1. The Evaluation of Canada’s Health Warning Messages: 18 Month Follow-Up Murrray Kaiserman 1, Eva M. Makomaski Illing 1, Donna Dasko 2 1 Tobacco Control Programme, Health Canada 2 Environics Research Group 12 th World Conference on Tobacco or Health, August 2003, Helsinki, Finland

2. Overview  Health Warning Messages in Canada Purpose As Health Intervention Examples  Evaluation of Health Warning Messages Data Collection Results  Conclusions

3. Health Warning Messages in Canada 1994-2000Post 2000  Two phase introduction: Dec 23, 2000 & June 26, 2001

4. Purpose of Health Warning Messages  To inform consumers of the hazards of tobacco use  Secondary Effects:  To encourage cessation  To reduce consumption  To encourage avoidance of the use of tobacco products where they can harm others

5. Health Warning Messages as a Health Intervention  Frequency of exposure – 74 million hits per day  Target audience – the smoker, including the potential quitter & the potential smoker  Intervention – delivered at time of smoking behaviour

6. Examples of New Health Warning Messages in Canada “Canadian warnings are the most vivid in the world and serve as the model for other countries” [The Tobacco Atlas, 2002]

7. Evaluation of the New Health Warning Messages – MAIN OBJECTIVE of SURVEYS – to provide information to assist in evaluation of the new health warning messages and their effect on public & consumer knowledge & behaviours

8. Data Collection – ADULTS (Ages 18+) General Population & Smokers Telephone Surveys  Wave 1 (Baseline - prior): November-December 2000 N=1,502 (1,000 smokers, 502 non-smokers)  Wave 2 (3 months - post): March-April 2001 N=1,532 (1,015 smokers, 517 non-smokers )  Wave 3 (6 months - post): July 2001 N=1,543 (1,029 smokers, 514 non-smokers)  Wave 4 (12 months - post): November-December 2001 N=1,518 (1,007 smokers, 511 non-smokers)  Wave 5 (18 months - post): July 2002 N=1,500 (1,000 smokers, 500 non-smokers )

9. Data Collection – YOUTH (Ages 12-18) Youth Telephone Surveys  Wave 1 (Baseline - prior): December 2000 N=1,015 (168 smokers, 847 non-smokers) [N=363 potential]  Wave 2 (3 months - post): March-April 2001 N=1,003 (135 smokers, 868 non-smokers) [N=365 potential ]  Wave 3 (6 months - post): July 2001 N=1,006 (162 smokers, 844 non-smokers) [N=338 potential ]  Wave 4 (12 months - post): November-December 2001 N=1,001 (159 smokers, 842 non-smokers) [N=340 potential]  Wave 5 (18 months - post): July 2002 N=1,000 (131 smokers, 869 non-smokers) [N=338 potential ]

10. RESULTS - SMOKING BEHAVIOUR

11. Smoking Behaviour

12. Number of Times Tried to Quit Q7/Q10 In the past year, how many times have you stopped smoking for at least 24 hours because you were trying to quit smoking? (W5 - Adults: 79%; W5 - Youth: 59%)

13. Methods Used to Quit Q8c/Q11c If you were to quit smoking at some point in the future, what ways or methods do you think that you would use?

14. RESULTS - HEALTH EFFECTS OF SMOKING

15. Sources of Information About the Health Effects of Smoking Q11/Q14 Thinking generally about information which talks about the health effects of smoking cigarettes, where have you seen or heard any of this kind of information recently? Anywhere else?

16. Sources of Information About the Health Effects of Smoking – Cigarette Packages Q11/Q14 Thinking generally about information which talks about the health effects of smoking cigarettes, where have you seen or heard any of this kind of information recently? Anywhere else?

17. Health Effects of Smoking – Top of Mind Responses – Gum or Mouth Diseases Q10/Q13 What specific health effects or diseases, if any, can you think of that can be caused by smoking cigarettes? Are there any others?

18. Health Effects of Smoking – Aided Responses - Gum or Mouth Diseases – ADULTS Q12/Q15 I am going to read you a list of human health effects and diseases that may or may not be caused by smoking cigarettes. Based upon what you know or believe, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree that smoking can cause each of the following?

