Pictorial Warnings Research Articles

Pictorial health warnings on cigarette packs and effect on smoking: Medical student's perspective.

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.

Awareness and attitude toward pictographs on tobacco products: A population-based study in field practice area.

Background:Tobacco use is a major global public health threat for all countries and no form of tobacco use is safe. Pictorial warnings covering 40% area of tobacco products are made mandatory from May 31, 2009 in India. The present study was aimed to investigate the awareness and attitude toward pictorial warnings on tobacco products among age 15 years and above population in field-practice area.Materials and Methods:A total of 1064 individuals were selected by systematic random sampling. A model containing the pictorial warnings were shown to the study subjects, and data were collected by semi-structured questionnaire. Data was analyzed using SPSS 20 and statistical tests used were Chi-square test. Significance level set at P ≤ 0.05.Results:Of the 1064 individuals participated in the study, 53.9% were male and the mean age of the study population was 31.24 ± 5.8. Nearly 45.8% reported using tobacco in some form and all of them were males. 51.3% of both males and females reported that they never came across antitobacco messages (pictorial warnings). 71.2% believed that the size and position of pictorial warnings on tobacco products were not sufficient to understand the harmful effects of tobacco. There was statistically significant difference between different age groups in their responses to the aforementioned questions.Conclusion:The results of present study demonstrate that the need for pictorial warnings on tobacco products to be more clear and explanatory since there is little point in having pictorial warnings when the prime purpose of having them is not being served.

How Effective are Pictorial Warnings on Tobacco Products? New Evidence on Smoking Behaviour Using Australian Panel Data

Studies examining the introduction of pictorial warnings on cigarette packages provide inconclusive evidence due to small samples and methodological issues. We use individual-level panel data from Australia to examine the association between pictorial warnings and smoking behaviour - prevalence, quitting, initiating and relapsing. The pictorial warnings were accompanied by a reference to a smoking cessation helpline and supportive television commercials. Applying an event study framework, we show that the reform reduced smoking rates by around 4% within the first year of the policy. The effect decreases with age, is similar for men and women, and is slightly larger for low-educated compared to high-educated individuals. The reform permanently lowered smoking rates primarily due to increased quitting in the year of the reform. Thus, pictorial warnings combined with a reference to a smoking cessation helpline and supportive media campaigns are an important tobacco control measure to reduce the social costs of smoking.

Communicating Risk: Assessing Compliance of Tobacco Products to Cigarettes and other Tobacco Products Act (Packaging and Labelling) Amendment Rules 2015 in Delhi, India.

Background:Tobacco is a public health problem with both health and economic consequences. Pictorial health warning (PHW) under cigarettes and other tobacco products Act, May 2003 (COTPA), offers advantages of being more universally available, low cost, and high exposure. The current study aims to assess compliance of smoking and smokeless tobacco products to Section 7, 8, and 9 of COTPA Amendment Rules 2015.Materials and Methods:This cross-sectional study was conducted in the city of New Delhi during November–December. 2017. All nine districts were included in the study and in each districts, three public places, a Metro station, a hospital, and a public park, were randomly chosen for tobacco products collection. A standardized protocol was implemented for acquiring tobacco products from these 27 diverse points. Data collected were entered into MS Excel to make digital spreadsheets and were analyzed using SPSS version 21.Results:Among 98 tobacco products, 57 (58%) and 41 (42%) were smoke form and smokeless form, respectively. Foreign Cigarette Brands and Beedi showed the least compliance followed by khaini and Gutkha. PHW was absent on 12 products (8 foreign brands of smoking type and 4 smokeless type). 42.8% (n = 42) of packaging was found to contain promotional inserts, while just 20.4% (n = 20) of the total sample size contained the presence of legislative information.Conclusions:Foreign brands and locally manufactured products (Beedi and Khaini) showed low compliance to new amendments of COTPA. Along with this, the presence of promotional inserts on tobacco packaging might be another issue to be dealt with in the future.

Knowledge and awareness of oral cancer and impact of pictorial warnings on the willingness to quit tobacco in young tobacco consumers in India.

