Pictorial Warnings Research Articles

Effectiveness of pictorial-warning intervention to reduce consumption of sugar-sweetened-beverages

Abstract Background & Aims Limited research have looked at pictorial-health-warnings (PHW) for sugar- sweetened beverages (SSB), despite the potential for behaviour change that pictorial warnings on tobacco products hold. This study aimed to examine how visual warnings impacted parents’ decisions to buy SSB for their children. Materials and methods All residents dwelling in the communities and local vendors available were subjected to a ten-week multi-strategy intervention by randomized stepped-wedge controlled trial to support the introduction of PHW labels. Stepped implementation of a two-week PHW intervention was delivered in a randomly selected order at one-week intervals. Follow-up data were collected for all three sectors two weeks following the completion of the PHW intervention in the third sector. The trial outcome was determined by comparing the overall perception change towards SSB among parents between the baseline and follow-up periods for three sectors combined. Secondary outcomes included reactions to the trial labels, attitudes toward SSB, and intentions to serve their child SSB. Results PHW led to a 30 % (-37.12%, -22.37%) reduction in purchases of SSB, along with lower intentions to serve SSB to children, higher thoughtfulness about the harms of SSB, more perceived control of healthy eating decisions, stronger negative emotional reactions, lower perceived healthfulness of SSB for their child, and greater injunctive norms to limit SSB for their child (all p < 0.05). No differences by sector or within sector were found between pre and post-intervention in the appeal of SSB or perceived tastiness of SSB (all p > 0.05). Nearly 53% of participants reported being more in control of making healthy eating decisions. Conclusions Warnings on SSB are a promising policy approach to reduce sugary drink purchasing. This evidence will support the health service adoption of implementation strategies to support PHW labels across the entire country. Key messages • Warnings on SSB are a promising policy approach to reduce sugary drink purchasing. • Support the health service adoption of implementation strategies to support PHW labels across the entire country.

How smokers perceive pictorial and non-pictorial health warnings on cigarette packages: An online survey

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.

Opportunities for plain packaging of tobacco products in the Philippines: results of a nationwide online survey.

This study aimed to contribute to local research evidence to promote the implementation of plain packaging of tobacco products in the Philippines. The study aimed to assess Filipinos' perception of the effectiveness of plain packaging and their readiness by assessing the potential impact of plain packaging. We conducted a nationwide geographically representative online panel survey with a sample size of 2,000 Filipinos. The survey recruited respondents 18-65 years old and residing in the Philippines, with 500 respondents each from the National Capital Region, Luzon, Visayas, and Mindanao. We showed respondents six different mock-ups of cigarette packs in plain packaging, with two sizes of graphic health warnings (50 and 75%) and three plain packaging colors (black, white, and Pantone 448C). Using five-point Likert scales, participants rated their agreement with 18 items assessing readiness and rationales for plain packaging and 54 items related to pack design (9 items for 6 pack designs). The study showed that Filipinos recognize the value of adopting plain packaging with larger graphic health warning labels on tobacco products in the Philippines. Both non-smokers and smokers agreed that plain packaging has the potential to reduce the attractiveness and appeal of packs, prevent advertisement and promotion of tobacco products, reduce the ability of tobacco products to mislead consumers, increase the noticeability and effectiveness of the pictorial health warnings, increase recall of the pictorial health warnings, affect consumer perceptions of the attractiveness of the tobacco products and their relative safety, reduce youth experimentation with the use of tobacco products, prevent the use of tobacco brand variants as a promotional tool, prevent branding targeted toward youth, promote quitting among current users, and to more clearly inform consumers about the harmful effects of tobacco use. We recommend that policymakers pursue plain packaging as legislation or as part of a reform of the Philippines' graphic health warnings law. The law should target tobacco products sold in the Philippines.

Relative efficacy of cigarillo warning statements in text and pictorial formats: An experimental study among a sample of US young adults.