19. Health Effects of Smoking – Aided Responses - Gum or Mouth Diseases – YOUTH Q12/Q15 I am going to read you a list of human health effects and diseases that may or may not be caused by smoking cigarettes. Based upon what you know or believe, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree that smoking can cause each of the following?

20. Health Effects of Smoking – Top of Mind Responses – Impotence Q10/Q13 What specific health effects or diseases, if any, can you think of that can be caused by smoking cigarettes? Are there any others?

21. Health Effects of Smoking – Aided Responses - Impotence – ADULTS Q12/Q15 I am going to read you a list of human health effects and diseases that may or may not be caused y smoking cigarettes. Based upon what you know or believe, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree that smoking can cause each of the following?

22. Health Effects of Smoking – Aided Responses - Impotence – YOUTH Q12/Q15 I am going to read you a list of human health effects and diseases that may or may not be caused by smoking cigarettes. Based upon what you know or believe, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree that smoking can cause each of the following?

23. Specific Health Effects Caused by Smoking Q12/Q15 I am going to read you a list of human health effects and diseases that may or may not be caused by smoking cigarettes. Based upon what you know or believe, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree that smoking can cause each of the following?

24. Specific Health Effects Caused by Second-Hand Smoke Q13/Q16 Here is a list of human health effects and diseases that may or may not be caused by breathing in second-hand smoke from cigarettes. Based on what you know or believe, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree that smoking can cause each of the following?

25. RESULTS – DEATHS FROM TOBACCO USE

26. Smoking Attributable Mortality – 45,000 Deaths Q15/Q18 Which of the following do you think is the closest approximation of the number of Canadians who die each year as a result of tobacco use? Is it closest to ….?

27. RESULTS – HEALTH WARNING MESSAGES

28. Looking at the Health Warning Messages Q21a/Q24a About how often do you find yourself looking at, or reading health warning messages on cigarette packages? Would it be …..?

29. Recall of Specific Health Warning Messages on Cigarette Packages – Adult Smokers Q23 Without looking at a cigarette package, when it comes to the new health warning messages on cigarette packages, what specific health warning messages can you remember? Are there any others?

30. Recall of Specific Health Warning Messages on Cigarette Packages – Youth Smokers Q26 Without looking at a cigarette package, when it comes to the new health warning messages on cigarette packages, what specific health warning messages can you remember? Are there any others?

31. Impact of the Health Warning Messages - Informing Q27/Q30 Thinking about the new health warning messages you have seen on cigarette packages, have these messages been very effective, somewhat effective, not very effective or not at all effective in each of the following ways ….?

32. Impact of the Health Warning Messages – Getting you to try quitting Q27/Q30 Thinking about the new health warning messages you have seen on cigarette packages, have these messages been very effective, somewhat effective, not very effective or not at all effective in each of the following ways ….?

33. Assessment of the Health Warning Messages - Accurate Q25/Q28 Thinking generally about new health warning messages on cigarette packages in Canada, do you strongly agree, somewhat agree, somewhat disagree or strongly disagree with each of the following statements….

34. Assessment of the Health Warning Messages – Provide Important Information Q25/Q28 Thinking generally about new health warning messages on cigarette packages in Canada, do you strongly agree, somewhat agree, somewhat disagree or strongly disagree with each of the following statements…

35. RESULTS – TOXIC SUBSTANCES

36. Toxic Substances in Cigarettes Q32/Q35 Without looking at anything, what if any, chemicals or toxic substances can you name that are in cigarettes or cigarette smoke? Are there any others?

37. Conclusions  Smokers’ awareness of the health outcomes of smoking remains high  Smokers continue to strongly support and approve the new health warning messages  Smokers continue to read the messages

38. Conclusions  After 18 months, messages continue to be noticed with a trend away from general mention of pictures and towards reference to specific images (e.g. pictures/diseases of mouth/teeth), design elements or messages  After 18 months, smokers’ learning is continuing to show definite signs of growth  After 18 months, health warning messages are not demonstrating any indication of wear out