Article Text

Awareness and impact of New York City's graphic point-of-sale tobacco health warning signs
1. Micaela H Coady,
2. Christina A Chan,
3. Kari Auer,
4. Shannon M Farley,
5. Elizabeth A Kilgore,
6. Susan M Kansagra
1. Bureau of Chronic Disease Prevention and Tobacco Control, New York City Department of Health and Mental Hygiene, Queens, New York, USA
1. Correspondence to S M Kansagra, Bureau of Chronic Disease Prevention and Tobacco Control, Gotham Center, 42-09 28th Street, 10th Floor, CN-18, Queens, NY 11101, USA; skansagr{at}health.nyc.gov

## Abstract

Background To increase knowledge of smoking-related health risks and provide smoking cessation information at the point of sale, in 2009, New York City required the posting of graphic point-of-sale tobacco health warnings in tobacco retailers. This study is the first to evaluate the impact of such a policy in the USA.

Methods Cross-sectional street-intercept surveys conducted among adult current smokers and recent quitters before and after signage implementation assessed the awareness and impact of the signs. Approximately 10 street-intercept surveys were conducted at each of 50 tobacco retailers in New York City before and after policy implementation. A total of 1007 adults who were either current smokers or recent quitters were surveyed about the awareness and impact of tobacco health warning signs. Multivariate risk ratios (RR) were calculated to estimate awareness and impact of the signs.

Results Most participants (86%) were current smokers, and the sample was 28% African–American, 32% Hispanic/Latino and 27% non-Hispanic white. Awareness of tobacco health warning signs more than doubled after the policy implementation (adjusted RR =2.01, 95% CI 1.74 to 2.33). Signage posting was associated with an 11% increase in the extent to which signs made respondents think about quitting smoking (adjusted RR =1.11, 95% CI 1.01 to 1.22).

Conclusions A policy requiring tobacco retailers to display graphic health warning signs increased awareness of health risks of smoking and stimulated thoughts about quitting smoking. Additional research aimed at evaluating the effect of tobacco control measures in the retail environment is necessary to provide further rationale for implementing these changes.

• Tobacco
• graphic health warnings
• smoking cessation
• cessation
• prevention
• public policy
• advertising and promotion

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## Introduction

The impact of exposure to tobacco advertising and promotion in the retail environment on adult and youth smoking behaviours is well characterised in the literature.1–3 More specifically, exposure to retail cigarette advertising and promotion among youth is associated with higher rates of youth smoking initiation and lifetime smoking.1 ,4 Exposure among adults is associated with increased impulse purchases of cigarettes that can lead to lower rates of successful cessation.3 ,5 Extant research suggests that characteristics of the retail environment, the primary source of tobacco industry expenditures on tobacco product marketing, are making it easier for adults and youth to smoke.6

Smokers' behaviours are also influenced by their understanding of the health risks of smoking.7 Smokers who perceive greater smoking-related health hazards are more likely to consider quitting and to quit smoking successfully.7 Although the harmful effects of smoking have been known for decades, there remain significant gaps in smokers' understanding of these risks.8 ,9 One survey found that 15% of US smokers believed that smoking did not cause heart disease.7 In New York City (NYC), almost 50% of smokers do not think that they are at greater risk of heart attack than non-smokers of the same age (unpublished data: NY State Adult Tobacco Survey, 2007). These gaps in risk awareness are widest among lower socioeconomic groups.10

### Measures

Demographic characteristics included in the analysis were age, sex, race/ethnicity, language spoken most often at home, education and income. Current smoking status was assessed through two questions: “Have you smoked at least 100 cigarettes in your entire life?” and “Do you now smoke cigarettes every day, some days or not at all?”. Recent quitters did not currently smoke but had smoked within the last 6 months. Cigarette consumption among current smokers was measured as the number of cigarettes smoked per day (CPD) (1–10, 11–20 and 21+ CPD).