Health warning labels (HWLs) communicate the health risks of cigar use and can decrease use when on cigar packages. This study assessed the relative efficacy of six FDA-proposed individual warning statements in text and pictorial format. A sample of young adults (ages 18-29) were randomized to a text or pictorial warning condition on generic cigarillo packages. The warning statements were about lung cancer and heart disease; cancers of the mouth and throat; secondhand smoke; not a safe alternative; nicotine/addiction; and harm to baby. Negative emotional reactions, cognitive elaboration, and perceived message effectiveness (PME) were assessed for each warning using linear mixed models. Of the 661 participants, 47.3% reported ever cigarillo smoking, 32.7% current smoking, and 20% were susceptible. In the pictorial format, cancers of the mouth and throat elicited lower levels of anxiety compared to secondhand smoke, not a safe alternative, nicotine/addiction, and harm to baby (ps<0.001). Pictorial HWLs with human imagery induced high anxiety, sadness, fear, and guilt reactions (p<0.001) and higher PME (p=0.011) compared to pictorial HWLs with diseased body parts. Compared to the text HWL cancers of the mouth and throat, the text HWL harm to baby elicited higher anxiety (p=0.003), sadness (p=0.002) and PME (p<0.001). Pictorial HWLs depicting people or human imagery, rather than images of diseased organs or body parts, to represent health effects elicited the most negative emotional reactions, such as anxiety and guilt, and higher PME. Including such images and texts highlighting effects on vulnerable populations like babies can better communicate cigarillo health risks, aiming to curb cigarillo use among young people. The study suggests that pictorial health warning labels (HWLs) with human imagery significantly enhance the communication of cigarillo smoking risks compared to images of diseased organs. These HWLs evoke stronger emotional responses, particularly anxiety and guilt, and higher perceived message effectiveness by depicting a recognizable person. Furthermore, text-only warnings describing the smoking effect on vulnerable populations such as babies might have a higher impact on young adults. This evidence supports a strategic shift in FDA policies to include such impactful images and texts, which could potentially lead to a significant reduction in cigarillo use among young people. Our findings underscore the urgent need for continued research and implementation of these enhanced warning labels to improve public health outcomes.

Tobacco Control Policy in India: Progress and Challenges Quantified Using the Tobacco Control Scale.

One of the most vexing challenges to public health today is the menace of tobacco. Despite the large body of evidence indicating the vast scale of health hazards, tobacco use continues to be a major cause of preventable death. This study was conducted with the objective of quantifying the progress and challenges of the tobacco control policy of India. The Tobacco Control Scale (TCS) was used, which has a maximum score of 100 and assesses nine components including, price of cigarettes, smoke-free public and work places, spending on public information campaigns, comprehensive bans on advertising and promotion, large pictorial health warning labels, treatment to help smokers stop, illicit tobacco trade, tobacco industry interference and ratification of the WHO FCTC. The components of the TCS for India were scored based on data obtained from the WHO, Report on The Global Tobacco Epidemic, 2021 and the Cigarettes and Other Tobacco Products Act 2003 and their amendments and the Tobacco India 2023 country profile. The total score for the tobacco control scale placed India at 65 points, scoring highest with respect to 'large pictorial health warning labels', and lower with respect to 'spending on public information campaigns', 'illicit tobacco trade' and 'price of cigarettes'. Strong tobacco control legislation and its equally robust implementation is an affirmative step in achieving the vision of the WHO-FCTC and empowering the world towards being tobacco free.

Impact of Pictorial Health Warnings on Cigarette Packs among Current Smokers of Sub-Metropolitan City of Nepal: A Descriptive Cross-sectional Study

Introduction: Pictorial health warning on cigarette packs is one of the strategies undertaken by Nepal Government as per the directive of World Health Organization Framework Convention on Tobacco Control to control smoking. It has been more than a decade since the introduction of pictorial health warnings on cigarette packs in Nepal. The objective of this study was to assess the impact of the pictorial warnings among current smokers of Dharan, Nepal.Methods: A descriptive cross-sectional study was conducted among current smokers visiting local shops located near ward offices of Dharan after obtaining ethical approval from Institutional Review Committee (Reference number: 204/080/01 -IRC). A structured and validated Nepali questionnaire was used to interview the smokers about the impact of the pictorial warnings based on their noticeability, behavioural and cognitive responses. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 20.0. The responses of the participants were tabulated in frequencies and percentages.Results: The pictorial warnings were noticed by 277 (98.93%) participants in past one month out of which 11 (3.93%) smokers had always read or looked closely at them. Smoking less frequently was the behaviour change reported by 70 (25%) participants and smoking less around others was reported by and 56 (20%) participants. In total, 189 (67.50%) smokers had thought about the harms of smoking and 160 (57.14%) had intention to quit smoking due to the pictorial warnings.Conclusions: The pictorial health warnings were not so effective in bringing about changes in smoking behaviour of smokers.

