Understanding Why Pictorial Cigarette Pack Warnings Increase Quit Attempts.
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ABSTRACT:
SUBMITTER: Brewer NT
PROVIDER: S-EPMC6265120 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Background:Pictorial warnings on cigarette packs are a cost-effective policy-level intervention for smoking cessation; however, little research has examined changes in the impact of warnings over time, especially shortly following the first exposure to pictorial warnings. We sought to characterize the trajectories of responses to pictorial cigarette pack warnings soon after first exposure. Methods:Participants were 2149 adult smokers in North Carolina and California, United States. In 2014-2015, we randomized smokers to have pictorial (intervention) or text-only (control) warnings on their cigarette packs for 4 weeks. Weekly surveys assessed psychosocial and behavioral outcomes. Results:After 1 week, smokers in the intervention arm reported higher levels of most outcomes, compared with the control arm. Over subsequent weeks, smokers in both trial arms had decreases in thinking about the harms of smoking (? = -0.046), positive (? = -0.036), and negative (? = -0.042) smoking reinforcement attitudes, and increases in quit intentions (? = 0.070) and cigarette forgoing (? = 0.137) (all p < .05). Only negative affective reactions decreased more in the intervention versus control condition (pinteraction < .01). Conclusions:The impact of pictorial cigarette pack warnings on emotions and cognitions may wane over time. In contrast, quit intentions and cigarette forgoing may continue to increase, at least during the initial period after introduction. Rotation of pictorial warnings may help prevent warning wear-out. Implications:Cigarette smoking is the leading cause of preventable morbidity and mortality and warnings on cigarette packs are a cost-effective policy-level intervention. Prior studies reporting on cigarette pack warning "wear out" have been limited by being short-term single-session experimental studies. Ours are the first study to experimentally examine the trajectories of several outcomes after first exposure and report that the impact of pictorial cigarette pack warnings on emotions and cognitions may wane over time while quit intentions and cigarette forgoing may continue to increase. Trials Registration:ClinicalTrials.gov identifier: NCT02247908; https://clinicaltrials.gov/ct2/show/NCT02247908.
| S-EPMC5991219 | biostudies-literature
Project description:OBJECTIVE:Pictorial warnings on cigarette packs increase motivation to quit smoking. We sought to examine the potential mediating role of negative affect, message reactance (ie, an oppositional reaction to a message) and perceived risk in shaping quit intentions. METHODS:In 2014 and 2015, we randomly assigned 2149 adult US smokers to receive either pictorial warnings or text-only warnings applied to their cigarette packs for 4?weeks. Analyses used structural equation modelling with bootstrapped SEs to test our theorised mediational model. FINDINGS:Pictorial warnings increased negative affect, message reactance and quit intentions (all P<0.001), but not perceived risk (ie, perceived likelihood and severity of harms of smoking). Negative affect mediated the impact of pictorial warnings on quit intentions (mediated effect=0.16, P<0.001). Message reactance weakened the impact of pictorial warnings on quit intentions, although the effect was small (mediated effect=-0.04, P<0.001). Although pictorial warnings did not directly influence perceived risk, the model showed additional small mediation effects on quit intentions through negative affect and its positive association with perceived risk (mediated effect=0.02, P<0.001), as well as reactance and its negative association with perceived risk (mediated effect=-0.01, P<0.001). CONCLUSIONS:Pictorial cigarette pack warnings increased quit intentions by increasing negative affect. Message reactance partially attenuated this increase in intentions. The opposing associations of negative affect and reactance on perceived risk may explain why pictorial warnings did not lead to observable changes in perceived risk.
| S-EPMC6004228 | biostudies-literature
Project description:ObjectiveTo inform international research and policy, we conducted a meta-analysis of the experimental literature on pictorial cigarette pack warnings.Data sourcesWe systematically searched 7 computerised databases in April 2013 using several search terms. We also searched reference lists of relevant articles.Study selectionWe included studies that used an experimental protocol to test cigarette pack warnings and reported data on both pictorial and text-only conditions. 37 studies with data on 48 independent samples (N=33,613) met criteria.Data extraction and synthesisTwo independent coders coded all study characteristics. Effect sizes were computed from data extracted from study reports and were combined using random effects meta-analytic procedures.ResultsPictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes (all p<0.05). Relative to text-only warnings, pictorial warnings (1) attracted and held attention better; (2) garnered stronger cognitive and emotional reactions; (3) elicited more negative pack attitudes and negative smoking attitudes and (4) more effectively increased intentions to not start smoking and to quit smoking. Participants also perceived pictorial warnings as being more effective than text-only warnings across all 8 perceived effectiveness outcomes.ConclusionsThe evidence from this international body of literature supports pictorial cigarette pack warnings as more effective than text-only warnings. Gaps in the literature include a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects.
| S-EPMC4636492 | biostudies-literature
Project description: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.
