Tobacco

Tobacco is the most important and avoidable public health problem, killing 5.4 million users per year. At least one in two and up to two in three smokers die prematurely from smoking. Such great and easily understood risks should be more effectively communicated to promote smoking cessation. This chapter describes how raising tobacco tax, banning smoking in public places, and forbidding tobacco advertising, promotion, and sponsorship have effectively reduced smoking rates in many countries. However, many low- and middle-income countries still lack the necessary resources or political will to implement tobacco control. Further progress may come from large and effective pictorial warnings; banning the display of tobacco products at retail outlets; extending smoking bans in public places; innovative use of the mass media; very brief warnings by doctors to promote cessation; telephone quitlines; and capitalizing on the risk perception towards third-hand smoke.

Responses to pictorial versus text-only cigarillo warnings among a nationally representative sample of US young adults

BackgroundThe US Food and Drug Administration requires six text-only warnings for cigar products, including cigarillos. Research has demonstrated the superiority of pictorial over text-only cigarette warnings, yet the relative effectiveness of pictorial warnings for cigarillos has not been examined. We examined the impact of pictorial cigarillo warnings compared with text-only warnings.MethodsData were collected from a nationally representative sample of US young adult (18–29) cigarillo users and susceptible non-users. Participants were randomised to one of three experimental conditions: text-only or one of two pictorial conditions (combined for analyses). For each warning, we assessed negative emotional reactions, cognitive elaboration (ie, thinking about cigarillo risks) and perceived message effectiveness (PME).ResultsParticipants (N=661) were 46.5% female, 64.7% white and 21.9% Hispanic; 34.1% reported past 30-day cigarillo use; 41.4% were lifetime users (excluding past 30-day use); and 24.4% were susceptible non-users. Pictorial warnings elicited more negative emotional reactions and higher PME than text-only warnings (p values<0.01), with interactions showing the largest effects for past 30-day users (emotional reactions: d=0.99, PME: d=0.63). For cognitive elaboration, there was no main effect of warning type, but an interaction revealed effects for past 30-day users (p<0.05, d=0.46).ConclusionsPictorial cigarillo warnings elicited greater negative emotional reactions and PME compared with text-only warnings. These effects and the effects on cognitive elaboration were strongest for past 30-day users. Our findings extend research on cigarette warnings to cigarillos, demonstrating that pictorial warnings are superior to text-only warnings for cigarillos in eliciting beneficial responses.

The Response of Smokers to Health Warnings on Packs in the United Kingdom and Norway Following the Introduction of Standardized Packaging

Introduction Standardized packaging was phased in between May 2016 and May 2017 in the United Kingdom and July 2017 and July 2018 in Norway. In both countries, the health warnings on packs prior to standardized packaging being implemented were from the former Tobacco Products Directive library of warnings (text warnings covering 43% of the pack front and pictorial warnings covering 53% of the pack reverse). The warnings on packs, postimplementation, were from the current Tobacco Products Directive library of warnings (novel pictorial warnings covering 65% of the pack front and reverse) for the United Kingdom but unchanged in Norway. Aims and Methods Longitudinal online surveys were conducted prior to standardized packaging (United Kingdom: April–May 2016; Norway: May–June 2017) and postimplementation (United Kingdom: September–November 2017 and May–July 2019; Norway: August–September 2018). We explored smokers’ response to the on-pack warnings (salience, cognitive reactions, and behavioral reactions). Results In the United Kingdom, noticing warnings on packs, reading or looking closely at them, thinking about them, thinking about the health risks, avoidant behaviors, forgoing cigarettes, and being more likely to quit due to the warnings significantly increased from waves 1 to 2, and then decreased from waves 2 to 3, but remained higher than at wave 1. In Norway, noticing warnings, reading or looking closely at them, thinking about them, thinking about the health risks, and being more likely to quit due to the warnings significantly decreased from waves 1 to 2; avoidant behaviors and forgoing cigarettes remained unchanged. Conclusions The inclusion of large novel pictorial warnings on standardized packs increases warning salience and effectiveness. Implications Two longitudinal online surveys in the United Kingdom and Norway explored the impact of standardized packaging on warning salience and effectiveness. That warning salience and effectiveness only increased in the UK postimplementation, where standardized packaging was implemented alongside new larger pictorial warnings on the pack front and reverse, and not in Norway, where standardized packaging was introduced but older smaller text warnings (pack front) and pictorial warnings (pack reverse) were retained, highlights the importance of removing full branding and introducing stronger warnings simultaneously.