Mobile Phone–Based Personalized and Interactive Augmented Reality Pictorial Health Warnings for Enhancing a Brief Advice Model for Smoking Cessation: Pilot Randomized Controlled Trial

Background Augmented reality (AR) is a novel modality for promoting smoking cessation (SC). AR-visualized adverse consequences for education and smoking prevention have only been evaluated in nonsmokers in previous studies. Objective To assess the feasibility and preliminary effectiveness for SC of AR pictorial health warnings (PHWs) on cigarette packs. Methods We conducted a pilot randomized controlled trial in adult daily smokers in communities in Hong Kong. All participants received AWARD (ask, warn, advise, referral, do-it-again) model–guided SC advice, a warning leaflet, and referral to SC services at baseline. Interactive, chat-based SC support comprising regular messages and real-time support was provided to all participants via instant messaging apps (eg, WhatsApp) for 3 months after randomization. Participants in the intervention group additionally received 6 links to the AR PHWs showing the worsening health status of various organs caused by smoking. The level of the AR PHWs was adjustable to smoking behaviors (ie, smoking duration or daily cigarette consumption) to increase interaction. Participants could swipe, drag, or rotate the 3D PHWs to reinforce their impression of the health consequences of smoking. The primary outcome was self-reported past 7-day point-prevalence abstinence (PPA) at 3 months. The acceptability of the AR intervention was assessed by the proportion of participants who had viewed AR PHWs during the intervention. Participants who viewed AR PHWs further evaluated the perceived effect of the AR PHWs on a scale of 0 (not helpful at all) to 10 (very helpful). Intention to treat was used, and the risk ratio (RR) of the intervention effect was estimated by Poisson regression. Results From April to November 2021, 80 participants were recruited and randomly assigned to intervention (n=40) and control (n=40) groups. Most participants were male (66/80, 83%) and planned to quit beyond 30 days or were undecided (65/80, 81%). The intervention group had a higher but nonsignificant 7-day PPA (7/40, 18% vs 5/40, 13%; RR 1.40, 95% CI 0.48-4.07) and quit attempts (15/40, 38% vs 11/40, 28%; RR 1.36, 95% CI 0.71-2.60) at 3 months than the control group. In the intervention group, 17 of 40 (43%) participants viewed the AR PHWs. The AR PHWs had modest effects on knowledge of the adverse consequences of smoking on personal health (mean score 3.94, SD 3.52), reducing the frequency of buying cigarettes (mean score 3.29, SD 3.08), increasing the perceived importance of quitting (mean score 3.88, SD 3.50), and making the PHWs more disgusting (mean score 3.41, SD 3.08) and horrible (mean score 3.38, SD 3.05). The 3-month self-reported 7-day PPA was higher in those who ever (vs never) viewed the AR PHWs (5/17, 29% vs 2/23, 9%). Conclusions The mobile-based interactive AR PHWs were feasible, and the effectiveness on smoking abstinence warrants further testing. Trial Registration ClinicalTrials.gov NCT04830072; https://clinicaltrials.gov/study/NCT04830072

The Extent of Illicit Cigarette Sales in Five Rural Districts of Pakistan: A Cross-sectional Study.

The Illicit Tobacco Trade (ITT) subverts tobacco control efforts. Cigarette packs sold without legal health warnings undermine efforts to warn the public about the dangers of tobacco. Furthermore, cigarettes sold below minimum retail prices are indicative of tax evasion leading to revenue loss and budgetary deficits in high tobacco-burden economies. The extent of the ITT in rural areas of such countries might differ from urban. We estimated the extent of illicit cigarette sales in selected rural areas of Pakistan. We analyzed cigarette packs collected from 85 villages in Pakistan as part of a cross-sectional consumer survey of 2550 rural households. We classified cigarette packs as noncompliant if these were missing: A text health warning, pictorial health warning (PHW), underage sale prohibition warning, retail price, or manufacturer details. To measure the extent of tax evasion, we estimated the proportion of packs purchased below the legal minimum retail price. Only 35% (429/1228) of rural smokers were able to show their cigarette packs. Out of these, 89% (382/429) of packs were noncompliant with the cigarette packaging and labeling laws. In rural areas, 83% (357/429) of packs did not have PHW and 33.8% (145/429) did not have printed retail prices. Among all packs, 41% (177/429) were purchased below the minimum retail price of 63 Pakistani Rupees and hence highly likely to have evaded taxes. We found a very high previously unreported proportion of noncompliant cigarette packs in selected rural areas of Pakistan indicating weaker implementation of tobacco control laws in rural areas. This paper presents previously unreported estimates of the share of illicit cigarette sales in rural areas of Pakistan. Most packs (89%) in our sample were noncompliant with the packaging and labeling regulations and a significant proportion (41%) were purchased below the minimum price. The extent of illicit tobacco was found to be far greater in rural than in urban areas of Pakistan. Taking advantage of poor law enforcement, the tobacco industry may be complicit in flooding the rural markets with illegal and cheap cigarettes. Given this disparity, law enforcement authorities must focus on rural areas.

