Research article
Cigarette Warning Label Policy Alternatives and Smoking-Related Health Disparities

https://doi.org/10.1016/j.amepre.2012.08.025Get rights and content

Background

Pictorial health warning labels on cigarette packaging have been proposed for the U.S., but their potential influences among populations that suffer tobacco-related health disparities are unknown.

Purpose

To evaluate pictorial health warning labels, including moderation of their influences by health literacy and race.

Methods

From July 2011 to January 2012, field experiments were conducted with 981 adult smokers who were randomized to control (i.e., text-only labels, n=207) and experimental conditions (i.e., pictorial labels, n=774). The experimental condition systematically varied health warning label stimuli by health topic and image type. Linear mixed effects (LME) models estimated the influence of health warning label characteristics and participant characteristics on label ratings. Data were analyzed from January 2012 to April 2012.

Results

Compared to text-only warning labels, pictorial warning labels were rated as more personally relevant (5.7 vs 6.8, p<0.001) and effective (5.4 vs 6.8, p<0.001), and as more credible, but only among participants with low health literacy (7.6 vs 8.2, p<0.001). Within the experimental condition, pictorial health warning labels with graphic imagery had significantly higher ratings of credibility, personal relevance, and effectiveness than imagery of human suffering and symbolic imagery. Significant interactions indicated that labels with graphic imagery produced minimal differences in ratings across racial groups and levels of health literacy, whereas other imagery produced greater group differences.

Conclusions

Pictorial health warning labels with graphic images have the most-pronounced short-term impacts on adult smokers, including smokers from groups that have in the past been hard to reach.

Introduction

Numerous studies1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 have demonstrated that prominent health warning labels with pictorial imagery are more effective than text-only labels in engaging smokers, increasing knowledge about risks, promoting thoughts about quitting, and decreasing demand for cigarettes. As of 2011, a total of 39 countries have implemented pictorial health warning labels.12 The U.S. was scheduled for implementation in 2012, but tobacco industry litigation has delayed implementation. To inform future warning label policy development and implementation, more data are needed on U.S. consumer responses to various label content.13 The current study addresses this issue, while focusing on responses among smokers from populations that bear a disproportionate burden of tobacco-related disease.14, 15, 16, 17, 18

Since 1985, the U.S. has had four text-only messages that appear on one side of cigarette packages. The 2009 Family Smoking Prevention and Tobacco Control Act (FSPTA) gave the U.S. Food and Drug Administration (FDA) regulatory authority over health warning labels, including the selection of content. In line with WHO recommendations,19 these labels are to cover 50% of the front and back of each cigarette package, and include nine unique combinations of text and image. The 2009 FSPTA stipulates that the labels be changed on a recurring basis in an effort to minimize “wear out” of their impacts due to repeated exposure to the same messages.20

Smoking increasingly is concentrated in lower-SES groups,17, 18 where health literacy is relatively low.17, 21 Among populations with basic or lower literacy, communication that involves pictures is more effective than text only.22, 23 Most of the research on health literacy, however, has focused on communication involving personal interaction (e.g., the clinical encounter),24, 25, 26 not communication involving only print media.

Nevertheless, studies27, 28, 29, 30 on text-only labeling of foods and medications indicate that populations with low literacy and numeracy find it difficult to understand. Efforts to promote pictorial labels for tobacco products emphasize their greater potential impact compared to textual labels among low-literacy populations,2 although this has not been tested directly. Nevertheless, the inverse association between educational attainment and responses to pictorial labels supports this contention,31 although this inverse association has not always been found.11

The specific type of pictorial health warning label content that works best is understudied, although some studies13, 32, 33 suggest that graphic imagery works best. For example, compared to Uruguayan smokers, whose pictorial labels included more-abstract imagery (e.g., a bomb to represent pending disease), Brazilian smokers exposed to pictorial labels with graphic imagery reported more-frequent thoughts about smoking-related risks, about quitting, and refrained from smoking more often because of these labels.31 Experiments with adult smokers and youth in the U.S. and Mexico are consistent with these findings.10, 34, 35, 36, 37 However, the U.S.-based research to evaluate specific content of pictorial labels has relied on young adult college students32 and online consumer panels36, 37 and which under-represent lower-SES groups that have higher smoking rates and low health literacy.38

The current paper presents results from a field experiment with a randomized design to assess whether adult smokers from lower-SES groups rated pictorial health warning labels as relatively more credible, personally relevant, and effective than current, text-only labels used in the U.S. Further, pictorial labels were varied systematically to assess whether graphic imagery was associated with higher ratings than imagery of human suffering and symbolic imagery. Finally, moderation of these influences by health literacy and race were examined, to determine whether study manipulations produced stronger impacts among black smokers than white smokers and among smokers with low compared to high health literacy.

Section snippets

Sample and Protocol

From July 2011 to January 2012, in-person field experiments were conducted with a convenience sample of 981 adult smokers recruited from public places (e.g., supermarkets, flea markets, sporting events) in low- and middle-income areas across the three main regions of South Carolina (Table 1). This intercept survey method is standard for marketing research.39, 40 Current daily smokers who had smoked 100 or more cigarettes in their lifetimes were eligible to participate. Eligible participants

Results

The study population was 59% female; 47% identified as white and 44% as black; and 43% of the sample was aged <30 years (Table 1). The recruitment strategy succeeded in enrolling a lower-SES population, as evidenced by 47% with a household income of ≤$25,000 per year, 47% with a high school education or less, and 63% with low health literacy according to the NVS. No differences were found between the experimental (n=774) and control groups (n=207).

Discussion

Study results provide further evidence for the greater effectiveness of pictorial health warning labels compared to text-only labels among adult smokers. Study results are consistent with observational studies of smokers across countries whose policies contrast on these characteristics,1, 3, 7 experimental economic studies among adult smokers in the U.S.,11 focus groups with young adults in the U.S.,6, 9 and similar experimental studies with online samples of adult smokers and youth in the U.S.

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      There is a substantial body of evidence demonstrating their impact on a range of outcomes including cessation-related behaviours (Hammond, 2011), with evidence indicating labels that generate negative emotions are most effective (Cho et al., 2018). This is shown by a greater effect of image-and-text (often called ‘pictorial’ or ‘graphic’) warnings than text-only warnings (Brewer et al., 2016; Hammond, 2011; Noar et al., 2015), including in socially and materially deprived groups in whom smoking rates are frequently higher (Thrasher et al., 2012). Given that the current implementation of HWLs on tobacco provides clear evidence that they are a feasible population-level intervention, there is high interest amongst researchers, policy-makers and the general media (Al-Hamdani & Smith, 2017; Parry, 2014; Popova, 2016) in their possible application to other health-damaging products including some foods, alcoholic and non-alcoholic drinks.

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