale, Afghanistan is recognized as one of the high-risk areas for HIV/AIDS transmission.&#x0D; The virus spreads through activities such as blood transfusion and mucous membrane abrasions. The primary reason for the spread of HIV in our country is the presence of vulnerable populations (drug addicts, prisoners, sex workers, and returning migrants infected from neighboring areas). Additionally, low levels of medical knowledge, poor healthcare services, cultural pressures, and constant stigma against patients lead infected individuals to avoid healthcare facilities, thereby creating a conducive environment for the further spread of AIDS.&#x0D; To effectively combat the AIDS epidemic in Afghanistan, implementing comprehensive policies for HIV control and treating injecting drug users is essential. Stronger control and monitoring of returning migrants at the country's borderlines, the use of impactful graphic warning labels on advertisements, regular advertising campaigns through media and healthcare centers, and establishing well-equipped centers for patient treatment are crucial and supportive measures.

Examining the Effectiveness of the 2012 Canadian Graphic Warning Label Policy Change by Sex, Income, and Education.

We examined the differential impact of the 2012 Canadian GWL policy changes on key indicators of warning label impact and quit intentions using national cohorts of Canadian and U.S. adults who smoke. We used data from all waves of the International Tobacco Control surveys (2002-2020) in Canada and the United States. Our key measures were quit intentions and an index of warning label effectiveness (salience, cognitive and behavioral reactions). We estimated overall policy impact by comparing Canada (treatment group) with the United States (control group) using controlled interrupted time series (CITS) regression models, with interactions to examine whether policy impact varied by sex, education, and income. The CITS model showed a statistically significant increase in the warning label effectiveness in Canada post-policy, compared to the United States (β = 0.84, 95% CI 0.35,1.33). Similarly, the odds of quit intentions were relatively higher among adults who smoked in Canada compared to the United States (OR = 1.89, 95% CI 1.51,2.36) post-policy. The three-way interaction model showed that these associations were greater among adults from low socioeconomic status (SES) groups than in high SES groups. The 2012 change in the Canadian GWL policy was associated with stronger cognitive and behavioral responses to GWLs and higher odds of quit intentions among adults who smoked in Canada when compared to the United States, specifically among individuals from low SES groups, suggesting a positive equity impact. Our findings affirm the need for countries to implement or enhance GWLs, in line with the WHO Framework Convention on Tobacco Control (FCTC). The evidence on the potential health equity benefit of GWL policies is mixed. To further understand the influence of GWL policies on tobacco use disparities, more systematic research using pre/post-policy designs with control groups is needed. Using a CITS model, we aimed to strengthen the available evidence on the causal influence of this tobacco control approach. Our findings show that the 2012 GWL policy change had a greater impact on adults who smoked from low SES groups than it did on adults who smoked from high SES groups, indicating a potentially positive equity impact and confirming the need for countries to implement or maximize the size of GWLs, as recommended by the WHO FCTC.

Reactions to Pictorial and Text Cigarette Pack Warning Labels among Chinese Smokers.

Objectives. This study aims at examining the impact of graphic pictorial warning labels on inten-tion to quit smoking and perceived harms among Chinese working-age adults (n = 661). Methods. A randomized controlled trial is utilized as the research design by comparing three scenarios: Group 1 as baseline (n = 193) and presented with real market tobacco products with text-only la-bels, Group 2 as price group and with hypothetical scenarios of manipulated prices, and Group 3 as the imaging group and with hypothetical scenarios of graphic pictorial cigarette warning la-bels. Both bivariate and multivariate analyses are utilized to determine the effectiveness of warn-ing labels. Results. Graphic pictorial cigarette warning labels are associated with stronger inten-tion to quit smoking and greater perceived harms. Smokers have a greater number of attempts if they are less nicotine dependent and express greater smoking risk perceptions. Conclusions. This study adds to the evidence that graphic pictorial warning labels are more effective than text-only labels in increasing intention to quit smoking. As China strives to achieve a reduction in smoking to meet the goal of the Healthy China 2030 initiative, this work strengthens the evidence base for policy makers, practitioners, and researchers to design low-cost warning labels on cigarette packs to promote tobacco control.

Predicting cigarette use initiation and dependence in adolescence using an affect-driven exploration model.