Systematic Review: Tobacco Control and Coronary Artery Disease

Backgrounds: The prevalence of cigarette consumption in Indonesia has reached a level that is cause for concern. Currently, more than one-third (36.3%) of Indonesia's population is classified as smokers. The World Health Organization (WHO) ranks Indonesia as the third-largest cigarette market in the world, after China and India. In fact, the prevalence of adult male smoking in Indonesia is the highest (68.8%) in the world, so tobacco consumption has many negative impacts on health, one of which is the main cause of non-communicable diseases (NCDs), such as coronary artery disease (CAD). Tobacco control is one of the efforts that can be made to prevent non-communicable diseases, namely coronary heart disease. Coronary artery disease is a pathological condition that arises due to the accumulation of atheroma in the blood vessels that supply blood to the heart, causing narrowing of the coronary arteries. Objectives: The aim of this study is to identifying tobacco as the main cause of non-communicable diseases such as coronary artery disease and tobacco control policies Methods: The method of this study is a literature review using PRISMA as a guide. Articles obtained from databases such as PubMed and Google Scholar with specific relevant keywords “tobacco AND coronary artery disease”, “tobacco AND Non-communicable disease”, “tobacco control”, and “tobacco policy”. Article restricted to only original study within 2019 until 2023. Results: Tobacco control and prevention efforts that can be carried out regarding NCDs according to the 30 articles are controlling media by a massive pictorial warning; prohibition advertising, promotion, and sponsorship; controlling the price of tobacco by increasing the excise, tax, and selling price; restriction on smoking area, and smoking cessation therapy in a health facility that covered by insurance. Nicotine replacement therapy could be the choice for smoking cessation in CAD patients. Conclusions: Since limited research on smoking cessation therapy, especially in patients with CAD, it is necessary to develop various therapeutic methods that are easier, affordable, and safe.

The Role of Harm Visibility for Pictorial Health Warning Labels on Cigars.

Pictorial health warning labels (HWLs) can communicate the harms of tobacco product use, yet little research exists for cigars. We sought to identify the most effective types of images to pair with newly developed cigar HWLs. In September 2021, we conducted an online survey experiment with US adults who reported using little cigars, cigarillos, or large cigars in the past 30 days (n = 753). After developing nine statements about health effects of cigar use, we randomized participants to view one of three levels of harm visibility paired with each statement, either: (1) an image depicting internal harm not visible outside the body, (2) an image depicting external harm visible outside of the body, or (3) two images depicting both internal and external harm. After viewing each image, participants answered questions on perceived message effectiveness (PME), negative affect, and visual-verbal redundancy (VVR). We used linear mixed models to examine the effect of harm visibility on each outcome, controlling for warning statement. Warnings with both and external harm depictions performed significantly better than the internal harm depictions across all outcomes, including PME (B = 0.21 and B = 0.17), negative affect (B = 0.26 and B = 0.25), and VVR (B = 0.24 and B = 0.17), respectively (all p < .001). Compared to both, the external depiction of harm did not significantly change PME or negative affect but did significantly lower VVR (B = -0.07, p = .01). Future cigar pictorial HWLs may benefit from including images depicting both or external harm depictions. Future research should examine harm visibility's effect for other tobacco pictorial HWLs. The cigar health warning labels (HWLs) proposed by the US Food and Drug Administration are text-only. We conducted an online survey experiment among people who use cigars to examine the effectiveness of warnings with images depicting different levels of harm visibility. We found HWLs with images depicting both an internal and external depiction of cigar harm, or an external depiction of harm alone, performed better overall than images portraying internal depictions of harm. These findings provide important regulatory evidence regarding what type of images may increase warning effectiveness and offer a promising route for future cigar HWL development.

Self-reported attention and responses to cigarette package labels at the end of a two-week randomized trial of cigarette package labeling configurations.

