Textual Health Warnings Research Articles

Restricting the content of alcohol advertising and including text health warnings: A between-group online experiment with a non-probability adult sample in the United Kingdom.

Statutory options for restricting alcohol advertising include limiting it to product-orientated information and requiring health warnings. We assess the impact of removing positive contextual factors from alcohol advertising and including a health warning among adults in the United Kingdom (UK). We conducted a 2 × 2 online between-group experiment with adults (18+) (n = 2421) recruited from a non-probability research panel in the United Kingdom. Participants were randomized to see an alcohol (vodka) advertisement (advert) which varied by context (no context vs. imagery depicting positive social interactions around alcohol) and message (multiple text health warning vs. "drink responsibly"). The multiple text health warning, based on recent legislation in Ireland, comprised three separate warnings (liver disease, cancers, drinking during pregnancy) and a web address for alcohol-related information and support. The "drink responsibly" control reflected the self-regulatory messages commonly used by alcohol companies. Participants rated the advert on 7-point scales for advert attractiveness, product appeal, trial intentions, perceived harm, and whether it made drinking alcohol seem enjoyable. Removing the positive social context reduced positive advert and product reactions (difference in estimated marginal means [EMM]: -1.57 [makes drinking alcohol seem enjoyable] to -0.23 [intention to try]). Including the multiple text health warning also reduced positive advert and product reactions (difference in EMM: -0.55 [advert attractiveness] to -0.25 [intention to try]) and increased perceived product harm (difference in EMM: +0.25). There were no interactions between advert context and message for any outcome. Restricting content and including a multiple text health warning (compared to a "drink responsibly" message) may attenuate the persuasive impact of alcohol advertising and increase perceived product harm. Further research is needed to examine different degrees of content restrictions, alternative warning content and design, generalizability to different alcohol products and advert formats, and whether the impact of content controls varies among population subgroups.

Effect of alcohol ad content regulations on young people: a multi-method study

PurposeUpstream social marketers advocate implementing effective public policies to protect vulnerable populations from the impacts of advertising harmful products. This study aims to explore how alcohol ad content restrictions (as practised in some countries where ads may only convey factual information and objective properties of alcohol products) versus non-regulated advertising affect consumers’ product perceptions, attitude towards the ad and desire to drink. This study also examines how such restrictions influence the noticeability of text health warnings in ads (signalling alcohol-related risks) depending on their prominence.Design/methodology/approachA multi-method study was used to increase the validity of results. An online quantitative survey (n = 348) and an eye-tracking study (n = 184) were conducted on young French people (15–30). The eye-tracking method is particularly relevant for objectively measuring visual attention.FindingsResults show that content restrictions on alcohol advertising reduce ad appeal and desire to drink. A more prominent format enhanced attentional processing of the text warning, whereas none of the tested ad contents influenced its noticeability.Practical implicationsThis study assesses scientific evidence of the effect on alcohol ad content regulations adopted by some countries and provides arguments for upstream social marketers to inform and influence policymakers.Originality/valueTo the best of the authors’ knowledge, this is the first multi-method study that assesses the effect of regulated vs non-regulated alcohol ads in terms of persuasion and of text warning visibility.

Compliance with COTPA (Packaging and Labeling) Rules, 2008 and its amendments in smokeless tobacco products sold across Mangaluru taluk, Karnataka, India.

India introduced the Cigarettes and Other Tobacco Products Act (COTPA) (Packaging and Labeling [P and L]) Rules in 2008. These rules utilize the tobacco package to communicate tobacco-caused harms; it also seeks to restrict the delivery of misleading information about the product on the pack. The enormous burden of tobacco-related oral cancers in India necessitates the compliance with the law regarding presentation of information in powerful and salient ways, intentionally designed to increase the awareness in target individuals. The objectives of the study are to assess the compliance to implementation and enforcement of the COTPA (P and L) Rules, 2008 and its amendments in 2014 and 2018. Chewing tobacco products were retrieved and evaluated for compliance with the law. The specified pictorial and textual health warnings, area, clarity, rotation, and language were assessed as per the recommendations. Even though chewing tobacco products in India have introduced pictorial and textual health warnings, majority of them do not comply with the law. The products displayed the specified health warnings on a total of 70.6% on average, failing to abide by the government-specified average of 85%. 50% of the products did not follow the rotation of pictorial and textual health warning even after completion of the interregnum period of 12 months (September 2019). To ensure consumers' right to be informed about the health risks from a product, all the details regarding the contents, health warnings and messages, and product care instructions must be mentioned as specified under the law.

