Effects of Graphic Health Warning on Tobacco Packs: A Cross-Sectional Study among Low Socioeconomic Group in Bangladesh

Background. Tobacco use is a significant health concern in Southeast Asia, particularly in Bangladesh, where the greatest incidence of tobacco consumption occurs in a number of forms smoking, smokeless, and indigenous. The WHO Framework Convention on Tobacco Control (FCTC) requires tobacco product packaging to include adequate health warnings (text and visual). The study’s objective is to investigate the effects of graphic health warnings on tobacco packs among Bangladeshi low socioeconomic groups. Study Design. Cross-sectional study. Methods. The study was conducted with 400 participants (low socioeconomic people) by using the systematic sampling technique through a semistructured questionnaire in Demra and Tongi industrial areas of Dhaka city in Bangladesh during September 2019-November 2020. Descriptive statistics (frequencies, percentages, means, and standard deviations) and inferential analysis (i.e., chi-square tests) were performed by Statistical Package for Social Sciences (SPSS version 25.0) to explore the relationship between the graphic warning and the use of tobacco. Results. This study illustrates that 89% of respondents smoke only cigarette or bidi, where 95.1% were daily smokers. About 72.2% reported pictorial warning message was more understandable while 90.8% reported the existing text warnings explicitly visualize the health harms. It has been found that there was a significant association between the respondent’s opinion on the text warning that encouraged the respondent to quit tobacco use and the text messages “smoking causes throat and lung cancer” ( p < 0.001 ) and “smoking causes respiratory problems” ( p < 0.001 ). Around 96.7% knew about the graphic health warnings on the cigarette packets where 99.2% reported graphic warning explicitly visualizes the health harms. In graphical warnings, text messages have a great influence on quitting smoking where “smoking causes throat and lung cancer” ( p < 0.001 ) and “smoking causes stroke” ( p < 0.001 ). Nearly 79.2% of respondents thought the color of the graphic warning should be “Red” and a significant association between the color and the education level of the respondents explored here ( p < 0.05 ). Conclusions. GHWs are more understandable on tobacco packets, and it has significant impacts on being aware of health consequences from tobacco consumption.

The Influence of Episodic Future Thinking and Graphic Warning Labels on Delay Discounting and Cigarette Demand

Delay discounting and operant demand are two behavioral economic constructs that tend to covary, by degree, with cigarette smoking status. Given historically robust associations between adverse health outcomes of smoking, a strong preference for immediate reinforcement (measured with delay discounting), and excessive motivation to smoke cigarettes (measured with operant demand), researchers have made numerous attempts to attenuate the extent to which behaviors corresponding to these constructs acutely appear in smokers. One approach is episodic future thinking, which can reportedly increase the impact of future events on present decision making as well as reduce the reinforcing value of cigarettes. Graphic cigarette pack warning labels may also reduce smoking by increased future orientation. Experiment 1 evaluated the combined effects of episodic future thinking and graphic warning labels on delay discounting; Experiment 2 evaluated solely the effects of episodic future thinking on delay discounting and operant demand. We observed no statistically significant effects of episodic future thinking when combined with graphic warning labels or when assessed on its own. These results serve as a call for further research on the boundary conditions of experimental techniques reported to alter behaviors associated with cigarette smoking.

The estimated effect of graphic warning labels on smoker’s intention to quit in Shanghai, China: a cross-sectional study

Background Tobacco consumption is the leading cause of death worldwide. Overwhelming studies demonstrate graphic warning labels (GWLs) on cigarette packs are effective in eliciting negative response to tobacco smoking, modifying beliefs about tobacco dangers, and increasing reported intention to quit, but the estimated effect of GWLs on smoking cessation intention among smokers is still limited in China. In this study, we aim to understand the smoking intensity, smoking duration and smoking cessation intention among current smokers, and to explore how their smoking cessation intention would be influenced by the GWLs in Shanghai. Methods From January to June 2021, we totally recruited 1104 current smokers in Songjiang district and Fengxian district of Shanghai by multistage sampling design. We used Android pad assisted electronic questionnaire for data collection, and then implemented logistic regression for odds ratio (OR) and 95% confidence interval (CI) calculation to explore how smoking cessation intention would be influenced by the GWLs among current smokers. Results One thousand one hundred four current smokers included 914 males (82.79%), with an average age of 43.61 years. 58.06% of current smokers reported smoking cessation intention due to GWLs. Logistic regression indicated a higher percentage of smoking cessation intention due to GWLs was among female smokers [OR = 2.41, 95% CI (1.61–3.59)], smokers with smoking intensity < 20 cigarette/day [OR = 1.92, 95% CI (1.44–2.55)], smokers with tobacco burden < 20% [OR = 1.94, 95% CI (1.35–2.79)], and among smokers had plan to quit in a year [OR = 6.58, 95% CI (4.71–9.18). Smokers with higher individual monthly income had lower percentage of smoking cessation intention (OR were 0.35, 0.46 and 0.41). Meanwhile, among 642 current smokers without plan to quit in a year, approximately 40% of them reported smoking cessation intention due to GWLs. Conclusions Smoking cessation intention due to the assumed GWLs on cigarette packs is high among current smokers in Shanghai, especially in female smokers, smokers with light tobacco burden and mild nicotine dependence. Incorporating smoking intensity as well as smoking burden into the implementation of GWLs as tobacco control measures would discourage smoking in China.