| S-EPMC6535087 | biostudies-literature
Project description:ImportancePictorial warnings on cigarette packs draw attention and increase quit intentions, but their effect on smoking behavior remains uncertain.ObjectiveTo assess the effect of adding pictorial warnings to the front and back of cigarette packs.Design, setting, and participantsThis 4-week between-participant randomized clinical trial was carried out in California and North Carolina. We recruited a convenience sample of adult cigarette smokers from the general population beginning September 2014 through August 2015. Of 2149 smokers who enrolled, 88% completed the trial. No participants withdrew owing to adverse events.InterventionsWe randomly assigned participants to receive on their cigarette packs for 4 weeks either text-only warnings (one of the Surgeon General's warnings currently in use in the United States on the side of the cigarette packs) or pictorial warnings (one of the Family Smoking Prevention and Tobacco Control Act's required text warnings and pictures that showed harms of smoking on the top half of the front and back of the cigarette packs).Main outcomes and measuresThe primary trial outcome was attempting to quit smoking during the study. We hypothesized that smokers randomized to receive pictorial warnings would be more likely to report a quit attempt during the study than smokers randomized to receive a text-only Surgeon General's warning.ResultsOf the 2149 participants who began the trial (1039 men, 1060 women, and 34 transgender people; mean [SD] age, 39.7 [13.4] years for text-only warning, 39.8 [13.7] for pictorial warnings), 1901 completed it. In intent-to-treat analyses (n = 2149), smokers whose packs had pictorial warnings were more likely than those whose packs had text-only warnings to attempt to quit smoking during the 4-week trial (40% vs 34%; odds ratio [OR], 1.29; 95% CI, 1.09-1.54). The findings did not differ across any demographic groups. Having quit smoking for at least the 7 days prior to the end of the trial was more common among smokers who received pictorial than those who received text-only warnings (5.7% vs 3.8%; OR, 1.53; 95% CI, 1.02-2.29). Pictorial warnings also increased forgoing a cigarette, intentions to quit smoking, negative emotional reactions, thinking about the harms of smoking, and conversations about quitting.Conclusions and relevancePictorial warnings effectively increased intentions to quit, forgoing cigarettes, quit attempts, and successfully quitting smoking over 4 weeks. Our trial findings suggest that implementing pictorial warnings on cigarette packs in the United States would discourage smoking.Trial registrationclinicaltrials.gov Identifier: NCT02247908.
| S-EPMC5458743 | biostudies-literature
Project description:This study evaluated the relationship between interpersonal communication about cigarette health warning labels (HWLs), psychological responses to HWLs, and smoking cessation attempts. Data were analyzed from online consumer panels of adult smokers in Australia, Canada and Mexico, during implementation of new pictorial health warning labels (HWLs) on cigarette packs. Approximately 1000 adult smokers were surveyed in each country every four months (September 2012, January 2013, May 2013, September 2013, January 2014). Only smokers followed for at least two waves were included in the analytic sample. Participants reported the frequency of talking about HWLs in the last month (in general, with family members, and with friends). For each country, poisson generalized estimating equation (GEE) models were estimated to assess the bivariate and adjusted correlates of talking about HWLs. Logistic GEE models regressed having attempted to quit by the subsequent wave on HWL talk, sociodemographics and psychological responses to HWLs. The frequency of HWL talk gradually decreased in Canada (48%-36%) after new HWLs were implemented; an increase (30%-58%) in Australia corresponded with implementation of new HWLs, after which talking stabilized; and the frequency of HWL talk in Mexico was stable over time, where new HWLs are implemented every six months. Talk about HWLs was an independent predictor of subsequent quit attempts in Canada (AOR = 1.50; 95% CI = 1.11-2.02), Australia (AOR = 1.41; 95% CI = 1.05-1.89), and Mexico (AOR = 1.53; 95% CI = 1.11-2.10), as was cognitive responses to HWLs (Australia AOR = 1.66; 95% CI = 1.22-2.24; Canada AOR = 1.56; 95% CI = 1.15-2.11; Mexico AOR = 1.30; 95% CI = 0.91-1.85). No interaction between talk and cognitive reactions to HWLs were found. These results suggest that interpersonal communication about HWLs influences smoking cessation attempts independent of other established predictors of smoking cessation, including cessation-related HWL responses. Future research should determine ways to catalyze interpersonal communication about HWLs and thereby potentiate HWL effects.
| S-EPMC4747859 | biostudies-literature
Project description:Packaging and labelling tobacco products has emerged as an effective policy to reduce the global health burden of tobacco use. The main purpose of this study was to explore Austrian smokers' and ex-smokers' responses to both the textual and pictorial cigarette pack health warnings (CPHWs) recently implemented.We analysed self-reported data (N=500) from an Austrian cross-sectional survey that was conducted after the implementation of the new pictorial CPHWs in 2016.The results showed only weak effects of the CPHWs on the decision to quit or reduce smoking, and the level of impact of the CPHWs remained limited particularly because of smokers denying the ill-effects of tobacco use.Although the CPHWs seem to have the potential to promote a change in smoking behaviour, the warnings reached only a rather small group of smokers, while the majority of smokers appeared to remain unaffected by this intervention. Public health policies are challenged to increase the salience of CPHWs and to overcome smokers' denial of detrimental health effects.