Awareness of signs was assessed through two questions: “During this visit to the store, did you notice health warning signs about smoking posted in the checkout area when you were paying for your purchases?” (prompted response options were ‘Yes, noticed and read’; ‘Yes, noticed but did not read’; ‘No’; ‘Don't know’) and “In the past 30 days, when you were paying for your purchases in stores, how often did you notice health warning signs about smoking posted in the checkout area?” (prompted response options were ‘Very often’; ‘Often’; ‘Sometimes’; ‘Rarely’; ‘Never’).

To assess knowledge of smoking-related health risks, a list of health effects and diseases related and not related to smoking were read and participants indicated the extent to which they agreed that smoking cigarettes was the cause of each. In the survey, the knowledge of health effects question was placed after tobacco purchasing behaviours, and before awareness and impact of the signage, to minimise recall bias.

### Analysis

Student t tests were used to determine the statistical significance of changes in responses to questions between the baseline and follow-up survey. Differences in demographic characteristics, smoking behaviours, awareness and impact of signs, knowledge of smoking-related health risks and purchasing behaviours were examined. Differences in awareness and impact of signs were also examined by location of store at the borough level.

## Results

Overall, the majority of participants in our study were 25–44 years old (42%) or 45–64 years old (37%) (table 1). More than half (59%) of those surveyed were male, and there were similar percentages of non-Hispanic whites, African–Americans and Hispanic/Latinos (range of 27%–32%). The majority of participants (81%) were English speakers, and 54% had a high school education or less. About half (52%) reported an annual income of <\$25 000. The only difference in demographic characteristics of participants in the two surveys was language: a larger proportion of English speakers were included in the baseline survey compared with the follow-up survey (83% vs 78%, p=0.03). Most participants (86%) were current smokers and about three-fourths (79%) smoked daily. Smokers were less likely to be light smokers (10 or fewer CPD) at baseline than at follow-up (55% vs 65%, p<0.01).

Table 1

Demographic and smoking behaviours of current smokers and recent quitters surveyed exiting tobacco retailers in New York City (November 2009 and August to September 2010)

Awareness of tobacco health warning signs at the POS during the current visit to the store or in the past 30 days increased from 30% before to 67% after (p<0.01) the signs were posted (table 2). Among respondents who noticed signs, the extent to which the signs made them think about the health risks of smoking ‘a lot’ increased from 34% to 47% (p=0.01) pre/post signage implementation. Among current smokers who noticed signs, the extent to which the signs made them think about quitting smoking ‘a lot’ increased from 31% to 43% (p=0.02). There was no difference across surveys in the signs helping recent quitters to stay quit (p=0.55). Differences in signs prompting smokers not to purchase cigarettes achieved only borderline significance (15% to 8%, p=0.05). The awareness and impact measures did not significantly vary by store location (data not shown).

Table 2

Awareness and impact of point-of-sale health warning signs on knowledge and smoking-related behaviours, New York City (November 2009 and August to September 2010)

Multivariate logistic regression modelling showed that following signage implementation, awareness of tobacco health warning signs at the POS doubled (ARR =2.01, 95% CI 1.74 to 2.33, p<0.01). Signage implementation was also borderline significantly associated with making respondents think about the health risks of smoking ‘a lot’ (ARR =1.11, 95% CI 0.96 to 1.28, p=0.16). Finally, signage posting was associated with an 11% increase (ARR =1.11, 95% CI 1.01 to 1.22, p=0.04) in the extent to which signs made respondents think about quitting smoking ‘a lot’.

The per cent of respondents who agreed that two of the three health conditions depicted in the signs (gum or mouth disease and stroke) were caused by smoking cigarettes increased across the two survey waves (table 3). The proportion of participants who agreed that gum or mouth disease was smoking related increased from 88% to 93% (p<0.01). Similarly, the per cent that agreed that throat or mouth cancers was smoking related increased across survey wave (93% to 96%, p=0.02). The proportion that agreed that stroke was related to smoking also increased, from 83% to 89% (p=0.01). However, knowledge of lung cancer being associated with smoking did not differ across survey waves (96% vs 98%, p=0.06). While there were no changes in knowledge of health conditions not related to smoking (ie, control conditions including liver disease and diabetes), there was an increase in knowledge of heart disease and impotence among men being smoking related. However, these health conditions were not depicted on signs. Knowledge of heart disease being associated with smoking increased from 86% to 91% (p=0.01) and knowledge of impotence increased from 46% to 57% (p<0.01).

