Effective Pictorial Warning Labels: Research Insights & Examples

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

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

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

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

5. International Pack Study • Parallel studies in 7 diverse countries: • Examine effective contentfor 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

6. Health Warning Topics & Stimuli

7. Health warning topic “sets” • 5 or 6 warnings tested for each topic Text Symbolic Human suffering Graphic External Graphic Internal Testimonial

8. Field experiments Topics • Brief Survey • Sociodemographics • Smoking-related perceptions & behavior • Warning labels • Rate 5 to 7 warnings from selected block in random order • Evaluate for each warning: • Attention • Credibility • Relevance • Negative emotional arousal • Impact • Rank warnings within a block: • Which most motivates you to stop smoking? • Which most motivates you to not start smoking? Addiction Throat cancer Mouth cancer Death Premature aging Stroke Random assignment Impotence Lung cancer Gangrene Heart attack Toxicity Enphysema Premature birth SHS in children 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. Graphic & human suffering rated as more effective than symbolic warnings (p<.001) Graphic & human suffering Symbolic vs. Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.

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

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

13. Warnings depicting suffering of OTHERSrated as more effective than suffering of SELF (p<.001) Other suffering vs. Self 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

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

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

18. “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 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 Didactic/scientific vs. testimonial content Didactic /scientific Testimonial - other Testimonial - self Contains particles that enter your blood stream, form blood clots and can block your arteries Contains particles that enter your blood stream, form blood clots and can block your arteries 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 • Brief survey • Sociodemographics • Smoking perceptions & behavior • HWL Condition 1: 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 • Ranking task of HWLs within block: • Which motivates you most to quit? • Which motivates you most to not start smoking? Condition 2: 4 blocks of packs on same health outcome Randomization Condition 3: 4 blocks of packs on same health outcome Condition 4: 4 blocks of packs on same health outcome Thrasher JF, Arillo-Santillán E, Villalobos V, et al. Cancer Causes & Control. 2012.

21. Sample characteristics

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

25. Focus groups • Mixed methods • Individual ratings • Group discussion • Callback two days later • 12 groups, 4 in each city:

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

27. New HealthWarningLabels

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. 2009 • Cigarette tax increase to 61.4% of final price • Advertising promotion restrictions • National smoke-free law regulations change ‘must’ to ‘may’ have DSRs • 2010 • Pictorial health warnings • State-level smoke-free implementation • Cigarette tax increase to 62.7% of final price MEXICO Timeline of Tobacco Control Policies and ITC Surveys 2004 Cigarette health warnings must occupy 50% of back of package 2011/12 New pictorial warning rotations 2011 Cigarette tax increase to 68.8% of final price (7pesos) 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 May 2004 FCTC ratification 2004 2005 2006 2007 2008 2009 2010 2011 2012 Wave 2 Oct-Dec 2007 N= 1080 Wave 4 Jan-Feb 2010 N= 2100 Wave 5 Apr-May 2011 N=2100 Wave 1 Sept-Nov 2006 N= 1080 Wave 3 Nov-Dec 2008 N= 2000 Survey Mode: Face-to-Face (F2F) Respondent Types: Smoker 29