Oral cancer is most common cancer globally and is one of the most life-threatening conditions worldwide. To assess the knowledge and awareness of oral cancer and the impact of pictorial warnings on the willingness to quit tobacco in young tobacco consumers in India. This cross-sectional study included 250 young tobacco consumers from Ranchi, Jharkhand. A pretested validated questionnaire was used that collected information on knowledge and awareness of oral cancer from the respondents. The responses were estimated on a three-point scale (No/Don't know/Yes). p-Value <0.05 was considered statistically significant. The majority of the respondents were aware of oral cancer (92.0%). Educational status was significantly associated with a good knowledge of awareness of oral cancer and its associated risk factors (p-Value <0.05). Media was identified as the main source for spreading oral cancer awareness (69.1%). The majority of the people were aware of the pictorial warnings on tobacco products (96.1%). However, the pictorial warnings seem to have a very low impact on willingness to quit tobacco by the respondents (20.0%). Alternative strategies need to be employed by the government to motivate people to quit tobacco consumption. Dental health education should be provided and educational pamphlets should be distributed to create awareness about the harmful effects of tobacco consumption.

Do pictorial health warnings on waterpipe tobacco packs matter? Recall effectiveness among Egyptian waterpipe smokers & non-smokers.

IntroductionDespite 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 methodsWe 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.ResultsParticipants’ 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.ConclusionsFindings 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.

Alcohol pictorial health warning labels: the impact of self-affirmation and health warning severity

BackgroundWe examined whether enhancing self-affirmation among a population of drinkers, prior to viewing threatening alcohol pictorial health warning labels, would reduce defensive reactions and promote reactions related to behaviour change. We also examined how health warning severity influences these reactions and whether there is an interaction between self-affirmation and severity.MethodsIn this experimental human laboratory study, participants (n = 128) were randomised to a self-affirmation or control group. After the self-affirmation manipulation was administered, we tracked participants’ eye movements while they viewed images of six moderately-severe and six highly-severe pictorial health warning labels presented on large beer cans. Self-reported responses to the pictorial health warning labels were then measured, including avoidance, reactance, effectiveness, susceptibility and motivation to drink less. Finally, participants reported their self-efficacy to drink less and their alcohol use.ResultsThere was no clear evidence that enhancing self-affirmation influenced any outcome. In comparison to moderately-severe health warnings, highly-severe health warnings increased avoidance and reactance and were perceived as more effective and increased motivation to drink less.ConclusionsThese findings call into question the validity of the self-affirmation manipulation, which is purported to reduce defensive reactions to threatening warnings. We discuss possible explanations for this null effect, including the impact of participants’ low perceived susceptibility to the risks shown on these pictorial health warning labels. Our finding that highly-severe health warnings increase avoidance and reactance but are also perceived as being more effective and more likely to motivate people to drink less will inform future health warning design and have implications for health warning label theory.

Are the Same Health Warnings Effective Across Different Countries? An Experimental Study in Seven Countries.

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.

Eye movement data reveal increased attention to combined health warnings on cigarette packs

IntroductionIn 2016 the UK introduced standardised pack design regulations, limiting branding and aiming to increase the salience of health warnings. Existing evidence suggests that the effectiveness of pack design in focusing a smoker’s attention toward warnings may depend on how much they smoke. Our study aimed to directly compare attention to branding and warnings between the pre-regulation and post-regulation packs in smokers, and to determine whether this was affected by the amount smoked, to assess the effectiveness of the new policies. Method47 adult smokers were recruited, including daily and non-daily smokers to ensure a wide range in cigarettes smoked per week. Eye movement data were recorded while images of cigarette packs were displayed sequentially on screen. Each trial presented one of two types of cigarette pack; pre-regulation packs with a text health warning, or post-regulation packs compliant with governmental guidance introduced in 2016, with plain branding and a combined pictorial and text health warning. Eye movement data were compared between packs, covarying the number of cigarettes smoked per week. ResultsEye movement analysis revealed that smokers attended more to health warnings and less to branding when looking at post-regulation packs compared with pre-regulation packs. These effects did not relate to number of cigarettes smoked per week. ConclusionStandardised regulations for cigarette packs successfully direct smokers’ attention away from branding, and towards health warnings, with no association with cigarettes smoked per week. This study adds to the growing body of evidence advocating broader uptake of similar packaging regulations.

Visual Attention Patterns Differ by Pictorial Health Warning Label Features.

