Ron Borland, David Hammond, Geoffrey T Fong, Hua H Yong, Warwick Hosking

1. The relativeeffectiveness 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. Tobacco industry control Tobacco use control Constrain tobacco marketing • Information: • Mandated, • Campaigns Programs to prevent uptake Cessation programs and aids Smoke-free rules Biology Regulate tobacco products Tobacco use Norms for use Consequences of use Elements of tobacco control

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

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 4

5. USA UK Australia Canada OLD NEW

6. 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 7

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

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

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

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

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

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

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

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

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

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

17. Impacts of Warning labels Australia 2006 NB: Impacts of Warning labels at least sometimes

18. 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

19. Predictors of making quit attempts by the next survey wave Predictor W1W2 W2W3 W3W4 W4W5 Notice WL1.02 0.93* 1.00 1.05 Read/look at 1.01 1.01 1.01 0.95 All analyses control for sociodemographics (including country) and cigarettes per day; plus other Warning label variables 21

20. Predictors of making quit attempts by the next survey wave Predictor W1W2 W2W3 W3W4 W4W5 Think about ------ 1.13* 1.05 1.10* risks ------ (1.07) (0.99) (1.04) More likely ------ 1.19* 1.26* 1.20* to quit ------ (1.08) (1.14*) (1.08) Think quit 1.26* 1.17* 1.09 1.11 (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. 22

21. Predictors of making quit attempts by the next survey wave Predictor W1W2 W2W3 W3W4 W4W5 Forego 1.51* 1.27* 1.42* 1.40* cigarettes (1.31*) (1.21*) (1.41*) (1.31*) Avoid 1.24* 1.15 1.02 1.04 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. 23

22. 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)

23. Reactions to warnings and concerns about future health

24. 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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