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The relative effectiveness of graphic and text based health-warnings: findings from
the ITC:4-country study.
Ron Borland, David Hammond, Geoffrey T Fong, Hua H Yong, Warwick Hosking
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Constrain tobacco
marketing
Tobacco use
Regulate tobacco products
Elements of tobacco control
Consequences of use
Smoke-free rules
Programs to prevent
uptake
Cessation programs and aids
Information:• Mandated,• Campaigns
Norms for use
Tobacco use controlTobacco industry control
Biology
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Mediational Model(s) of Policy Effects
Proximal Variables(Policy-Specific)
Distal Variables(Psychosocial Mediators)
Policy Behavior
Warning labels
LabelsLabel Salience Perc EffectivenessDepth of Processing
Intentionsto Quit
QuitAttempt
Perceived risk Perceived severity
Immediate reactions: foregoing cigarettes
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The ITC Surveys
Cohorts with replenishment
• 2000 per country per wave
• Around 30% new recruits in waves 2-5
Common questions
• 5 questions asked all waves
• 2 introduced at wave 2
5
OLD
NEW
USA UK Australia Canada
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Questions in ITC surveys Processing frequency
• Noticing
• Reading or looking closely at
Cognitive reactions• Concern about health (W2 on)
• Thoughts about quitting• Extent (W2 on)
• Amount over last 6 mths
Behavioral reactions• Concern about health (W2 on)
• Thoughts about quitting
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Scale:1 = never2 = rarely3 = sometimes4 = often5 = very often
How often have you noticed WL in the last month?
1
1.5
2
2.5
3
3.5
4
4.5
2002 2003 2004 2005 2006
Canada
USA
UK
Australia
Processing of Warning Labels (current smokers at each wave)
UK AUST
UK peak and increase higher than Aust
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Scale:1 = never2 = rarely3 = sometimes4 = often5 = very often
How often have you read or looked closely at WL in the last month?
1
1.5
2
2.5
3
3.5
4
2002 2003 2004 2005 2006
Canada
USA
UK
Australia
Processing of Warning Labels (current smokers at each wave)
UK AUST
UK peak and increase higher than Aust
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Summary
Text warnings processed more often• ? Graphic taken in more quickly
• Or processed differently
• ? Artifact of larger change in prominence
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Scale:1 = not at all2 = a little3 = somewhat4 = a lot
To what extent do WL make you think about health risks of smoking?
1
1.2
1.4
1.6
1.8
2
2.2
2.4
2.6
2003 2004 2005 2006
Canada
USA
UK
Australia
Cognitive reactions to Warning Labels (current smokers)
UK AUST
Australian peak higher than UK
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Scale:1 = not at all2 = a little3 = somewhat4 = a lot
To what extent do WL make you more likely to quit smoking?
1
1.2
1.4
1.6
1.8
2
2.2
2003 2004 2005 2006
Canada
USA
UK
Australia
Cognitive reactions to Warning Labels (current smokers)
UK AUST
Australian peak higher than UK
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Scale:1 = not at all2 = somewhat3 = very much
In last 6 months, how much have WL made you think about quitting?
1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
2002 2003 2004 2005 2006
Canada
USA
UK
Australia
Cognitive reactions to Warning Labels (current smokers)
UK AUST
No diffs, Aust vs UK)
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Summary
Graphic warnings stimulate more appropriate thoughts (ie more intense thoughts)• ? Graphic more emotionally salient
• No clear effect for frequency over time
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Avoidance of WL in last month (composite measure on a 4-point scale, where 0 = no avoidance, 4 = avoid WL in all 4 ways)
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
2002 2003 2004 2005 2006
Canada
USA
UK
Australia
Behavioral reactions to Warning Labels (current smokers)
UK AUST
Australian peak and increase greater than UK
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Scale:1 = never2 = once3 = a few times4 = many times
Have WL stopped you from smoking in the last month?
1
1.05
1.1
1.15
1.2
1.25
1.3
1.35
1.4
2002 2003 2004 2005 2006
Canada
USA
UK
Australia
Behavioral reactions to Warning Labels (current smokers at each wave)
UK AUST
No clear diffs Aust vs UK
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Comparisons with Canada
Slower decline in effects in Canada than UK, especially to cognitive and behavioral reactions
• See also Hammond et al, 2007
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Impacts of Warning labels Australia 2006
Current plans to quit
Notice them
Read them
Think about risk
More likely to quit
Forego cigs
Avoid them
In next month 90% 67% 70% 55% 28% 40%
< 6 months 88% 67% 68% 47% 18% 44%
> 6 months 86% 65% 49% 33% 12% 36%
Not planning 81% 51% 29% 14% 5% 31%
NB: Impacts of Warning labels at least sometimes
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Demographic effects
• Females avoid the new warnings more.
• Stronger effects with younger age group.
• especially main effects
• foregoing cigarettes
• thinking about risks
• motivating to quit/stay quit
• No consistent education effects
Australian data only
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Predictors of making quit attempts by the next survey wave
Predictor W1W2 W2W3 W3W4W4W5
Notice WL 1.02 0.93* 1.00 1.05
Read/look at 1.01 1.01 1.01 0.95
All analyses control for sociodemographics (including country)
and cigarettes per day;plus other Warning label variables
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Predictors of making quit attempts by the next survey wave
Predictor W1W2 W2W3 W3W4 W4W5
Think about ------ 1.13* 1.05 1.10*risks ------ (1.07) (0.99) (1.04)
More likely ------ 1.19* 1.26* 1.20*to quit ------ (1.08) (1.14*) (1.08)
Think quit 1.26* 1.17* 1.09 1.11(6 months) (1.12*) (1.13*) (1.03) (1.07)
All analyses control for sociodemographics (including country)and cigarettes per day; plus other Warning label variables.
Figures in brackets below are after controlling for intention to quit.
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Predictors of making quit attempts by the next survey wave
Predictor W1W2 W2W3 W3W4 W4W5
Forego 1.51* 1.27* 1.42* 1.40*cigarettes (1.31*) (1.21*) (1.41*) (1.31*)
Avoid 1.24* 1.15 1.02 1.04warnings (1.14) (1.11) (1.02) (1.03)
All analyses control for sociodemographics (including country)and cigarettes per day; and other Warning label variables.
Figures in brackets below are after controlling for intention to quit.
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Reactions to warning labels and quit attempts
• ITC data: 4 wave-wave transitions• Forego cigs and attempts
– All 4 (sociodemogs + other reactions + CPD)
– All 4 (+ Plans)
• Report prompting attempts and attempts– All 4 (sociodemogs + other reactions + CPD)
– 3 of 4 (+ Plans)
• Think of risks and attempts– 2 of 3 (sociodemogs + other reactions + CPD)
– ?0 of 3 (+ Plans)
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Reactions to warnings and concerns about future health
Worried about future health
Not at all Very
Forego cigarettes 2004 2% 13%
2005 4% 25%
Think of risks 2004 12% 52%
2005 16% 76%
Increase quit prob 2004 4% 35%
2005 8% 55%
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Conclusions
• Graphic and text based warnings may have different paths of effect– Graphic more emotionally charged and stimulate
more cognitions related to quitting
• Graphic warnings better at stimulating cognitions that predict quitting
• Graphic warnings seem to be more sustained• Graphic warnings work with less specific
processing• Size is also critically important• Novelty also plays an important role
– but, warnings do not wear out completely
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