Table 3

Knowledge of smoking-related health risks, New York City (August 2009 and September 2010)

## Discussion

This paper provides the first known results of an evaluation of the awareness and impact of graphic tobacco health warning signs at the POS in the USA. Our results show that signage implementation was associated with a doubling in the awareness of health warning signs and an 11% increase in stimulating thoughts about quitting. The ARR for signs stimulating thoughts about the health risks of smoking achieved borderline significance. The signs did not help recent quitters to stay quit or stop smokers from purchasing cigarettes at the current visit to the store.

There was a high level of awareness of tobacco health warning signs at the POS in the baseline survey (30%), although signs were not yet posted. This finding may be related to the posting of other signs about tobacco at the POS, including the legal age of sale sign and the Surgeon General's warning that smoking causes lung cancer, which is present on cigarette advertisements. Respondents may also have been reacting to anti-tobacco media and education efforts in other venues, including text-based warnings on cigarette packs as well as television, print, outdoor or online anti-tobacco advertisements, which are common in NYC. The high level of baseline awareness may even have been due to social response bias. Regardless, NYC POS signs did have a measurable impact on increasing awareness of tobacco health warnings, despite the high baseline awareness. Finally, this finding is consistent with the high levels of awareness reported in a previous study of POS anti-smoking warnings in Australia.11

Research shows that there are significant gaps in health knowledge related to the risks of smoking.8 ,9 Although our results achieved only borderline significance in stimulating thoughts about the health risks of smoking, the signs did increase knowledge of the health effects depicted in the signs, including gum and mouth diseases and stroke. This is similar to results from other studies, which have demonstrated that large, colour graphic cigarette pack warnings increase knowledge of the health consequences of smoking.14 ,16

The increases in knowledge of heart disease, impotence and throat/mouth cancers being related to smoking were unexpected, as they were not featured on the POS warning signs. Other public education efforts occurring in different venues between waves could have increased knowledge of these specific health effects. Also, there was a borderline significant difference in income level across survey waves, with participants in the follow-up survey less likely to be low income. As income is correlated with educational status, this difference may be contributing to the increased knowledge of smoking-related diseases not featured in the signs. The POS signs may also be stimulating thoughts and awareness of smoking-related health risks more generally.

Two-thirds of NYC smokers reported trying to quit at least once during the past year but only about half of adults in NYC reported that it is easy for smokers to get information about smoking cessation services17 (unpublished data: NY State Adult Tobacco Survey, 2007–2008). Our signs contained cessation information; however, our results did not show an impact of the signs on helping recent quitters to stay quit or in preventing smokers from purchasing cigarettes. This could be because the follow-up surveys were conducted only 9 months following signage distribution to retailers. We anticipate that the warning signs could have had an effect on behavioural outcomes such as preventing relapse or cigarette purchases had the signs been posted for a longer time period. The signs did, however, stimulate thoughts about quitting smoking, which has been shown to be related to motivation to quit and successful quits.18–20 Other anti-tobacco education efforts, including graphic cigarette pack warnings, have had a demonstrated effect on stimulating thoughts about quitting as well.7 ,19 ,21 ,22