Adolescent decisions, especially in novel contexts, are often guided by affective evaluations (i.e., feelings associated with a stimulus) rather than knowledge of the risks and probabilities of different outcomes. In this study, we used the affect-driven exploration (ADE) model to illustrate how affective evaluations can play a critical role in driving early use of cigarettes, as well as the adaptive function of the resulting experiential learning in informing future affect and cigarette use. We analyzed five waves of data collected from a large, diverse community sample of adolescents who were followed from early to late adolescence (N = 386; 50.9% female; Baseline age = 11.41 ± 0.88 years) during years 2004–2010 to model trajectories of positive affect and risk perceptions (associated with cigarette use) and examined the associations of these trajectories with their self-reported cigarette use and dependence symptoms. Consistent with the ADE model, early initiators reported higher levels of positive affect at baseline, which we argue may have led them to try cigarettes. Notably, most early initiators reported a decline in positive affect over time, suggesting an experience-based shift in affective evaluations associated with cigarette use. Risk perceptions associated with cigarette use did not emerge as a significant predictor of cigarette use or subsequent dependence. Therefore, for deterring adolescent cigarette use, efforts to influence affect (through graphic warning labels and other media) may be more effective than directly influencing risk perceptions. Despite the affective basis for initiating cigarette use, few adolescents engaged in early use (N = 20) or developed symptoms of dependence (N = 25). Majority of those who engaged in early cigarette use showed a decline in positive affect, with corresponding increase in risk perceptions over time. Some early users may indeed continue to engage in cigarette use, but this is likely driven by the addictive properties of the drug. Overall these findings challenge the popular stereotype of impulsive and emotionally reactive behaviors during adolescence, and suggest a more nuanced interpretation of adolescent risk behavior.

“Sugary drinks” and graphic warning labels: Critique of a recent U.S. study of parents' beverage choices for their children

AbstractA laboratory experiment by U.S. public health researchers Hall et al. claimed to demonstrate that a graphic picture‐and‐text warning label placed on so‐called sugary drinks would substantially reduce parents' purchase of them for their children. Hall et al., however, misclassified the alleged “sugary drinks,” omitting those containing natural but equally harmful sugars such as fructose in fruit juice and lactose in milk. They also implied that artificially sweetened “non‐sugary” drinks are harmless when available research indicates otherwise. The experiment was further invalidated by the fact that warning labels are illegal in the U.S., and those that Hall et al. used would not be permitted in any case because they partially obscured the manufacturer's brand label. There were many other methodological problems with Hall et al.'s experiment, among them the failure to do what any competent consumer researcher would do—namely ask the parents afterwards why they made the choices that they did.

