Pictorial Cigarette Pack Warnings Research Articles

The Awareness, Perceptions and Attitudes towards health warnings on cigarette packages in Northern Cyprus: a community-based descriptive study

Background: Health warnings displayed on tobacco products are important sources of health information for the community. Aims: The aim of this study was to determine the awareness, perceptions and attitudes towards the impact of health warnings on cigarette packages of a community in Nicosia, where no previous data was available. Methods: The descriptive cross-sectional study was conducted among 629 cafe attendants in Nicosia in October 2019, using a structured questionnaire to determine the impact of pictorial and text-only cigarette pack warnings. Since cigarette packs include only text-only warnings in Northern Cyprus, sample pictorial warnings from Turkey were presented to the participants.The data were analysed by IBM–SPSS-18.0 to compare perceptions regarding sex, age, smoking status with significance level accepted as p<0.05. Results: Of all the participants, 48%were smokers and smokers among men were significantly higher (56.8%) than women (40.6%). The results demonstrated that 71.2% of the participants were aware of the health warnings on packages and 59.4% rated health warnings as effective. Stronger pictorial health warnings were deemed as more effective. However, 65.6% of the “smoker” group were not aware of the warnings.There were significant differences between smokers and non-smokers regarding perceptions of pictorial warnings. Non-smokers, including former smokers adopted positive views more; 54% of ex-smokers declared health warnings had contributed to their quitting process. Conclusion: The perceptions of the non-smokers of this community group displayed more positive attitudes towards health warnings. This study has pointed to the urgent need for the implementation of pictorial warnings for smokers in Northern Cyprus.

Effectiveness of Cigarette Graphic Warnings in Informing Smokers about the Dangers of Tobacco

Purpose: Pictorial cigarette pack warnings are a promising solution for curbing the tobacco epidemic and are considered as one of the most direct, effective and prominent means of communicating with smokers. Over 8,300 Cameroonians are killed by smoking-caused diseases every year with 112 men and 47 women dying every week because of smoking. In a country were 2.3 billion cigarettes were sold in 2016, this study seeks to find out how effective cigarette warning labels are in influencing smokers’ intake of cigarette. We sought to assess the effectiveness of cigarette warning labels, to determine if smokers’ belief and trust the graphics on cigarette warning labels and if they are directly or indirectly influenced by cigarette warning labels.
 Methodology: This study adopted a qualitative research design in order to better understand and illuminate the Effectiveness of Cigarette Warning Labels to smokers. A purposive sample of eighteen (18) cigarette smokers were interviewed
 Findings: Our findings point to the fact that there is perceived ineffectiveness of cigarette warning labels, that cigarette smokers don’t believe the warning labels are real and there exist a limited influence of cigarette warning labels to smokers. The analysis of our data led to the emergence of three distinct themes: Perceived ineffectiveness of warning labels; Lack of belief in warning labels; Limited influence of cigarette warning labels to smokers.
 Unique Contribution to Theory, Practice and Policy: This study was informed by the Trans theoretical Model (TTM) which focuses on the decision-making of smokers and is a model of intentional change. It was observed that smokers may not change their habits quickly and decisively only because of cigarette graphic warnings. Other communication channels especially the media may reinforce cigarette graphic warnings to persuade smokers to quit smoking. This study has implications for programs aimed at reducing the rate of cigarette smoking. Based on the findings, the warning labels appear not be very effective in persuading smokers to quit the deadly practice of smoking.

Differential changes in quitting smoking by daily cigarette consumption and intention to quit after the introduction of a tobacco tax increase and pictorial cigarette pack warnings in Korea, 2013–2017

Background: This study examined whether changes in quitting smoking differed according to smokers’ cigarettes consumed per day (CPD) and intention to quit (ITQ) after the introduction of two tobacco control measures in Korea, a tobacco tax increase in 2015 and pictorial cigarette pack warnings (PCW) in 2016. Methods: We utilized data from the Korea Welfare Panel Study from 2013 to 2017, an interval that was divided into four periods (2013–2014, 2014–2015, 2015–2016, and 2016–2017). We examined differential changes in quitting smoking by smokers’ CPD and ITQ using a generalized estimating equation model. Results: Smokers with 1–14 CPD or an ITQ were more likely to quit smoking in each period. However, when compared to the pre-policy period (2013–2014), smokers with 15 or more CPD and those with an ITQ had a higher risk ratio of quitting smoking in all study periods. In stratified analyses, when the tobacco excise tax was increased, the risk ratios of quitting smoking increased in most subgroups, especially smokers with 15 or more CPD or an ITQ. The increased risk ratio of 15 or more CPD smokers subgroup sustained afterward. However, after the introduction of PCW, there were no significant changes from the previous period in most subgroups. Conclusions: The addictive nature of tobacco and the type of tobacco control policies jointly contributed to changes in quitting smoking among Korean smokers. Tobacco control policies, particularly substantial tobacco tax increase, acted as a cue-to-action for quitting smoking among more dependent smokers.