Cigarette package inserts that describe quitting benefits and tips may promote cessation; however, research is needed to understand better their effects, including potentially enhancing the effects of pictorial health warning labels (PHWLs). A randomized trial with a 2×2 factorial design was conducted with adult smokers (n=356) assigned to either small text-only health warning labels (HWLs; control); inserts with cessation messages, and the small text-only HWLs (inserts-only); large PHWLs (PHWLs-only); both inserts and PHWLs (inserts + PHWLs). Participants received a 14-day supply of their preferred cigarettes with packs labeled to reflect their group. Upon finishing the trial, participants reported their past 14-day frequency of noticing, reading, thinking about smoking harms and cessation benefits, talking about labels, and forgoing cigarettes because of the labels. Ordered logistic models regressed these outcomes on labeling groups, and mediation analyses assessed whether attention (i.e. noticing, reading) to labels mediated effects of labeling exposure on other outcomes (i.e. thinking about harms/benefits, talking, forgoing). The inserts + PHWLs group reported higher frequencies than the control group for all outcomes. Compared to the control group, both the inserts-only and PHWLs-only groups reported higher frequency of noticing (AOR=3.53 and 2.46, respectively) and reading labels (AOR=2.89 and 1.71), thinking about smoking risks because of the labels (AOR=1.93 and 1.82), and talking about labels (AOR=2.30 and 2.70). Participants in the inserts-only group also reported more frequent thinking about quitting benefits (AOR=1.98). Attention mediated all labeling effects except for the contrast between PHWLs only and control. Compared to text-only HWLS, cigarette labeling that involves inserts, PHWLs, or both appears more effective at drawing attention to warnings, which mediated the effects on cessation-related psychosocial and behavioral outcomes.

Are Tobacco Companies in Nigeria Complying With Health Warning Label Regulations on Cigarettes and Other Tobacco Products?

BACKGROUND: Nigeria has approved 50% coverage of text and images of pictorial health warning labels (PHWLs) on packages of cigarettes and other tobacco products such as cigars, smokeless tobacco, and loose tobacco. While there is knowledge on the extent to which LMICs like Nigeria adopt the WHO Framework Convention of Tobacco Control (FCTC), there is need to examine the compliance with adopted packaging and labeling policies to generate knowledge for strengthening existing policies and efforts at enforcement. We assessed agreement with FCTC regulations as well as compliance with Nigerian requirements which are not adequate and do not effectively capture all FCTC requirements to identify the gaps being explored by these companies in an environment of poor regulation in Lagos, Nigeria. METHODS: This descriptive study was conducted in Lagos State, Nigeria, from October 2022 to January 2023. A multistage random sampling method was utilized. Four local government areas (LGAs) with a combined population of 16 million, accounting for 70% of the population in Lagos, Nigeria were selected while three points‑of‑sale were randomly picked from two selected wards in each LGA. Empty discarded packs of cigarette and other tobacco products were collected from these outlets. The pack dimensions were measured and assessed for PHWLs, health warning manipulations and cessation assistance. Findings were assessed for compliance with the FCTC and national legislation. For each compliance feature, we calculated the frequencies and percentages of the packs that were compliant. RESULTS: 704 packs: 434 packs of 22 cigarette brands and 270 packs of 17 different tobacco products including cigars, snuff and loose tobacco were included in the study. Of 434 cigarette packs assessed, 50.3% were compliant with 9 indicators measured. These ranged from 48.8% to 55.5% for individual brands. For cessation assistance, image variability and image manipulation, compliance was 0% across all cigarette packs. Out of 270 tobacco product packs assessed, 10.6% were compliant with the 9 indicators assessed. Of the 12 multinational parent companies and product distributors assessed, the overall level of compliance among them was 24.9%. Level of compliance was noted to very low for companies involved in marketing other tobacco products, ranging from 0% to 20% but moderate for those marketing cigarettes, ranging from 37% to 55.5%. Companies that had no presence or subsidiaries in Nigeria but only export their products were highly non-compliant. CONCLUSIONS: Tobacco companies had low compliance with PHWL on cigarettes and negligible compliance on other tobacco products like cigars, loose and smokeless tobacco. The government should expand and strictly enforce all regulations applying to health warnings, especially on non-cigarette tobacco products and closely monitor companies that merely export their products to the country.

Differential Responses to Cigarette Package Labeling Alternatives Among Adults Who Smoke: Results From a Randomized Trial