Effect of Graphic Warning Labels on Cigarette Pack–Hiding Behavior Among Smokers

The inclusion of graphic warning labels (GWLs) on cigarette packs is recommended for tobacco control but has not yet been implemented in the US. It is unknown whether and to what extent the inclusion of GWLs on cigarette packs affects smokers' willingness to display the packs in public. To determine whether the inclusion of GWLs on cigarette packs affects pack-hiding behavior among smokers in social settings. This community-based randomized clinical trial assessed smokers' real-world experience of using cigarettes repackaged to include GWLs (GWL packs) compared with standard US packs and blank packs over a 3-month intervention period with 12 months of follow-up between September 6, 2016, and December 3, 2019. The study included 357 participants aged 21 to 65 years from San Diego County, California, who smoked 5 or more cigarettes per day, were not actively planning to quit smoking, were not pregnant, and had no unstable medical conditions. Participants purchased and received cigarette packs through the study website. During the 1-month run-in period, participants received their usual US cigarette packs. During the 3-month intervention period, participants were randomized to receive GWL packs (study-manufactured packs with 3 rotating images under license from the Commonwealth of Australia; GWL pack group), blank packs (study-manufactured packs devoid of industry marketing imagery; blank pack group), or standard US packs (US pack group). Pack hiding was queried daily (with participants reporting behavior within the last 4 hours) and weekly via interactive text messages during the 1-month run-in and intervention periods. Self-reported smoking behavior was biochemically validated. Among 357 enrolled participants, the mean (SD) age was 39.3 (11.8) years; 195 participants (54.6%) were female, 40 (11.2%) were Hispanic, 243 (68.1%) were non-Hispanic White, and 74 (20.7%) were of other non-Hispanic races (including American Indian or Alaska Native, Asian or Pacific Islander, Black or African American, or multiracial). A total of 18 987 cigarette packs were purchased and delivered during the run-in and intervention periods. Daily querying showed that the inclusion of GWLs on cigarette packs increased the percentage of smokers who hid their packs at least some of the time from 41.3% (95% CI, 39.6%-43.0%) during the run-in period to 57.1% (95% CI, 55.9%-58.1%) by the end of the intervention period. In the postintervention period, returning to standard US packs reduced pack-hiding behavior to the levels observed during the run-in period. Pack hiding remained at run-in levels for both the blank pack group (35.2%; 95% CI, 33.6%-36.8%) and the US pack group (41.4%; 95% CI, 39.7%-43.1%]) throughout the study. Although even participants in the GWL group with the lowest prestudy tendency to conceal score (ie, 1) had a mean (SE) probability of pack hiding during the intervention of 0.84 (0.02), this group's probability of pack hiding decreased to a mean (SE) of 0.43 (0.03) after intervention. When social reactions to packs were queried at the end of the study, the modal response from participants in the GWL pack group was observers' aversive reactions to the packs, whereas the modal response from participants in the blank pack group was observers' positive interest in the study. Neither smoking prevalence nor consumption differed by group at any point in the study. In this randomized clinical trial, receiving cigarettes in GWL packs vs blank packs increased pack-hiding behavior in social settings, which may be associated with aversive reactions from observers. However, 12-month smoking behavior did not change. ClinicalTrials.gov Identifier: NCT02676193.

Risk perception of smokers on graphic warning labels: a qualitative study in East Nusa Tenggara, Indonesia

The Indonesian government has mandated Graphic warning labels (GWLs) on cigarette packages to achieve more comprehensive tobacco control interventions. However, smoking prevalence remains a public health issue in Indonesia. This current qualitative research aimed to explore the effect of cigarette GWLs on smokers’ perceptions about smoking and cigarette packaging in East Nusa Tenggara (NTT) and its influence on smoking behavior. The study participants consisted of 15 current smokers who were individually interviewed by using a semi-structured interview guide. Data were analyzed using a thematic analysis technique. Most participants perceived smoking as health-risk behavior yet lowered their risk perceptions of smoking-related diseases due to positive feelings of perceived current benefits of smoking and personal justification for smoking. None expressed any intention to quit or showed smoking behavior changes due to GWLs exposure on cigarette packages. Participants also implicitly expressed themselves as victims willing to quit but unable and unconfident to act due to smoking addiction and other stressors. In contrast, others perceived themselves as risk-taker who enjoyed smoking. Further research is still needed to provide robust evidence on GWLs effectiveness on smoking perception and smokers’ cognitive and behavioral responses. Behavior change interventions should address positive feelings experienced and rationalization made by smokers to provide effective risk communication.

The Differential Impact of the 2000 Canadian Graphic Warning Label Policy on Smoking Prevalence by Sex and Education: A Difference-in-Difference-in-Difference Model.

Using a quasiexperimental design, we compared the impact of the 2000 Canadian introduction of graphic warning labels (GWLs) on differences in smoking prevalence by sex and education, to the United States, where no GWLs were introduced. We pooled 1999-2004 data from the Canadian Tobacco Use Monitoring Survey and the U.S. Behavioral Risk Factor Surveillance System. We used a difference-in-difference (DD) model to assess the impact of Canadian policy introduction on smoking prevalence, and a difference-in-difference-in-difference (DDD) model to examine differences in the policy impact by sex and education, comparing Canada (the treatment group) with the United States (the control group). From 1999 to 2004, smoking prevalence decreased from 23.7% to 18.6% in Canada, and from 21.7% to 20.0% in the United States. Results from the DD regression models showed that Canadian respondents reported lower odds of being a current smoker compared to the U.S. respondents following the 2000 introduction of GWLs (OR = 0.84, 95% CI = 0.74-0.94). The DDD model showed that the impact of the Canadian GWLs versus the United States did not differ by sex or education. The 2000 Canadian GWL policy reduced smoking prevalence overall, with similar reductions for males and females and across education levels. The impact of the Canadian GWLs in reducing smoking prevalence did not reduce differences by sex or education. Although beneficial for all smokers, GWLs may not serve to decrease existing disparities, especially those by socioeconomic status. Existing evidence shows that GWL implementation is associated with reductions in smoking prevalence. But there is limited evidence from past evaluation studies on whether the impact of GWLs on smoking prevalence differs by sociodemographic subgroup. Our findings confirm existing studies that the 2000 implementation of GWLs in Canada was significantly associated with an overall reduction in smoking prevalence in Canada compared to the United States. However, our study improves existing evidence by showing that the impact of the Canadian GWLs on smoking prevalence did not differ by sex or education, and thus did not reduce existing smoking disparities by educational levels.