Conversations about pictorial cigarette pack warnings: Theoretical mechanisms of influence

BackgroundSocial interactions are a key mechanism through which health communication campaigns influence behavior. Little research has examined how conversations about pictorial warnings motivate behavior. PurposeWe sought to establish whether and how smokers' conversations explain the effect of pictorial warnings on quit attempts. MethodsUS adult smokers (n = 2149) participated in a controlled trial that randomly assigned them to have their cigarette packs labeled with pictorial or text-only warnings for four weeks. Surveys assessed the number of conversations sparked by pictorial warnings and the theoretical mechanisms cognitive elaboration and social norms at each visit. Analyses used structural equation modeling to test our theorized mediation models. ResultsThe number of conversations about the warnings mediated the relationship between exposure to pictorial warnings and quit attempts (p < .001). In serial mediation analysis examining possible theoretical mechanisms, the number of conversations was associated with greater cognitive elaboration, which in turn was associated with being more likely to make a quit attempt (p < .05). Social norms did not explain the influence of conversations on quit attempts. ConclusionsPictorial warnings increased conversations about the warnings, which led to greater cognitive elaboration, which led to greater quit attempts. Our findings suggest designing warnings that increase conversations in order to better inform and motivate smokers. Furthermore, these findings improve our understanding of why conversations matter in health communication.

Understanding Why Pictorial Cigarette Pack Warnings Increase Quit Attempts.

Our randomized trial found that pictorial cigarette pack warnings elicited more quit attempts than text-only warnings. In the current study, we sought to identify psychological mechanisms that explain why pictorial cigarette pack warnings change behavior. In 2014 and 2015, we recruited 2,149 adult smokers in NC and CA, USA. We randomly assigned smokers to receive on their cigarette packs for 4 weeks either a text-only warning (one of the USA's current warnings on the side of cigarette packs) or a pictorial warning (one of the USA's proposed text warnings with pictures on the top half of the front and back of cigarette packs). Pictorial warnings increased attention to, reactions to, and social interactions about cigarette pack warnings (all p < .05). However, pictorial warnings changed almost no belief or attitude measures. Mediators of the impact of pictorial warnings included increased attention, negative affect, social interactions, thinking about the warning and harms of smoking, and intentions to quit (all p < .05). Analyses also found that pictorial warnings led to greater avoidance of the warnings, which was associated with more quit attempts (p < .05). Pictorial warnings increased quit attempts by eliciting aversive reactions and by keeping the message vividly in smokers' minds. Contrary to predictions from several theories of health behavior, the warnings exerted little of their influence through changes in beliefs and attitudes and none of their influence through changes in risk perception. We propose the Tobacco Warnings Model based on these findings. ClinicalTrials.gov identifier: NCT02247908; https://clinicaltrials.gov/ct2/show/NCT02247908.

Trajectories of Responses to Pictorial Cigarette Pack 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.

Frequency and Content of Conversations About Pictorial Warnings on Cigarette Packs.

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.

Recruiting Diverse Smokers: Enrollment Yields and Cost.

To help tobacco control research better include vulnerable populations, we sought to identify effective ways to recruit diverse smokers. In 2014–2015, we recruited 2149 adult cigarette smokers in California and North Carolina, United States, to participate in a randomized trial of pictorial cigarette pack warnings. The most effective means of recruiting smokers were the classified advertising website Craigslist (28% of participants), word of mouth (23%), Facebook (16%), and flyers or postcards (14%). Low-income and African American smokers were more likely to respond to interpersonal contact (including staff in-person recruitment and word of mouth) than were high-income and non-African American smokers (all p < 0.05). Hispanic and gay, lesbian, and bisexual smokers were more likely to be recruited by Craigslist than non-Hispanic and straight smokers (both p < 0.05). Of the recruitment methods requiring cost, the cheapest was Craigslist ($3–7 per smoker). The most expensive methods were newspaper ads in California ($375 per smoker) and staff in-person recruiting in North Carolina ($180 per smoker). Successfully recruiting diverse smokers requires using multiple methods including interpersonal, online, and other media. Craigslist and word of mouth are especially useful and low-cost ways to recruit diverse smokers.

Social Interactions as a Source of Information about E-Cigarettes: A Study of U.S. Adult Smokers.

The novelty of e-cigarettes and ambiguity about their effects may foster informal sharing of information, such as through social interactions. We aimed to describe smokers’ social interactions about e-cigarettes and their recommendations that others use e-cigarettes. Data were collected from 2149 adult smokers in North Carolina and California who participated in a study of the impact of pictorial cigarette pack warnings. In the previous month, almost half of participants (45%) reported talking to at least one person about e-cigarettes and nearly a third of participants (27%) recommended e-cigarettes to someone else. Smokers recommended e-cigarettes to cut back on smoking (57%), to quit smoking (48%), for health reasons (36%), and for fun (27%). In adjusted analyses, more frequent e-cigarette use, positive views about typical e-cigarette users, and attempting to quit smoking in the past month were associated with recommending e-cigarettes for health reasons (all p < 0.05). Social interactions appear to be a popular method of information-sharing about e-cigarettes among smokers. Health communication campaigns may help to fill in the gaps of smokers’ understanding of e-cigarettes and their long-term effects.

Social Interactions Sparked by Pictorial Warnings on Cigarette Packs.

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.