In this study, we sought to determine how smokers allocate their attention when viewing the 9 cigarette pictorial warning labels (PWLs) proposed by the Food and Drug Administration (FDA), and identify PWL attributes associated with increased attention. Using eye-tracking data from an exploratory within-subject study, we examined smokers' attention (latency, latency duration, and dwell time) to areas of interest (image vs textual warning) for each PWL among 95 daily, non-treatment-seeking smokers (62.1% male, 48.4% white, mean [SD] age = 32.98 [10.14], mean [SD] cigarettes/day = 15.51 [8.43]). We also compared attention measures by PWL message congruency, textual warning location, and participant rankings of effectiveness. Attention measures differed significantly among PWLs (p s < .001) and by features and self-reported effectiveness rankings (p s < .001 - .039). Congruent PWLs, those displaying text across the warning label, and those ranked most effective were associated with sustained attention to image, whereas incongruent PWLs, those displaying left text, and those ranked least effective, were associated with faster and sustained attention to text. Smokers allocated their attention differently across PWLs. Formats and participant effectiveness rankings of PWLs were associated with visual attention patterns, suggesting the importance of these features to the design of potential future PWLs.

Perceived effectiveness of pictorial health warnings on changes in smoking behaviour in Asia: a literature review

BackgroundSeveral Asian countries have implemented pictorial health warnings on cigarette packs as suggested by the World Health Organization with various policies based on countries’ systems. The study is aimed to analyse multiple research studies on the perceived effectiveness of Pictorial Health Warnings as a deterrent to smoking intention and as a stimulant of smoking behaviour in smokers and non-smokers in Asian countries.MethodPeer-reviewed articles were identified through multiple science databases indexed by Scopus, MEDLINE or PubMed. The review was limited to articles that reported original research findings, were conducted in Asian countries and were available for review by January 2010. A PRISMA Flow diagram was used to identify the articles through the process of data screening and extractions.ResultA total of 14 original articles which met the criteria were included in the review, consisting of 12 quantitative studies and 2 studies with both quantitative and qualitative methods from 17 jurisdictions. The reviewed studies found that pictorial health warnings were associated with a greater perception of salience (reading and noticing the warning), emotional effects, and cognitive increase. Additionally, in the reviewed studies, pictorial health warnings were perceived as more effective in deterring smoking initiation and encouraging smoking cessation than text-only warnings. Several studies also evaluated the effectiveness of a new pictorial warning compared with the old one. However, the relevance of refreshing the pictures of pictorial health warnings and the length of the effective period of the implementation of pictorial health warnings were less frequently studied.ConclusionPictorial health warnings perceived as more effective in deterring smoking initiation among non-smokers and as well as in stimulating smoking cessation among smokers. Future studies on pictorial health warnings should study the relevance of changing or refreshing pictorial health warning on cigarette packages in a period of time.

The Influence of Health Numeracy and Health Warning Label Type on Smoking Myths and Quit-Related Reactions.

Health numeracy helps individuals understand risk information, but limited data exist concerning numeracy's role in reactions to varying types of health warning labels (HWLs) for cigarettes. A nationally representative online panel of adult current smokers received two exposures (1 week apart) to nine HWLs with either text-only or pictorial images with identical mandated text. Following the second exposure, participants (n = 594) rated their beliefs in smoking myths (eg, health-promoting behaviors can undo the risks of smoking) and how much the warnings made them want to quit smoking. Generalized estimating equation regression examined the relation of objective health numeracy and its interaction with HWL type to smoking-myth beliefs and quit-related reactions. Health numeracy was not significantly associated with smoking-myth beliefs; the interaction with HWL type was also nonsignificant. Adult smokers with lower health numeracy had higher quit-related reactions than those with higher numeracy following exposure to HWLs. The type of HWL significantly modified numeracy's associations with quit-related reactions; no significant association existed between text-only HWLs and quit-related reactions, whereas among those who viewed the pictorial warnings, lower numeracy was associated with greater quit-related reactions (β = -.23; p < .001). Lower as compared to higher health numeracy was significantly associated with higher quit-related reactions to HWLs and especially with pictorial HWLs. Health numeracy and HWL type were not associated with the endorsement of smoking myths. The role of health numeracy in effectively communicating risks to smokers warrants thoughtful consideration in the development of tobacco HWLs. Health numeracy plays an important role in an individual's ability to understand and respond to health risks. Smokers with lower health numeracy had greater quit-related reactions to pictorial health warnings than those who viewed text-only warning labels. Development and testing of health warning labels should consider health numeracy to most effectively communicate risk to US smokers.

