1 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

2 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 control Tobacco industry control Biology

3 3 Mediational Model(s) of Policy Effects Proximal Variables (Policy-Specific) Distal Variables (Psychosocial Mediators) PolicyBehavior Warning labels Labels Label Salience Perc Effectiveness Depth of Processing Intentions to Quit Quit Attempt Perceived risk Perceived severity Immediate reactions: foregoing cigarettes

4 4 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

6 Graphic warning labels Canada: large text to graphic 2001 UK: small to large text 2003 Australia: large text to graphic 2006 USA: small text on side This is for key info, if needed

7 7 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

8 Scale: 1 = never 2 = rarely 3 = sometimes 4 = often 5 = very often How often have you noticed WL in the last month? Processing of Warning Labels (current smokers at each wave) UKAUST UK peak and increase higher than Aust

9 Scale: 1 = never 2 = rarely 3 = sometimes 4 = often 5 = very often How often have you noticed WL in the last month? Processing of Warning Labels (current smokers at each wave) UKAUST UK peak and increase higher than Aust

10 Scale: 1 = never 2 = rarely 3 = sometimes 4 = often 5 = very often How often have you read or looked closely at WL in the last month? Processing of Warning Labels (current smokers at each wave) UKAUST UK peak and increase higher than Aust

11 Summary  Text warnings processed more often ? Graphic taken in more quickly Or processed differently ? Artifact of larger change in prominence

12 Scale: 1 = not at all 2 = a little 3 = somewhat 4 = a lot To what extent do WL make you think about health risks of smoking? Cognitive reactions to Warning Labels (current smokers) UKAUST Australian peak higher than UK

13 Scale: 1 = not at all 2 = a little 3 = somewhat 4 = a lot To what extent do WL make you more likely to quit smoking? Cognitive reactions to Warning Labels (current smokers) UKAUST Australian peak higher than UK

14 Scale: 1 = not at all 2 = somewhat 3 = very much In last 6 months, how much have WL made you think about quitting? Cognitive reactions to Warning Labels (current smokers) UKAUST No diffs, Aust vs UK)

15 Summary  Graphic warnings stimulate more appropriate thoughts (ie more intense thoughts) ? Graphic more emotionally salient No clear effect for frequency over time

16 Avoidance of WL in last month (composite measure on a 4-point scale, where 0 = no avoidance, 4 = avoid WL in all 4 ways) Behavioral reactions to Warning Labels (current smokers) UKAUST Australian peak and increase greater than UK

17 Scale: 1 = never 2 = once 3 = a few times 4 = many times Have WL stopped you from smoking in the last month? Behavioral reactions to Warning Labels (current smokers at each wave) UKAUST No clear diffs Aust vs UK

18 Comparisons with Canada  Slower decline in effects in Canada than UK, especially to cognitive and behavioral reactions See also Hammond et al, 2007

19 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

20 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

21 Predictors of making quit attempts by the next survey wave Predictor W1  W2W2  W3W3  W4W4  W5 Notice WL * Read/look at All analyses control for sociodemographics (including country) and cigarettes per day; plus other Warning label variables

22 Predictors of making quit attempts by the next survey wave PredictorW1  W2W2  W3W3  W4W4  W5 Think about * * risks------(1.07)(0.99)(1.04) More likely *1.26*1.20* to quit------(1.08)(1.14*)(1.08) Think quit1.26*1.17* (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.

23 Predictors of making quit attempts by the next survey wave PredictorW1  W2W2  W3W3  W4W4  W5 Forego 1.51*1.27*1.42*1.40* cigarettes(1.31*)(1.21*)(1.41*)(1.31*) Avoid1.24* warnings(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.

24 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)

25 Reactions to warnings and concerns about future health Worried about future health Not at allVery Forego cigarettes %13% %25% Think of risks %52% %76% Increase quit prob2004 4%35% %55%

26 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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