A health policy analysis of the implementation of the National Tobacco Control Act in Nigeria.

Non-communicable diseases (NCDs) have emerged as a public health issue of concern in Nigeria. The massive increase in tobacco use amongst different population groups is a common NCDs risk factor. To this effect, the National Tobacco Control Act (NTCA) was enacted following the WHO Framework Convention on Tobacco Control (FCTC). This article conducts a health policy agenda-setting analysis of the NTCA using the Kingdon's multiple streams model and analyses its implementation using the Principal-Agent theory. The purposive and snowballing sampling methods were used to select and review relevant peer-review literature. Other data sources included gray literature, government reports, Non-Governmental Organization briefs and media resources. Though NTCA conforms to WHO FCTC, Nigeria only domesticated her obligation to this framework legislatively while the executive and administrative measures were found lacking. The challenges and gaps identified in the NTCA implementation include; revision of textual health warnings and lack of pictorial health warnings on cigarette packs, poor taxation, and the National Tobacco Control Commission's (NTCC) lack of regulatory autonomy, hence, the poor policy implementation reported in this article. To effectively implement NTCA, a review of textual warnings, enforcement of pictorial warnings, regulatory autonomy of the NTCC and review of the tobacco taxation are suggested to help in the prevention and control of NCDs.

Do Young Adults Attend to Health Warnings in the First IQOS Advertisement in the U.S.? An Eye-Tracking Approach.

In October 2019, a heated tobacco product (HTP) IQOS debuted in the United States. This study examined young adults' attention and cognitions in response to an IQOS ad that carried two mandated textual health warnings (Surgeon General's warning and nicotine warning), and how their vaping and smoking status may interact with attention patterns to affect attitude and intention to use IQOS. In November 2019, college students (N = 164) viewed IQOS' first U.S. magazine ad and two distractor ads. Viewing patterns were recorded with eye-tracking. Masked recall and aided recognition, attitude and intention towards IQOS use were later assessed with self-report. Ordinary Least Squares (OLS) regressions and moderated mediation analyses examined the associations between visual attention and viewers' cognitions about IQOS use. Promotional content attracted significantly more attention compared to the warnings. Attention to the Surgeon General's warning but not to the nicotine warning was associated with recall and recognition of the warning's content. For ever-vapers, greater attention allocation to the promotional content in the IQOS ad was associated with more favorable attitude toward IQOS use, which was in turn positively associated with intention to use IQOS. Attention allocation to the warnings did not affect attitude or intentions, regardless of tobacco use status. The results revealed the effects of IQOS promotional content overshadowed the two health warnings in influencing young people's attitude and intention to use IQOS. Young adults who vaped were more vulnerable to HTP advertising with respect to future use and vaping may be a gateway to HTP use. This is the first eye-tracking study examining attention and cognitions associated with the new IQOS ad exposure among young adults. Promotional content in the ad attracted significantly more attention than the two warnings combined. Attention to the Surgeon General's warning but not to the nicotine warning was associated with recall and recognition of the warning's content. Greater attention allocation to the promotional content led to a more favorable attitude toward IQOS use which was associated with increased intention to use IQOS for ever-vapers. However, greater attention allocation to the warnings did not affect attitude or intentions to use IQOS.

The effectiveness of plain packaging in discouraging tobacco consumption in Australia.

The removal of all branding and promotions from tobacco products, known as 'plain packaging', is intended to decrease tobacco consumption. Here we examine the effectiveness of Australia's plain packaging law, which coincided with a change in graphic and text health warnings, by using nationally indicative data 5 years post implementation. We measured the effect of the law on smoking prevalence, tobacco expenditure, expenditure intensity and quantity of tobacco consumed, using New Zealand as a control country in a difference-in-differences research design. We uncover a substitution effect that is robust to different specifications and control countries. In response to the policy, smokers switched from more expensive to cheaper cigarettes and reduced their overall tobacco expenditure and expenditure intensity. However, as smoking became less costly, smokers consumed more cigarettes. To discourage such substitution and to help the policy achieve its intended outcomes, policymakers should consider implementing auxiliary measures, such as taxes or price floors.

