1. James F. Thrasher, Edna Arillo-Santillán, Marta Caballero, David Hammond ITC-Mexico: An update & example of research to select effective pictorial warning label content

2. Mexican health warnings labels (HWLs) 3rd largest in the world (65% of pack)  30% of the front (picture & text)  100% of the back and one side (text only)  2 new HWLs every 3 months, fastest rotation in the world  50% of the back (text only)  4 messages (2004-2010) (2010-present)

3. 1st round of Mexican Pictorial Health Warning Labels (HWLs)

4. 4 Phase 1 Objective:  Most effective HWL imagery Method:  Field experiments Phase 2 Objective:  Most effective HWL textual content Method:  Field experiments Phase 3 Objective:  Confirm findings about HWL imagery & text Method:  Focus groups 3-stage process to select second round of HWLs

5. Second level Third level Fourth level Fifth level 5 International Pack Study  Parallel studies in 7 diverse countries:  Examine effective content for pictorial warnings  Examine individual differences in responses  Examine cultural, national level differences P01 CA138389, Tobacco packaging and labeling policies: Expanding the evidence on novel policies Mexico US China India Germany Bangladesh South Korea

6. Health Warning Topics & Stimuli

7. Health warning topic “sets” 5 or 6 warnings tested for each topic TextSymbolicHuman suffering Graphic ExternalGraphic Internal Testimonial

8. Field experiments Random assignment Addiction Stroke Toxicity Rate 5 to 7 warnings from selected block in random order Evaluate for each warning: Attention Credibility Relevance Negative emotional arousal Impact Brief Survey Sociodemographics Smoking-related perceptions & behavior Warning labels Rank warnings within a block: Which most motivates you to stop smoking? Which most motivates you to not start smoking? Throat cancer Mouth cancer Death Heart attack Enphysema Premature aging Impotence Lung cancer Gangrene Premature birth SHS in children Topics Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.

9. Samples Mexico: Sample – 535 16 to 18 years old, smokers and nonsmokers – 527 adult smokers Mode – Intercept surveys in Mexico City (July 2010) – In-person administration – Stimulus presentation by laptop Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.

10. Second level Third level Fourth level Fifth level 10 Graphic & human suffering rated as more effective than symbolic warnings (p<.001) Graphic & human suffering vs. Symbolic Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.

11. Second level Third level Fourth level Fifth level 11 Warnings with graphic content rated more effective than with human suffering (p<.001) Graphic vs. Human suffering Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.

12. Second level Third level Fourth level Fifth level 12 Testimonial Non-Testimonial Adding testimonial information increased effectiveness (p<.001) Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.

13. Second level Third level Fourth level Fifth level 13 Warnings depicting suffering of OTHERS rated as more effective than suffering of SELF (p<.001) Self sufferingvs. Other suffering Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.

14. Impact on knowledge Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012. Mutti S, Hammond D, Reid J, Thrasher JF. Jnl Health Communicaiton. In press.

15. Images with the greatest impact in study 1 TopicImage Throat cancer Mouth cancer Lung cancer Emphysema Adiction TopicImage Heart disease Stroke Gangrene SHS & children Fetus & Premature birth

16. Phase 1 Objective:  Most effective HWL imagery Method:  Field experiments Phase 2 Objective:  Most effective HWL textual content Method:  Field experiments Phase 3 Objective:  Confirm findings about HWL imagery & text Method:  Focus groups 2nd phase: Selection of textual content for pictorial HWLs

17. Characteristics of Mexican pictorial HWLs 30% of front with image and text 100% of one side, reinforcing the central message “Qualitative” focus on toxic constituents Call to action with 1800 number

18. Didactic/scientific vs. testimonial content Breathing tobacco smoke causes the arteries of your heart to clog. The clogging damages your heart and can kill you. You can quit smoking. Call us 01800 966 3863 “My husband was a smoker, and while he was still young, he died from a heart attack. I was left stranded to take care of the family all by myself.” Celia Juárez You can quit smoking. Call us 01800 966 3863 “Tobacco smoke is a silent killer. Without thinking, I breathed it in, unable to feel the damage it had done…until it gave me a heart attack.” César Guerrero You can quit smoking. Call us 01800 966 3863 Didactic /scientificTestimonial - otherTestimonial - self Contains particles that enter your blood stream, form blood clots and can block your arteries Thrasher JF, Arillo-Santillán E, Villalobos V, et al. Cancer Causes & Control. 2012.