Persepsi terhadap Peringatan Kesehatan Bergambar pada Bungkus Rokok dan Perilaku Merokok Remaja di Yogyakarta

Background: The prevalence of teenage smokers increase steadily in Indonesia. The Government issued Government Regulation No. 109 of 2012 on the Security of Ingredient-Containing Addictive Substances in the form of Tobacco Products For health and the implementation of pictorial health warning on cigarette packaging has been enforced since July 2014 to overcome it. Objective: To know the relationship of perception forwad pictorial health warning (PHW) with smoking behavior of adolescents who are incorporated in the Manggarai Raya Yogyakarta Family Association (IKAMAYA). Method: This research used explanatory research design. Respondents were IKAMAYA teenagers totaling 145 people. Data collection with questionnaire then analyzed by univariat and bivariat. Result: The five PHW are considered very helpful in reminding smokers to quit smoking or reduce smoking habits. The number of male adolescents who smoked 37.2% while the number of adolescent girls who smoked 6.9%. There is a significant correlation between adolescent perception toward five PHW with adolescent smoking behavior. P value respectively from p1-p5 (0,039; 0,001; 0,025; 0,022; 0,027). Conclusion: Pictorial Health Warning on cigarette packing effective in reducing smoking habit of adolescents. Respondents who have positive perceptions forwad PHW tend to reduce cigarette consumption, whereas respondents who have negative perception of PHW tend to remain smoking behavior.Keywords: Perception, Pictorial Health Warning, smoking behavior, adolescent

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.

Prevalence of Smoking and Impact of Pictorial Health Warning on Quit Attempts Among Youths in Bhaktapur, Nepal

Background: Nepal for the first time implemented laws regarding the pictorial health warnings in April 2014 regardless of an unsuccessful challenge that was set up by the tobacco industry in 2011. Results from several studies have shown that health warnings on cigarette packages have been helpful in warning smokers as well as nonsmokers regarding the harms of cigarette smoking, encouraging smokers to quit and also preventing nonsmokers from starting to smoke. Aim: The objective of this study was to find the impact of pictorial health warning on quit attempts. Methods: An explanatory cross-sectional study was conducted among youths aged 15-24 years in Suryabinayak-5, Bhaktapur with probability systematic random sampling technique using self-administered questionnaire. Results: Half (50%) of the respondents first tried smoking at the age of 16 or older. Seventeen percent of the respondents smoked cigarettes either occasionally or regularly during the past 30 days. Most of the respondents (91%) have not tried smokeless tobacco products ever in their life. Sixty-seven percent of the respondents had noticed PHW on cigarette packages during the past 30 days. One fourth (21.8%) respondents made an quit attempt due to PHW during the past 12 months and their maximum duration of abstinence during the last quit attempt was more than a week but less than a month. From the study it is found that there is statistically significant association between noticing pictorial health warning and thought about quitting smoking or intention about not starting smoking. Conclusion: Pictorial warnings effectively increased peoples quitting intentions, attempts as well as relinquishing cigarettes. Our findings suggest that implementing 90% pictorial health warnings on cigarette packs in Nepal would discourage smoking.

Plain packaging of waterpipe tobacco? A qualitative analysis exploring waterpipe smokers’ and non-smokers’ responses to enhanced versus existing pictorial health warnings in Egypt

ObjectiveDespite the global increase in waterpipe tobacco smoking (WTS) including in Egypt, few studies have assessed the effectiveness of waterpipe tobacco (WT) health warnings. Egypt has used pictorial health warnings...

Role of Pictorial Warning on Cigarette Packets in Tobacco Cessation: A Questionnaire Survey Among Cigarette Smokers in Chennai, India

Background: Tobacco is used in various forms (smoking/smokeless forms) all over the world today. The World Health Organization reports it to be the leading preventable cause of death worldwide, and estimates that it currently causes 5.4 million deaths per year. Rates of smoking have leveled off or declined in developed countries. However, they continue to rise in the developing countries. As in other developing countries, India too suffers a stage of the tobacco epidemic, hosting nearly 17% of the world´s smokers, with the number constantly on the rise. According to the report of the Tobacco Control in India, 800,000-900,000 Indians die annually due to diseases attributable to tobacco. Among these deaths, 50% are due to cancer and 40% are other reported health-related problems such as cardiovascular and lung disorders. Tobacco is used by various groups of people irrespective of their social, economic or educational background, and majority of them use it despite knowing the hazards to their health. Warning labels on cigarette packages are meant to communicate such smoking-associated risks. The study is designed to find out the effectiveness of pictorial warnings present on cigarette packets in India for tobacco cessation among cigarette smokers. Methodology: A questionnaire was distributed to 800 current smokers attending an outpatient department of a college. Statistical analysis was done to find association between socioeconomic status and effectiveness of pictures to quit cigarette smoking. Results: 48% smokers perceive text warning is an efficient method to create awareness. 56% emphasized the importance of pictorial warning and greater area to be covered. 43% felt that warning on cigarette packets helped them to quit smoking. Conclusions: Though pictorial warning is an effective method to improve the awareness among smokers on the ill effects of smoking, the size, area covered and the position of the picture on cigarette packets needs to be reviewed to improve the quit rate.