Reactions to graphic and text health warnings for cigarettes, sugar-sweetened beverages, and alcohol: An online randomized experiment of US adults

We aimed to examine reactions to graphic versus text-only warnings for cigarettes, SSBs, and alcohol. A convenience sample of US adults completed an online survey in 2018 (n = 1352 in the analytic sample). We randomly assigned participants to view a: 1) text-only warning without efficacy information (i.e., message intended to increase consumers' confidence in their ability to stop using the product), 2) text-only warning with efficacy information, 3) graphic warning without efficacy information, or 4) graphic warning with efficacy information. Participants viewed their assigned warning on cigarettes, SSBs, and alcohol, in a random order. Across product types, graphic warnings were perceived as more effective than text-only warnings (p < .001) and led to lower believability, greater reactance (i.e., resistance), more thinking about harms, and lower product appeal (all p < .05); policy support did not differ. Compared to SSB and alcohol warnings, cigarette warnings led to higher perceived message effectiveness, believability, fear, thinking about harms, policy support, and greater reductions in product appeal (all p < .05). The efficacy information did not influence any outcomes. Graphic warnings out-performed text-only warnings on key predictors of behavior despite causing more reactance.

Quasi-experimentally examining the impact of introducing tobacco pictorial health warnings: Findings from the International Tobacco Control (ITC) 4C and Netherlands surveys in the Netherlands, Australia, Canada, United Kingdom, and the United States

BackgroundOur study evaluated the short-term impact of introducing European Union’s tobacco pictorial health warnings (PHWs). MethodsLongitudinal data were collected at two time-points from adult smokers, participating in the International Tobacco Control (ITC) surveys, conducted in the Netherlands, Australia, Canada, the United Kingdom and the United States. In the Netherlands, textual health warnings (THWs) were replaced by PHWs between both time-points. Health warning policies did not change in the other countries. Data from continuing smokers were used (N = 3,487) and analyzed using Generalized Estimating Equations. ResultsBetween both time-points, only Dutch smokers showed increases in noticing health warnings (β = 0.712, p < 0.001), self-reports of health warnings leading to a cognitive response such as thinking about smoking health-risks (SHRs) (OR = 1.834, p < 0.001), knowledge about SHRs (β = 0.369, p < 0.001), and avoiding health warnings (OR = 9.869, p < 0.001). However, Dutch smokers showed no changes in attitude towards smoking (β = 0.035, p = 0.518), intention to quit smoking (OR = 0.791, p = 0.157), self-efficacy to quit smoking (β=-0.072, p = 0.286), or reporting that health warnings helped them to resist having a cigarette (OR = 1.091, p = 0.714). ConclusionsResults suggest that introducing the European PHWs was effective in provoking changes closely related to health warnings, but there was no direct impact on variables more closely related to smoking cessation.

Health warnings promote healthier dietary decision making: Effects of positive versus negative message framing and graphic versus text-based warnings

Food product health warnings have been proposed as a potential obesity prevention strategy. This study examined the effects of text-only and text-and-graphic, negatively and positively framed health warnings on dietary choice behavior. In a 2 × 5 mixed experimental design, 96 participants completed a dietary self-control task. After providing health and taste ratings of snack foods, participants completed a baseline measure of dietary self-control, operationalized as participants' frequency of choosing healthy but not tasty items and rejecting unhealthy yet tasty items to consume at the end of the experiment. Participants were then randomly assigned to one of five health warning groups and presented with 10 health warnings of a given form: text-based, negative framing; graphic, negative framing; text, positive framing; graphic, positive framing; or a no warning control. Participants then completed a second dietary decision making session to determine whether health warnings influenced dietary self-control. Linear mixed effects modeling revealed a significant interaction between health warning group and decision stage (pre- and post-health warning presentation) on dietary self-control. Negatively framed graphic health warnings promoted greater dietary self-control than other health warnings. Negatively framed text health warnings and positively framed graphic health warnings promoted greater dietary self-control than positively framed text health warnings and control images, which did not increase dietary self-control. Overall, HWs primed healthier dietary decision making behavior, with negatively framed graphic HWs being most effective. Health warnings have potential to become an important element of obesity prevention.