Exploring context specific anti-smoking warning labels on cigarette packs: A quasi-experiment.

To evaluate the impact of introducing newly-designed warning labels in relation to the available conventional cigarette packs. The quasi-experimental study was conducted at four co-educational academic institutions selected using cluster random sampling technique in Gulshan-e-Iqbal town of Karachi from September 2016 to October 2017. The respondents, aged 16-24 years, were exposed with an experimental condition using five graphic cards; each comprising of two separate labels; label 1 being a cigarette pack currently rotated, and label 2 being the newly designed graphic and text warning label. Each participant responded over efficacy measures for each label separately. The difference in the efficacy scores between the two labels was assessed using repeated measure ANOVA with Bonferroni correction in analysis. Of the 388 students, 256(66%) were males and 132(34%) were females. The overall mean age was 18±2.76 years. Also, 188(48.5%) subjects were studying in higher secondary, 179(46.1%) undergraduate and 21(5.4%) postgraduate level. Of them, 104(26.8%) were ever-smokers and 284(73.2%) reported to be never-smokers. A difference was observed in the efficacy of the newly designed label "poverty" compared with current cigarette pack on the measure of not to start smoking(p=0.006). Never-smoking males perceived newly-designed label element 'dead person' as fear-arousing (p=0.045), while never-smoking females considered 'look after family' as efficacious (p=0.024). There was some evidence of variation in efficacy scores after stratifying on gender and smoking status. A more holistic approach is needed in this regard.

Evaluating US smokers’ willingness to pay for different cigarette packaging designs before and after real-world exposure in a randomised trial

IntroductionRemoval of tobacco industry branding from cigarette packs may reduce their appeal. Adding graphic warning labels (GWLs) should enhance this effect. We investigate whether willingness to pay for various packaging...

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

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

Association Between Graphic Health Warning Labels on Cigarette Packs and Smoking Cessation Attempts in Korean Adolescent Smokers: A Cross-Sectional Study.

Graphic health warning labels on cigarette packs inform smokers about the health risks associated with tobacco smoking. Adolescents are generally the main targets to influence by graphic health warning labels. This study investigated the association between graphic health warning labels on cigarette packs and attempts to quit smoking in South Korean adolescents. This cross-sectional study used data from the 2017 to 2019 Korea Youth Risk Behavior Web-based Survey, using multiple logistic regression for the analysis. The study population comprised 11,142 adolescents aged 12–18 years. The outcome variable was attempts to quit smoking among adolescent smokers who had seen graphic health warning labels. Attempts to quit smoking were higher among adolescent smokers who had seen graphic health warning labels compared to those who had not {boys, odds ratio (OR) = 1.72 [95% confidence interval (CI), 1.48–2.00]; girls, OR = 1.74 (95% CI, 1.33–2.28)}. The correlation was greater for adolescents who thought about the harm of smoking [boys, OR = 1.86 (95% CI, 1.60–2.16); girls, OR = 1.85 (95% CI, 1.41–2.43)] and the willingness to quit [boys, OR = 2.03 (95% CI, 1.74–2.36); girls, OR = 2.04 (95% CI, 1.55–2.68)] after seeing graphic health warning labels. Our findings indicate that graphic health warning labels on cigarette packs have the potential to lower smoking intentions of adolescents. We suggest that the use of graphic health warning labels is an effective policy-related intervention to reduce smoking in South Korean adolescents.

The Influence of Episodic Future Thinking and Graphic Warning Labels on Delay Discounting and Cigarette Demand.