Abstract Introduction Little experimental research has evaluated whether the effects of cigarette package inserts with efficacy messages and/or pictorial health warning labels (PHWLs) differ across key subgroups of adults who smoke. Aims and Methods Adults who reported currently smoking (n = 367) were randomly assigned to one of four groups: Small text-only HWLs on pack sides (control); inserts with efficacy messages and small HWLs (inserts-only); PHWLs showing harms of smoking (PHWLs-only); both (inserts + PHWLs). Participants received a 14-day supply of cigarettes labeled to reflect their group. Every evening over 2 weeks, participants reported forgoing and stubbing out cigarettes before they finished smoking over the prior 24 hours, combined into a binary indicator of either behavior (eg, forgoing/stubbing). Separate mixed-effects logistic models were estimated to evaluate moderation of labeling group contrasts (ie, PHWLs vs not; inserts vs. not; inserts-only vs. inserts + PHWLs; PHWLs-only vs. inserts + PHWLs) by baseline covariates (self-efficacy to quit, intention to quit, education, health literacy, and time discounting), predicting day-level forgoing/stubbing. Results Education moderated PHWL effects, with PHWLs predicting more forgoing/stubbing only among those with low education (OR = 4.68, p &amp;lt; .001). Time discounting moderated insert effects, with inserts promoting forgoing/stubbing only among those with low time discounting (ie, lower impulsivity; OR = 4.35, p &amp;lt; .001). Conclusions Inserts with efficacy messages appear effective mostly among people with low time discounting, whereas PHWLs appear most effective among those with low education, suggesting their potential to address education-related disparities. Labeling strategies appeared equally effective across subgroups defined by self-efficacy to quit, quit intention, and health literacy. Combining inserts with PHWLs did not appear to mitigate moderation effects. Implications This randomized trial with adults who smoke suggests that cigarette packs with inserts describing cessation benefits and tips can promote cessation-related behaviors (ie, forgoing or stubbing out cigarettes) among those with low-time discounting (ie, low impulsivity). Alternative interventions may be needed for people with high-time discounting, as found in cessation trials. PHWLs appear most effective among those with low education, potentially addressing education-related disparities. No differential effects were found for those with different levels of self-efficacy to quit, quit intentions, or health literacy. Combining inserts and PHWLs may not be more effective than either alone.

Managing Fear Responses: A Qualitative Analysis of Pictorial Warning Labels Five Years Post-Plain Packaging.

Although pictorial warning labels (PWLs) now dominate tobacco packages sold in many countries, few studies have probed how people who smoke respond to the threats presented several years post-plain packaging and larger PWLs. Understanding how people manage the fear and dissonance PWLs arouse, and the strategies they use to rationalize, diminish, and reject risk messages, could inform future PWL design. We undertook 27 in-depth interviews with people aged 18 and over (16 female, 8 Māori, and 13 aged ≤35) who smoked roll-your-own tobacco and lived in Aotearoa New Zealand. We probed participants' views on current PWLs and how they responded to these, then asked them to use alternative images and headlines to create new PWLs. We drew on the extended parallel processing model to interpret the data, which we analyzed using a reflexive thematic analysis approach. People who smoke dislike PWLs, which they think reduce them to diseased body parts. While a minority thought existing PWLs were believable and effective, most reported avoiding PWLs by hiding or cognitively blocking them. Participants used diverse counterarguments to diminish PWLs' relevance and impact, and a minority displayed strong reactance. Several suggested developing PWLs that recognized them as whole people rather than patients in waiting, and recommended greater use of testimonials, particularly from people who had successfully become smoke free. PWLs using more holistic and diverse messages could elicit greater engagement and responsiveness, and motivate cessation more effectively than existing health-oriented warnings. Our findings suggest existing PWLs, which aim to arouse fear of ill health, could be complemented by warnings that emphasize the benefits of quitting. Continuing to use threat-based PWLs could stimulate greater rationalization and reactance. By contrast, PWLs that aim to illustrate how cessation could benefit people who smoke and their families, rather than instill a fear of disease, could avoid message rejection and counter-argument, and may prove a more powerful way of motivating cessation.

Implementing pictorial health warning labels on waterpipe tobacco products in Lebanon: A policy framework analysis of content, actors, context, and process.

Lebanon has one of the world's highest waterpipe (WP) consumption rates. Research has documented the effectiveness of implementing pictorial health warning labels (PHWLs) on WP products at encouraging smoking cessation and discouraging youth uptake of smoking. This study aims to gain insight into key informants' (KIs) views on the issuance, implementation, and compliance of a decree for PHWLs on WP products. Thirteen KIs (policymakers, media, and international/local non-government organization representatives) were interviewed online and asked about potential barriers and facilitators they saw to issuing and implementing a PHWL decree. They were shown examples of PHWLs and asked about processes needed for implementation and compliance. The policy triangle framework (content, actors, context, and process) was used to interpret findings. Although there was clear discrepancy and ambiguousness among the KIs' views regarding process and actors, there was more consensus and clarity around context and content. Challenges to implementation were: (1) multiple sources of production and supply of WP (2) uncertainty regarding the responsible actors for each step, (3) prioritization of a tobacco control decree amidst a political and economic crisis, and (4) challenges to practicality of applying PHWL on the WP given its multi-component nature. This research provides an in-depth understanding of KI's views regarding content, actors, context, and process in relation to the issuance, implementation, and compliance to PHWLs on WP products. Noted challenges require careful consideration if progress is to be made to introduce PHWLs. A growing research base has documented the potential effectiveness of PHWLs on reducing WP consumption.Findings of this study show that implementing PHWLs on WP products requires a distinct understanding of the policy environment and context, as well as content, actors, and processes.Implementing PHWLs on waterpipe tobacco products needs to address the complex nature of waterpipe smoking as a multi-component tobacco use method.