Perceived Effectiveness of Differing Health Warning Label Messaging Strategies among Adults in the Republic of Georgia: One Size Does Not Fit All.

Background: While pictorial health warning labels (HWLs) are evidence-based, the different messaging strategies are understudied. Methods: We analyzed 2014 national survey data from 1163 Georgian adults to examine: (1) perceived effectiveness of pictorial vs. text-only HWLs; (2) pictorial HWL themes; and (3) correlates of perceived effectiveness of different pictorial themes. Participants were randomized to evaluate the effectiveness of either Set A or Set B of HWLs (each contained half pictorial, half text-only). Results: All but 2 pictorial HWLs were perceived as more effective than text-only. Factor analyses identified one factor among Set A (“benign”) and two in Set B pictorial HWLs (“benign”, “gruesome”). Among Set A pictorial HWLs, correlates of greater perceived effectiveness included being female, rural residence, not having children, and nonsmoker status. Among smokers, correlates included being female and unmarried, fewer smoking friends, and higher quitting importance. Among Set B, 43.8% rated gruesome pictorial HWLs more effective, 12.9% benign more effective, and 43.4% equally effective. Correlates of perceiving benign more effective included fewer smoking friends and higher income. Among smokers, lower income predicted gruesome being perceived as more effective; fewer smoking friends and higher quitting importance predicted perceiving benign as more effective. Conclusion: A variety of pictorial HWL strategies should be used.

Exploring the impact of efficacy messages on cessation-related outcomes using Ecological Momentary Assessment

INTRODUCTIONObservational studies indicate that cigarette package inserts with efficacy messages about the benefits of quitting (i.e. response efficacy) and recommendations for successful cessation increase smokers’ self-efficacy to quit and promote sustained cessation. However, the effects of inserts with such efficacy messages have not been studied using experimental designs. This study used ecological momentary assessment (EMA) to assess smokers’ responses to efficacy inserts.METHODSIn a randomized case-crossover study among smokers from the United States (n=23), participants received a one-week supply of cigarettes with efficacy inserts and a one-week supply without any inserts, and were randomized to use the packs with inserts on either the first or second week of the study. For 14 consecutive days, participants used a smartphone to answer brief surveys on cessation-related variables during smoking sessions and at the beginning of each day. Multilevel mixed-effects linear and logistic regression models compared responses during the insert period to those of the non-insert period.RESULTSThe insert period was associated with greater desire to quit (b=0.21, p=0.012), motivation to quit (b=0.18, p=0.001), self-efficacy to cut down (b=0.26, p<0.001) and to quit (b=0.28, p<0.000), and response efficacy/perceived benefits of quitting (b=0.13, p=0.012). Insert exposure was not significantly associated with forgoing cigarettes (OR=1.9, p=0.2)CONCLUSIONSResults from this EMA study suggest that inserts with efficacy messages may promote determinants of smoking cessation. This is consistent with observational research in Canada, which is the only country to use inserts with efficacy messages as well as pictorial warnings about smoking risks on the outside of packs. Future studies should assess the extent to which efficacy inserts can not only be used to communicate health information to smokers but also work in synergy with pictorial warnings.

\u201cThat\u2019s probably what my mama\u2019s lungs look like\u201d: how adolescent children react to pictorial warnings on their parents\u2019 cigarette packs

BackgroundPictorial cigarette pack warnings discourage smoking, but most evidence comes from studies of adults. Our qualitative study explored adolescents’ reactions to pictorial warnings on their parents’ cigarette packs.MethodsWe interviewed 24 adolescents whose parents received pictorial warnings on their cigarette packs as part of a randomized clinical trial. We conducted a thematic content analysis of the interview transcripts.ResultsPictorial cigarette pack warnings led adolescents to imagine the depicted health effects happening to their parents, which elicited negative emotions. The warnings inspired adolescents to initiate conversations with their parents and others about quitting smoking. Adolescents believed the warnings would help smokers quit and prevent youth from starting smoking. Some current smokers said the warnings made them consider quitting.ConclusionsConversations about the pictorial warnings may amplify their effectiveness for smokers, their adolescent children, and friends of the adolescent children. Cigarette pack warnings may reach a broad audience that includes adolescent children of smokers.