19. Field experiments in 8 public places Randomization Condition 1: 4 blocks of packs on same health outcome Condition 2: 4 blocks of packs on same health outcome Condition 3: 4 blocks of packs on same health outcome Condition 4: 4 blocks of packs on same health outcome Random presentation of packs within each block Assessment of each HWL: Attention Credibility Relevance Emotional arousal Impact Brief survey Sociodemographics Smoking perceptions & behavior HWL Ranking task of HWLs within block: Which motivates you most to quit? Which motivates you most to not start smoking? Thrasher JF, Arillo-Santillán E, Villalobos V, et al. Cancer Causes & Control. 2012.

21. Sample characteristics Characteristics Youth sample % (n) Adult smoker sample % (n) Age (average) 20.6 (range 18 – 24)32.8 (range 25 – 80) Sex Male Female 50% (266) 50% (263) 62% (330) 38% (199) Education Secondary or less Technical school High school University + 28% (146) 8% (44) 57% (302) 7% (37) 18% (100) 14% (76) 42% (223) 25% (130) Smoking behavior Nonsmoker Non-daily smoker Daily smoker, < 5 /day Daily smoker, 5+ / day 49% (258) 30% (159) 12% (63) 10% (53) N/A 43% (225) 25% (131) 33% (173) Intend to quit in next 6 months 31% (77 / 252)31% (165)

22. Overall impact of scientific vs. testimonial Thrasher JF, Arillo-Santillán E, Villalobos V, et al. Cancer Causes & Control. 2012.

23. Adjusted ORs* of selecting a testimonial as most influential, lowest vs. highest educational attainment *adjusted for age, sex, smoking status, level of consumption, perceived risk, and quit intentions

24. Phase 1 Objective:  Most effective HWL imagery Method:  Field experiments Phase 2 Objective:  Most effective HWL textual content Method:  Field experiments Phase 3 Objective:  Confirm findings about HWL imagery & text Method:  Focus groups 3rd phase: confirm best combination of imagery and textual content

25. Population characteristics Mexico CityGuadalajaraMonterrey Smokers Non- smokers Smokers Non- smokers Smokers Non- smokers 18 - 24 25 - 65 18 - 24 25 - 65 18 - 24 25 - 65 18 - 24 25 - 65 18 - 24 25 - 65 Female (n=80)71740614651650 Male (n=67)4119161056861 Total (n=147)1128131122411 24111 Focus groups Mixed methods Individual ratings Group discussion Callback two days later 12 groups, 4 in each city:

26. Versión: 3A Versión: 3B TEMA 3: CÁNCER DE BOCA

27. New Health Warning Labels

28. Future research Every 4 months in Mx, Canada, Australia, US Define and measure real world outcomes “Understanding of risks” Cessation behavior Targeted messages - Which features matter?: Perceived credibility and relevance? Matching of social identity characteristics? Message complexity? Define & explain patterns of “wear out”

29. Survey Mode: Face-to-Face (F2F) Respondent Types: Smoker May 2004 FCTC ratification 2007 Cigarette tax increase from 54.2% to 58.9% of final price 2008 Cigarette tax increase to 60.2% of final price Mexico City Implements 100% smoke-free public places and workplaces with no exceptions National smoke-free law restricts smoking in public places and workplaces but ‘must’ have DSRs 2009 Cigarette tax increase to 61.4% of final price Advertising promotion restrictions National smoke-free law regulations change ‘must’ to ‘may’ have DSRs 2004 Cigarette health warnings must occupy 50% of back of package 29 2011 Cigarette tax increase to 68.8% of final price (7pesos) 2010 Pictorial health warnings State-level smoke-free implementation Cigarette tax increase to 62.7% of final price 2011/12 New pictorial warning rotations MEXICO Timeline of Tobacco Control Policies and ITC Surveys 200420052006200720082009201020112012 Wave 1 Sept-Nov 2006 N= 1080 Wave 2 Oct-Dec 2007 N= 1080 Wave 3 Nov-Dec 2008 N= 2000 Wave 4 Jan-Feb 2010 N= 2100 Wave 5 Apr-May 2011 N=2100 29