Are Tobacco Companies in Nigeria Complying With Health Warning Label Regulations on Cigarettes and Other Tobacco Products?

BACKGROUND: Nigeria has approved 50% coverage of text and images of pictorial health warning labels (PHWLs) on packages of cigarettes and other tobacco products such as cigars, smokeless tobacco, and loose tobacco. While there is knowledge on the extent to which LMICs like Nigeria adopt the WHO Framework Convention of Tobacco Control (FCTC), there is need to examine the compliance with adopted packaging and labeling policies to generate knowledge for strengthening existing policies and efforts at enforcement. We assessed agreement with FCTC regulations as well as compliance with Nigerian requirements which are not adequate and do not effectively capture all FCTC requirements to identify the gaps being explored by these companies in an environment of poor regulation in Lagos, Nigeria. METHODS: This descriptive study was conducted in Lagos State, Nigeria, from October 2022 to January 2023. A multistage random sampling method was utilized. Four local government areas (LGAs) with a combined population of 16 million, accounting for 70% of the population in Lagos, Nigeria were selected while three points‑of‑sale were randomly picked from two selected wards in each LGA. Empty discarded packs of cigarette and other tobacco products were collected from these outlets. The pack dimensions were measured and assessed for PHWLs, health warning manipulations and cessation assistance. Findings were assessed for compliance with the FCTC and national legislation. For each compliance feature, we calculated the frequencies and percentages of the packs that were compliant. RESULTS: 704 packs: 434 packs of 22 cigarette brands and 270 packs of 17 different tobacco products including cigars, snuff and loose tobacco were included in the study. Of 434 cigarette packs assessed, 50.3% were compliant with 9 indicators measured. These ranged from 48.8% to 55.5% for individual brands. For cessation assistance, image variability and image manipulation, compliance was 0% across all cigarette packs. Out of 270 tobacco product packs assessed, 10.6% were compliant with the 9 indicators assessed. Of the 12 multinational parent companies and product distributors assessed, the overall level of compliance among them was 24.9%. Level of compliance was noted to very low for companies involved in marketing other tobacco products, ranging from 0% to 20% but moderate for those marketing cigarettes, ranging from 37% to 55.5%. Companies that had no presence or subsidiaries in Nigeria but only export their products were highly non-compliant. CONCLUSIONS: Tobacco companies had low compliance with PHWL on cigarettes and negligible compliance on other tobacco products like cigars, loose and smokeless tobacco. The government should expand and strictly enforce all regulations applying to health warnings, especially on non-cigarette tobacco products and closely monitor companies that merely export their products to the country.

Assessment of compliance to packaging laws in Pakistan by local and international tobacco manufacturing companies

Background: Tobacco control law is one of the most effective means of controlling the widespread use of tobacco. However, enforcement of this law in Pakistan is weak. Aim: To analyse compliance to cigarette packaging laws by tobacco brands in Pakistan. Methods: This cross-sectional study was conducted in August and September 2022. We collected data on tobacco packaging of 100 cigarette brands from 24 outlets selling cigarettes in different parts of Karachi, Pakistan. To assess compliance, we scored the products on a scale of 0–5, based on regulations issued by the Ministry of National Health Services, Regulations and Coordinations. Results: Fifty-five of the 100 assessed brands were manufactured locally and 45 were imported. Only 28% of the brands fully complied to the packaging law. Although 54.5% of the brands had a 4/5 score for the presence of pictorial warnings on the packaging, the sizes of pictorial warnings did not cover up to 60.0% of the total package area in most cases. More than 85.0% of the brands severely lacked the placement of a small health warning on the side of the box, and 5 products did not have this warning at all. Conclusion: Adherence to tobacco packaging law in Pakistan is poor, as majority of the brands lacked at least one component of the regulations. Pakistani authorities need to strengthen monitoring and enforcement of the law to ensure compliance by tobacco manufacturing companies.