Evidence suggests that smoking-related interventions aimed at increasing awareness and knowledge as well as prompting behaviour change such as quit attempts generally have a larger impact on awareness and knowledge measures in comparison to behavioural change.23–25 Research also shows that while smoking interventions often have modest effects on immediate behavioural outcomes, they are more successful in altering long-term behaviour.26 While changing smokers' purchasing behaviours and preventing relapse is clearly more challenging, a large body of scientific evidence has demonstrated that graphic cigarette pack warnings can increase quit smoking success and decrease youth smoking initiation.14 ,27 While pack warnings influence smoking attitudes and behaviours after the cigarette purchase has already occurred, graphic depictions of the health consequences of smoking available to customers through POS signs may have a stronger impact on cigarette purchasing behaviours since they are visible before purchase. The ability of POS information to positively affect consumer purchasing has also been demonstrated by NYC's rule requiring calorie labelling on chain restaurant menus, which has led to fewer calories being purchased.28 ,29

There were limitations to this study. First, while signage posting was never enforced, some retailers (20%) did not have signs posted during the follow-up survey. While the absence of signs in stores likely influenced the level of awareness and impact of signs at the current visit to the store, these measures were also assessed within the last 30 days, which would capture the effect of signage viewed elsewhere. As this study employed a convenience sample based on the underlying distribution of retailers, the study sample may not be representative of the NYC adult smoker and recent quitter population. While the demographic characteristics of our sample were largely similar to those of current smokers and recent quitters based on data from a 2010 population-based survey of NYC adults, NYC smokers were significantly more likely to be aged 65 years and older, white and report higher education levels compared with participants in this study.17

The results may not be generalisable to other retailer types, as the study was restricted to two types of retailers (grocery/supermarkets and pharmacies). However, these two retailer types represent the majority of licensed tobacco retailers in the City. Given the unique urban environment of NYC, with almost 11 000 licensed tobacco retailers, these results may also not be generalisable to smaller cities or towns. Additionally, the high recall of signage at baseline, measured before the policy implementation, may contribute to underestimating the awareness and impact overall. Finally, while the knowledge of health effects question was placed in the survey before awareness and impact of the signage to minimise recall bias, this question order may stimulate better memory of signs. In future studies, multiple versions of the survey could be fielded to test for order effects.

## Conclusions

The results described here highlight the effectiveness of graphic health warning signs at the POS in stimulating thoughts about quitting smoking and, to a lesser extent, the health effects of smoking. The US Food and Drug Administration's graphic cigarette pack warnings were required beginning in September 2012, although the requirement was struck down in federal court and is currently being appealed.30 If implemented in the future, the pack warnings could have a synergistic effect with the POS signs in terms of increasing awareness of the consequences of smoking and providing cessation information. Future studies could also assess intentions to seek quit-smoking assistance from smokers' quitlines as a result of this information being included on POS warning signs. Additional research aimed at evaluating the effect of tobacco control measures in the retail environment is necessary to provide further rationale for implementing these evidence-based changes.

### What this paper adds

This study is the first to evaluate the impact of graphic tobacco health warning signs at the POS in tobacco retailers in the USA. Findings from street-intercept surveys conducted before and after signage implementation in NYC demonstrate that the signs were associated with increased awareness of tobacco health warning signs at the POS. Signage posting also had an effect on increasing knowledge of the health effects of smoking and stimulating thoughts about quitting smoking. These findings can be used to provide additional rationale for implementing policy changes in the retail environment.

## Acknowledgments

We greatly appreciate the guidance and direction provided by Ann Pearson, JD, Kristen Keneipp, MPH, and Jamie Sokol, MPH, in the development and distribution of the NYC tobacco health warning signs. We also appreciate the oversight provided by Thomas A. Farley, MD, MPH, Thomas R. Frieden, MD, MPH, and Sarah Perl, MPH. Finally, we thank Global Strategy Group for conducting the street-intercept surveys on behalf of the New York City Department of Health and Mental Hygiene.

## Footnotes

• Funding This work was supported by the New York City Department of Health and Mental Hygiene, City Tax Levy. No outside funding was provided. Funded data collection and personnel time.

• Correction notice This article has been corrected since it was published Online First. The conclusion section in the abstract has been amended.

• Competing interests None.

• Ethics approval Ethics approval was provided by the New York City Department of Health and Mental Hygiene.

• Provenance and peer review Not commissioned; externally peer reviewed.