Elsevier

Preventive Medicine

Volume 88, July 2016, Pages 59-65
Preventive Medicine

Cigarette package inserts can promote efficacy beliefs and sustained smoking cessation attempts: A longitudinal assessment of an innovative policy in Canada

https://doi.org/10.1016/j.ypmed.2016.03.006Get rights and content

Highlights

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    Reading cigarette pack warnings decreased and reading inserts increased over time.

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    Reading warnings was associated with stronger response efficacy at follow up.

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    Reading inserts was associated with stronger self-efficacy to quit at follow up.

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    Reading inserts was independently associated with attempting to quit at follow up.

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    Reading inserts was associated with quitting for 30 days or more at follow up.

Abstract

Background

In June 2012, Canada implemented new pictorial warnings on cigarette packages, along with package inserts with messages to promote response efficacy (i.e., perceived quitting benefits) and self-efficacy (i.e., confidence to quit). This study assessed smokers' attention toward warnings and inserts and its relationship with efficacy beliefs, risk perceptions and cessation at follow-up.

Methods

Data were analyzed in 2015 from a prospective online consumer panel of adult Canadian smokers surveyed every four months between September 2012 and September 2014. Generalized Estimating Equation models were estimated to assess associations between reading inserts, reading warnings and efficacy beliefs (self-efficacy, response efficacy), risk perceptions, quit attempts of any length, and sustained quit attempts (i.e., 30 days or more) at follow-up. Models adjusted for socio-demographics, smoking-related variables, and time-in-sample effects.

Results

Over the study period, reading warnings significantly decreased (p < 0.0001) while reading inserts increased (p = 0.004). More frequent reading of warnings was associated independently with stronger response efficacy (Boften/very often vs never = 0.28, 95% CI: 0.11–0.46) and risk perceptions at follow-up (Boften/very often vs never = 0.31, 95% CI: 0.06–0.56). More frequent reading of inserts was associated independently with stronger self-efficacy to quit at follow-up (Btwice or more vs none = 0.30, 95% CI: 0.14–0.47), quit attempts (ORtwice or more vs none = 1.68, 95% CI: 1.28–2.19), and sustained quit attempts (ORtwice or more vs none = 1.48, 95% CI: 1.01–2.17).

Conclusions

More frequent reading of inserts was associated with self-efficacy to quit, quit attempts, and sustained quitting at follow-up, suggesting that inserts complement pictorial HWLs.

Introduction

Prominent pictorial health warning labels (HWLs) on tobacco packaging were first implemented in Canada in 2000, with more than 70 countries adopting them since then (Canadian Cancer Society, 2014). Countries print HWLs on package exteriors; however, package inserts (i.e., small leaflets inside of packs) remain underutilized for health messaging, even though tobacco companies have long used them for promotions (Brandt, 2007). Canada is the only country to use inserts to supplement HWLs (Thrasher et al., 2015a), providing an important case study for understanding whether inserts can help enhance pictorial HWL effects.

Section snippets

Background

Experimental and observational studies indicate that pictorial HWLs are more effective than text-only HWLs in increasing consumer understanding of smoking-related risks and promoting cessation-related behaviors (Thrasher et al., 2012a, Huang et al., 2014, Hammond et al., 2012, Hammond, 2011, Noar et al., 2015, Hammond and Reid, 2012, Yong et al., 2014). Pictorial HWLs appear to work, at least partly, because they are threatening (Peters et al., 2013). Reviews of threat appeals in general (

Sample

Data were analyzed in 2015 from an online consumer panel of Canadian residents purposively recruited by diverse methods for Internet-based market research on key consumer segments (www.gmi-mr.com). Recruitment involved sending invitation emails to panelists of eligible age (18–64 years old) who were either known smokers or whose smoking status was unknown. Eligible panelists had smoked at least once in the prior month and more than 100 cigarettes in their lifetime. Participant follow-up also

Sample characteristics

In addition to some socio-demographic and smoking-related differences between the follow-up sample (n = 1432 smokers, 4,734 observations) and smokers who participated in only one survey wave (n = 1,748 smokers), smokers in the follow-up sample were more likely to report lower self-efficacy to quit, lower response efficacy, greater risk perceptions, and less frequent reading of HWLs and inserts (see Table 1). At each wave, 72% to 82% of the entire sample read HWLs in the prior month, with 29% to 36%

Discussion

This study suggests that reading cigarette package inserts with efficacy messages enhances follow-up self-efficacy to quit and promotes smoking cessation above and beyond reading pictorial HWLs on cigarette package exteriors. Reading inserts was associated not only with a greater likelihood of subsequent quit attempts, as in prior research (Thrasher et al., 2015a), but also with sustained quit attempts that are more indicative of successful cessation (Dale et al., 1997, Ferguson et al., 2003,

Conclusions

This study suggests that cigarette package inserts influence key psychosocial variables and promote sustained quitting behavior. Inserts have long been used by the tobacco industry, and the elaborated messaging that inserts allow is commonly used in integrated marketing approaches to communicate with different consumer segments (Krugman et al., 2005) and should be considered by public health authorities.

Conflict of interest statement

This work was supported by the U.S. National Cancer Institute (R01 CA167067). The funding agency had no role in study design; collection, analysis, and interpretation of data; writing the report; or the decision to submit the report for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Financial disclosure

KMC has received grant funding from the Pfizer, Inc., to study the impact of a hospital based tobacco cessation intervention. JFT, KMC and DH receive funding as an expert witness in litigation involving the tobacco industry. Authors JFT, KS, DA, DMK and JWH have no financial disclosures.

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Acknowledgments

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