Efektifitas tulisan dan gambar peringatan kesehatan pada produk rokok terhadap kesadaran merokok di Kabupaten Badung, Bali-2015

Starting in June 2014 tobacco products circulating in Indonesia must be accompanied by pictures and written health warnings. Pictorial warnings can raise public awareness about the impact of smoking, and advocates people to stop smoking. The research objective is to analyze changes in the awareness of smokers after the Ministry of Health policy writing and picture health warnings on the pack of cigarettes. This is an observational study with sample of the population of smokers in Badung. The sample size is 100 people. Sampling is using cluster sampling method, the number of clusters as many as 10 clusters and each cluster includes 10 respondents, 10 clusters selected by PPS. Primary data collection techniques and awareness about the characteristics of smokers using a questionnaire by the officer. Analysis of data using statistical multivariance. The results of the research article health warnings on a cigarette can alter consciousness quit smoking the next 12 months amounted to 74.2% of smokers. Picture health warnings on a cigarette can alter the consciousness of quit smoking the next 12 months amounted to 91.2% of smokers. Cigarettes contain writings average time quitting is 50.42 months and picture health warnings on a cigarette average of 18.78 months to quit smoking. There is a significant difference in the average time a smoker stopped smoking after writing and picture health warnings. We conclude that text health warnings and picture health warnings on a cigarette can raise awareness to quit smoking.

Motivation to quit smoking and acceptability of shocking warnings on cigarette packages in Lebanon.

IntroductionHealth warnings on tobacco packages have been considered an essential pillar in filling the gap of knowledge and communicating the health risks of tobacco use to consumers. Our primary objective was to report the perception of smokers on the textual health warnings already appearing on tobacco packages in Lebanon versus shocking pictures about the health-related smoking consequences and to evaluate their impact on smoking behaviors and motivation.MethodsA pilot cross-sectional study was undertaken between 2013 and 2015 in five hospitals in Lebanon. Participants answered a questionnaire inquiring about sociodemographic characteristics, chronic respiratory symptoms, smoking behavior and motivation to quit smoking. Only-text warning versus shocking pictures was shown to the smokers during the interview.ResultsExactly 66% of the participants reported that they thought shocking pictorial warnings would hypothetically be more effective tools to reduce/quit tobacco consumption compared to only textual warnings. Also, 31.9% of the smokers who were motivated to stop smoking reported that they actually had stopped smoking for at least 1 month secondary to the textual warnings effects. A higher motivation to quit cigarette smoking was seen among the following groups of smokers: males (odds ratio [OR] =1.8, P=0.02), who had stopped smoking for at least 1 month during the last year due to textual warning (OR =2.79, P<0.001), who considered it very important to report health warning on cigarette packs (OR =1.92, P=0.01), who had chronic expectoration (OR =1.81, P=0.06) and who would change their favorite cigarette pack if they found shocking images on the pack (OR =1.95, P=0.004).ConclusionLow-dependent smokers and highly motivated to quit smokers appeared to be more hypothetically susceptible to shocking pictorial warnings. Motivation to quit was associated with sensitivity to warnings, but not with the presence of all chronic respiratory symptoms.

Tobacco plain packaging: Evidence based policy or public health advocacy?

In December 2012, Australia became the first country to require all tobacco products be sold solely in standardised or 'plain' packaging, bereft of the manufacturers' trademarked branding and colours, although retaining large graphic and text health warnings. Following the publication of Sir Cyril Chantler's review of the evidence on the effects of plain tobacco packaging, the Ministers of the United Kingdom Parliament voted in March 2015 to implement similar legislation. Support for plain packaging derives from the belief that tobacco products sold in plain packs have reduced appeal and so are more likely to deter young people and non-smokers from starting tobacco use, and more likely to motivate smokers to quit and stay quit. This article considers why support for the plain packaging policy has grown among tobacco control researchers, public health advocates and government ministers, and reviews Australian survey data that speak to the possible introductory effect of plain packaging on smoking prevalence within Australia. The article concludes by emphasising the need for more detailed research to be undertaken before judging the capacity of the plain packaging policy to deliver the multitude of positive effects that have been claimed by its most ardent supporters.