Role of affective reactivity induced by cigarette packaging including graphic warning labels: the CASA Study

ObjectiveTo identify whether three types of cigarette pack designs, including three versions of graphic warning label (GWL) plain packs, one GWL absent and branding absent pack (blank) and the smoker’s own GWL absent and branding present pack (US), elicit different valence, type and levels of affect.DesignUS daily smokers (n=324) were asked to handle each of the five pack types and ‘think aloud’ their reactions. To avoid a muted familiarity response, exposure to their own US pack followed exposure to at least one GWL plain pack. Reactions were scored on a reactivity scale (−3 to +3) and the text was coded for speech polarity (−1 to +1) and emotive word frequency.ResultsReactivity scores had excellent inter-rater reliability (agreement ≥86%; intraclass correlation coefficient ≥0.89) and were correlated with speech polarity (r=0.21–0.37, p<0.001). When considering their US pack, approximately two-thirds of smokers had a low (31.5%) to medium (34.6%) positive response (reactivity=1.29; polarity=0.14) with expressed feelings of joy and trust. Blank packaging prompted a largely (65.4%) neutral response (reactivity=0.03; polarity=0.00). The gangrenous foot GWL provoked mostly medium (46.9%) to high (48.1%) negative responses (reactivity=−2.44; polarity=−0.20), followed by neonatal baby (reactivity=−1.85; polarity=−0.10) and throat cancer (reactivity=−1.76; polarity=−0.08) warnings. GWLs varied in their elicitation of disgust, anger, fear and sadness.ConclusionInitial reactions to GWL packs, a blank pack, and smokers’ current US pack reflected negative, neutral, and positive affect, respectively. Different versions of the GWL pack elicited different levels and types of immediate negative affect.

Responses to Graphic Warning Labels among Low-income Smokers

Objective: Graphic warning labels (GWLs) are effective in communicating tobacco-related harms. Methods: In this mixed-methods study, we used purposive sampling to recruit 100 low-income smokers in the San Francisco Bay Area between October 2017 and February 2018 to participate in an intervention promoting smoke-free homes. We presented the 2009 Food and Drug Administration-proposed GWLs and explored perceptions of affect, efficacy, and appeal using questionnaires at baseline, 3- and 6-months follow-up. Because of participants' interest in this topic, we subsequently conducted a qualitative sub-study among 20 participants exploring perceived efficacy of GWLs on smoking cessation. Results: In all, 87.3% and 59.2% agreed that GWLs were useful and would motivate cessation behaviors, respectively, at baseline. We found that the most common responses were shock (61.8%) and disgust (55.3%), whereas anger (29.0%) and annoyance (19.7%) were less common. Participants also reported that GWLs unequivocally illustrating smoking's harmful effects were more appealing than non-specific images, as were images that depicted positive cessation-related effects. Conclusions: GWLs appear to be an important health communication among low-income smokers. Future studies on GWLs should examine the association of negative affect and cessation among this population.

Should Graphic Warning Labels Proposed for Cigarette Packages Sold in the United States Mention the Food and Drug Administration?

Introduction Under the US Family Smoking Prevention and Tobacco Control Act, the US Food and Drug Administration (FDA) has the authority to implement graphic warning labels (GWLs) on cigarette packages. Neither the original labels proposed by the FDA nor the revised labels include a source to indicate sponsorship of the warnings. This study tests the potential impact of adding a sponsor to the content of GWLs. Methods We recruited adult smokers (N = 245) and middle-school youth (N = 242) from low-income areas in the Northeastern US. We randomly assigned participants to view one of three versions of the original FDA–proposed warning labels in a between-subjects experiment: no sponsor, “US Food and Drug Administration,” or “American Cancer Society” sponsor. We tested the effect of varying sponsorship on source attribution and source credibility. Results Compared to unsponsored labels, FDA sponsorship increased source attributions that the FDA sponsored the labels among both middle-school, largely nonsmoking youth and adult smokers. However, sponsorship had no effect on source credibility among either population. Conclusions We found no evidence that adding FDA as the source is likely to boost source credibility judgments, at least in the short term; though doing so would not appear to have adverse effects on credibility judgments. As such, our data are largely consistent with the Tobacco Control Act’s provisions that allow, but do not require, FDA sponsorship on the labels. Implications This study addresses the FDA’s regulatory efforts by informing the possible design and content of future cigarette warning labels. Our results do not offer compelling evidence that adding the FDA name on GWLs will directly increase source credibility. Future work may test more explicit FDA source labeling and continue to examine the credibility of tobacco message content among high–priority populations.