IJCM_141A: Determinants of Awareness on Pictorial Health Warnings on Tobacco Products in the Eastern State of India

Background: Pictorial health warnings (PHWs) are an effective strategy to deter or reduce tobacco use. Objective: This study was conducted to determine the level of awareness of PHWs on tobacco products and their correlates among adults attending the outpatient department (OPD) of a tertiary care facility in Eastern India Methodology: This cross-sectional study was conducted over a period of 3 months among 307 patients aged 18 to 65. A pre-tested, semi-structured questionnaire was used for the collection of data, and inferential statistics were performed using JAMOVI version 2.3.21. Results: About 84% (95% CI, 78.9 - 87.2) of the participants were aware of PHW on tobacco products [82.4% (95% CI, 77.8 - 86.3)] for smoked forms, 51.8% (95% CI, 46.2 - 57.3) for smokeless forms. More than half of the participants felt that the current PHW was ineffective. Male [AOR, 3.13; 95% CI, 1.33 - 7.37], being educated [AOR, 3.37; 95% CI, 1.29 - 8.76], employment [AOR, 5.65; 95% CI, 1.21 - 26.30] and ever-tobacco use [AOR, 3.23; 95% CI, 1.43 - 7.2] were found to be independent correlates of PHW awareness for smoked tobacco products, whereas as being male [AOR, 2.01; 95% CI, 1.02 - 3.95] and being young (18-30 years) [AOR, 2.51; 95% CI, 1.08 - 5.84] were found to be the independent predictors of PHW awareness for smokeless tobacco products (SLT). Conclusion: Four out of every five individuals were aware of pictorial health warnings (PHW) on tobacco products; however, it was much less for SLT compared to smoked tobacco products. Male, being educated, employment and ever-tobacco use were independent correlates of awareness for the smoked form of tobacco products, whereas being young (18-30 years) was an independent predictor of awareness for SLT.

Effectiveness of pictorial warnings on food fat content: consumers’ perception and neurological responses

PurposeThis paper delves into evaluating the effectiveness of warning messages as a deterrent against excessive fat consumption. It examines how consumers perceive the fat content of food products when presented with two distinct label types: (1) a textual warning, providing succinct information about the fat content, and (2) a pictorial warning, offering a visual representation that immediately signifies the fat content.Design/methodology/approachTwo quantitative studies were carried out. Study 1 employed a questionnaire to evaluate the efficacy of textual and pictorial warning messages on high- and low-fat food products. Similarly, Study 2 replicated this comparison while incorporating a neuromarketing instrument to gauge participants’ cerebral reactions.FindingsResults indicate that pictorial warnings on high-fat foods significantly deter consumers’ purchasing intentions. Notably, these pictorial warnings stimulate the left prefrontal area of the cerebral cortex, inducing negative emotions in consumers and driving them away from high-fat food items.Originality/valueWhile the influence of images over text in shaping consumer decisions is well understood in marketing, this study accentuates the underlying mechanism of such an impact through the elicitation of negative emotions. By understanding this emotional pathway, the paper presents fresh academic and managerial perspectives, underscoring the potency of pictorial warnings in guiding consumers towards healthier food choices.Highlights Textual warnings do not seem to discourage high-fat product consumption.A pictorial warning represents the fat content of an equivalent product.Pictorial warnings decrease the intention to purchase a high-fat product.Pictorial warnings determine an increase in negative emotions.

Association between textual and pictorial warnings on tumbac (waterpipe tobacco) boxes and motivation to quit waterpipe smoking among Lebanese and Iraqi adolescents

BackgroundWaterpipe tobacco smoking has increased tremendously at a global level among all age groups, particularly young people. Previous studies have examined the impact of waterpipe tobacco pictorial health warnings on adults but scarce studies were done on adolescents. The aim of this study was to assess the association of textual versus pictorial warnings on tumbac boxes and the motivation to quit waterpipe smoking among adolescents located in two Eastern Mediterranean countries Lebanon and Iraq.MethodsA cross-sectional study was conducted between May and November 2022, involving 294 adolescents waterpipe smokers from Lebanon and Iraq. The questionnaire included the Lebanese Waterpipe Dependence Smoking-11, the Depression, Anxiety and Stress Scale, the Waterpipe Harm Perception Scale, Waterpipe Knowledge Scale, Waterpipe Attitude Scale, the Fagerstrom Test for Nicotine Dependence, and the Motivation to Stop Scale.ResultsWhen adjusting the results over confounding variables, the results showed that compared to finding the warnings to stop smoking not efficacious at all, adolescents who find the warnings moderately (aOR = 2.83) and very (aOR = 6.64) efficacious had higher motivation to quit. Compared to finding the warnings not increasing their curiosity for information about how to stop waterpipe smoking at all, participants who confessed that warnings increased their curiosity a little (aOR = 2.59), moderately (aOR = 3.34) and very (aOR = 3.58) had higher motivation to quit. Compared to not considering changing the tumbac brand if the company uses pictorial warnings, adolescents who would consider changing the tumbac brand (aOR = 2.15) had higher motivation to quit.ConclusionPictorial and textual warnings on waterpipe packs were associated with higher motivation to stop waterpipe smoking. Public health education programs for this purpose seem warranted.