Delay discounting and operant demand are two behavioral economic constructs that tend to covary, by degree, with cigarette smoking status. Given historically robust associations between adverse health outcomes of smoking, a strong preference for immediate reinforcement (measured with delay discounting), and excessive motivation to smoke cigarettes (measured with operant demand), researchers have made numerous attempts to attenuate the extent to which behaviors corresponding to these constructs acutely appear in smokers. One approach is episodic future thinking, which can reportedly increase the impact of future events on present decision making as well as reduce the reinforcing value of cigarettes. Graphic cigarette pack warning labels may also reduce smoking by increased future orientation. Experiment 1 evaluated the combined effects of episodic future thinking and graphic warning labels on delay discounting; Experiment 2 evaluated solely the effects of episodic future thinking on delay discounting and operant demand. We observed no statistically significant effects of episodic future thinking when combined with graphic warning labels or when assessed on its own. These results serve as a call for further research on the boundary conditions of experimental techniques reported to alter behaviors associated with cigarette smoking.

The estimated effect of graphic warning labels on smoker\u2019s intention to quit in Shanghai, China: a cross-sectional study

BackgroundTobacco consumption is the leading cause of death worldwide. Overwhelming studies demonstrate graphic warning labels (GWLs) on cigarette packs are effective in eliciting negative response to tobacco smoking, modifying beliefs about tobacco dangers, and increasing reported intention to quit, but the estimated effect of GWLs on smoking cessation intention among smokers is still limited in China. In this study, we aim to understand the smoking intensity, smoking duration and smoking cessation intention among current smokers, and to explore how their smoking cessation intention would be influenced by the GWLs in Shanghai.MethodsFrom January to June 2021, we totally recruited 1104 current smokers in Songjiang district and Fengxian district of Shanghai by multistage sampling design. We used Android pad assisted electronic questionnaire for data collection, and then implemented logistic regression for odds ratio (OR) and 95% confidence interval (CI) calculation to explore how smoking cessation intention would be influenced by the GWLs among current smokers.ResultsOne thousand one hundred four current smokers included 914 males (82.79%), with an average age of 43.61 years. 58.06% of current smokers reported smoking cessation intention due to GWLs. Logistic regression indicated a higher percentage of smoking cessation intention due to GWLs was among female smokers [OR = 2.41, 95% CI (1.61–3.59)], smokers with smoking intensity < 20 cigarette/day [OR = 1.92, 95% CI (1.44–2.55)], smokers with tobacco burden < 20% [OR = 1.94, 95% CI (1.35–2.79)], and among smokers had plan to quit in a year [OR = 6.58, 95% CI (4.71–9.18). Smokers with higher individual monthly income had lower percentage of smoking cessation intention (OR were 0.35, 0.46 and 0.41). Meanwhile, among 642 current smokers without plan to quit in a year, approximately 40% of them reported smoking cessation intention due to GWLs.ConclusionsSmoking cessation intention due to the assumed GWLs on cigarette packs is high among current smokers in Shanghai, especially in female smokers, smokers with light tobacco burden and mild nicotine dependence. Incorporating smoking intensity as well as smoking burden into the implementation of GWLs as tobacco control measures would discourage smoking in China.

Factors Related to Adolescent Smoking: A Nationally Representative Cross-Sectional Study in Thailand

Objective: This study aimed to explore the individual, familial, and social factors associated with different smoking status in Thai adolescents from the 2017 Cigarette Smoking and Alcohol Drinking Behavior Survey (CSAD)&#x0D; Methods: The nationally representative sample of 6046 adolescents aged 15-19 years who took part in the 2017 CSAD in Thailand. Multinomial logistic regression analysis was conducted to explore the associations between the individual, familial, and social factors and different smoking status. &#x0D; Results: The daily smoking and occasional smoking was 6.4% and 3.3%, respectively. Gender, alcohol use, substance use, attitudes toward smoking, exposure to secondhand smoke at home, anti-smoking social media campaign, and graphic warning labels were related to both daily and occasional smoking. Daily smoking was associated with exposure to secondhand smoke at school, restaurant, and public transport, and exposure to tobacco advertising.&#x0D; Conclusion: These findings suggest that smoking prevention intervention should particularly focus on these factors and also need to develop the anti-smoking policies for smoking prevention among adolescents.