| S-EPMC5883578 | biostudies-other
Project description:PurposePictorial cigarette pack warnings are a promising policy solution to increase smoking cessation among adults. However, little is known regarding adolescents' responses to pictorial warnings, particularly in real-world settings.MethodsParticipants were 112 adolescent children, ages 13-17, whose parents received either text-only warnings on the side of their cigarette packs or pictorial warnings on the top half of the front and back of their cigarette packs for 4 weeks as part of a trial. We measured adolescents' recall and recognition of these warnings, negative emotional reactions to the warnings, perceived effectiveness of the warnings, social interactions about the warnings, and smoking risk beliefs.ResultsAdolescents accurately recalled pictorial warnings more often than text-only warnings (82% vs. 19%, p < .001). Recognition of warnings was also higher for pictorial than text-only warnings (82% vs. 34%, p < .001). Pictorial warnings drew greater attention (p < .001), elicited greater negative emotional reactions (p < .05), and sparked more social interactions (p < .01) than text-only warnings.ConclusionsPictorial warnings on cigarette packs may have important effects on adolescent children of smokers. Future research should further investigate the impact of such messages on adolescents' susceptibility to smoking initiation and interest in quitting smoking, particularly as the United States and other countries work to implement pictorial warning regulations.
| S-EPMC5341376 | biostudies-literature
Project description:IntroductionSocial interactions are a key mechanism through which health communication efforts, including pictorial cigarette pack warnings, may exert their effects. We sought to better understand social interactions elicited by pictorial cigarette pack warnings.MethodsA controlled trial randomly assigned US adult smokers (n = 2149) to have their cigarette packs labeled with pictorial or text-only warnings for 4 weeks. Smokers completed surveys during the baseline visit and each of the subsequent 4 weekly visits.ResultsSmokers with pictorial warnings on their packs had more conversations throughout the trial compared to those with text-only warnings (8.2 conversations vs 5.0, p<.01). The highest number of conversations occurred during the first week. Smokers with pictorial warnings were more likely than those with text-only warnings to discuss the health effects of smoking, whether the warnings would make them want to quit and whether the warnings would make others want to quit (all p < .05). Smokers were more likely to describe pictorial warnings as scary, gross, or depressing and gloomy during conversations than text-only warnings (all p < .05).ConclusionsPictorial warnings sparked more conversations about the warnings, the health effects of smoking, and quitting smoking than text-only warnings. These social interactions may extend the reach of pictorial warnings beyond the targeted smoker and may be one of the processes by which pictorial warnings have impact.ImplicationsHealth communication can influence behavior by changing social interactions. Our trial characterized social interactions about pictorial cigarette pack warnings with a large longitudinal sample in a real-world setting. Understanding these conversations can inform the United States and other countries as they improve existing warnings and help tobacco control policy makers and health communication theorists understand how social interactions triggered by warnings affect smoking.
| S-EPMC5991214 | biostudies-literature
Project description:BackgroundWe sought to describe characteristics and psychometric properties of measures used in pictorial cigarette pack warning experiments and provide recommendations for future studies.MethodsOur systematic review identified 68 pictorial cigarette pack warning experiments conducted between 2000 and 2016 in 22 countries. Two independent coders coded all studies on study features, including sample characteristics, theoretical framework, and constructs assessed. We also coded measurement characteristics, including construct, number of items, source, reliability, and validity.ResultsWe identified 278 measures representing 61 constructs. The most commonly assessed construct categories were warning reactions (62% of studies) and perceived effectiveness (60%). The most commonly used outcomes were affective reactions (35%), perceived likelihood of harm (22%), intention to quit smoking (22%), perceptions that warnings motivate people to quit smoking (18%), and credibility (16%). Only 4 studies assessed smoking behavior. More than half (54%) of all measures were single items. For multi-item measures, studies reported reliability data 68% of the time (mean α = 0.88, range α = 0.68-0.98). Studies reported sources of measures only 33% of the time and rarely reported validity data. Of 68 studies, 37 (54%) mentioned a theory as informing the study.ConclusionsOur review found great variability in constructs and measures used to evaluate the impact of cigarette pack pictorial warnings. Many measures were single items with unknown psychometric properties. Recommendations for future studies include a greater emphasis on theoretical models that inform measurement, use of reliable and validated (preferably multi-item) measures, and better reporting of measure sources.ImplicationsRobust and consistent measurement is important for building a strong, cumulative evidence base to support pictorial cigarette pack warning policies. This systematic review of experimental studies of pictorial cigarette warnings demonstrates the need for standardized, theory-based measures.
| S-EPMC5896543 | biostudies-literature