Country Participation in the WHO Framework Convention on Tobacco Control Health Warnings Database

Background The World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC) Health Warnings Database is an online, publicly available resource created for countries to upload and share pictorial health warnings for tobacco packaging. The purpose of this study was to evaluate the extent to which the database is used by countries for the sharing of pictorial warnings. Methods The study’s sample included parties to the FCTC who required graphic health warning labels on cigarette packaging from. Those countries were categorized as having a low, middle, and high Socio-Demographic Index (SDI). The Health Warnings Database was then analyzed for those countries’ unique pictorial images, as well as the number of pictorials that were shared between countries. Results Of the 110 countries that required pictorial warnings on cigarette packaging, only 53 (48%) voluntarily contributed pictorials to the database, with most of those (53%) being high SDI-level countries. There were 342 unique pictorials on the database, with 62 images posted by seven countries that were used by 13 other countries. Conclusion While sharing was evident from the database, there remains a need for more countries to upload the pictorials to the database. There is also a need to expand the database to include alternative tobacco products, such as waterpipe tobacco and e-cigarettes.

The impact of including cessation resource information on health warnings on standardised tobacco packaging on awareness and use: A longitudinal online survey in the United Kingdom

Introduction Since May 2017, all cigarettes and roll-your-own (RYO) tobacco in the UK must be sold in standardised packs with pictorial warnings displaying, for the first time, a stop-smoking website. Methods Data comes from three waves of a longitudinal online survey with smokers and ex-smokers conducted pre- and post-standardised packaging, with Wave 1 (W1) in April-May 2016, Wave 2 (W2) in October-November 2017, and Wave 3 (W3) in May-June 2019. Only smokers are included in the analysis: W1 (N=6233), W2 (N=3629) and W3 (N=2412). We explored any change in citing warnings on packs as a source of information about a stop-smoking website, and whether citing warnings as a source was associated with use of a stop-smoking website. As the warnings, and therefore the stop-smoking website, are larger on RYO packs than on cigarette packs due to the larger pack size, we explored differences in awareness of a stop-smoking website among exclusive cigarette smokers (W1=3142, W2=1884, W3=1247) and exclusive RYO smokers (W1=2046, W2=1119, W3=814). Results Among smokers recalling seeing information about a stop-smoking website, citing warnings as a source increased between waves (W1=14.0%, W2=24.2%, W3=25.1%) and was associated with having visited a stop-smoking website (OR=11.81, 95% CI 8.47-16.46). Citing warnings as a source of a stop-smoking website increased among exclusive RYO smokers at each wave (W1=15.5%, W2=26.3%, W3=32.1%), while for exclusive cigarette smokers it only increased at W2 (W1=10.5%, W2=22.4%, W3=19.9%). Conclusions Warnings are an important source of cessation resource information. Making this information more prominent may help sustain awareness. Implications The findings support the inclusion of a stop-smoking website on warnings as awareness among smokers increased and citing warnings as a source of information about a stop-smoking website was associated with having visited a stop-smoking website. We also explored whether the stop-smoking website on warnings on RYO packs, which is larger than on cigarette packs as a function of the larger size of RYO packs, would have any impact on awareness of this information. That exclusive RYO smokers were more likely than exclusive cigarette smokers to notice a stop-smoking website on warnings suggests that this information should be more prominent.