The effect of plain cigarette packaging on attention to hea»warnings

BackgroundWhile the Australian Government pushes ahead with the introduction of standardised packaging for tobacco products, the UK Government completed a consultation on this issue in August, 2012. There are several potential benefits, including scope for increasing the effectiveness of health warnings. A recent review suggests that standardised packaging increases the salience of health warnings. Notably, however, the review identified only one study using the most direct measure available to investigate attention: eye movements. The sharpest vision is produced by the central retina, so we use rapid (saccadic) eye movements to fixate on different parts of an image and accrue visual information. By use of eye tracking technology commonly used in psychological research to record eye movements, fixation times on different areas of an image can be calculated as a proxy for attention. Branding is of course designed to be eye-catching, taking advantage of our eyes' tendency to seek areas of high image contrast. Consistent with this fact, removal of branding in the aforementioned study increased the number of saccades towards health warnings, at least for non-smokers or non-daily smokers. However, this result was obtained with graphic warning labels whereas, in the UK, front-of-pack warnings are text only. We aimed to examine the effect of plain packaging on text health warnings by presenting participants with a mocked-up display of branded and plain packaged cigarette packs and asking them to select a pack for purchase. Methods28 adults were recruited by convenience sampling (six men, age 18–40 years, mean age 23·29 years), and consisted of daily (n=9), weekly (n=7), non (n=8), and ex (n=4) smokers. Participants viewed displays containing six packets of cigarettes, with each of the two current UK text health warnings present on three packets. Displays always contained the same six brands, but brand position and assignment of the health warnings was randomised in every trial. Each participant received six consecutive presentations, which alternated between all branded and all plain displays (with order counterbalanced across participants). A mouse pointer appeared 5 s after display onset to allow brand selection, which also ended the trial. A video eye tracker recorded eye movement data. The key measure was the proportion of time participants spent fixating health warnings compared with the rest of the packet, which was either plain or contained the branding. FindingsAs expected, most time was spent looking at branding. Crucially, however, fixation times on warning labels increased in the unbranded compared with the branded presentations (18·1%vs 15·8%). This difference was not uniform across the experiment, but rather was significant only in the first pair of trials (paired-sample t test, p=0·043). InterpretationThe finding suggests that in contexts without recent habituation to warning labels (eg, first-time smokers) plain packaging helps to redirect the eyes towards text-only health warnings. However, the effect appears transient relative to that obtained with graphic warnings. Hence we suggest that a change to plain packaging might be most profitable if accompanied by a shift to front-of-packet graphic warning labels. FundingNone.

Effectiveness of the European Union text-only cigarette health warnings: findings from four countries

The European Commission requires tobacco products sold in the European Union to display standardized text health warnings. This article examines the effectiveness of the text health warnings among daily cigarette smokers in four Member States. Data were drawn from nationally representative samples of smokers from the International Tobacco Control Policy Evaluation Project surveys in France (2007), Germany (2007), the Netherlands (2008) and the UK (2006). We examined: (i) smokers' ratings of the health warnings on warning salience, thoughts of harm and quitting and forgoing of cigarettes; (ii) impact of the warnings using a Labels Impact Index (LII), with higher scores signifying greater impact; and (iii) differences on the LII by demographic characteristics and smoking behaviour. Scores on the LII differed significantly across countries. Scores were highest in France, lower in the UK, and lowest in Germany and the Netherlands. Across all countries, scores were significantly higher among low-income smokers, smokers who had made a quit attempt in the past year and smokers who smoked fewer cigarettes per day. The impact of the health warnings varies greatly across countries. Impact tended to be highest in countries with more comprehensive tobacco control programmes. Because the impact of the warnings was highest among smokers with the lowest socioeconomic status (SES), this research suggests that health warnings could be more effective among smokers from lower SES groups. Differences in warning label impact by SES should be further investigated.

Recall of tobacco pack health warnings by the population in Ukraine and its association with the perceived tobacco health hazard

After years of prevalence of smoking increase, Ukraine observes its decline. Recent tobacco control measures included smoke-free policies, new textual health warnings (THW) since late 2006, ban of outdoor tobacco advertising since January 2009 and tobacco tax increase since late 2008. The objective was to estimate potential contribution of THW to smoking decline process in Ukraine. The study is based on a nationwide omnibus survey of 2008 Ukrainian adults (18+). quitting smoking after 2006 and perception of tobacco-related hazards. To measure the exposure to THW respondents were asked to describe the warnings they recall. Multivariate regression analysis was performed in SPSS 15.0. Those who considered health hazard of smoking as serious were significantly more likely to quit. Male smokers were more likely to perceive health hazard if they recalled health warnings 'Smoking is addictive, do not start to smoke!' and 'Smokers die early'. THW reach those groups of the population they are aimed to and may potentially result in consequent quitting smoking in male smokers.