1 The relative effectiveness of graphic and text based health-warnings: findings from the ITC:4-country study. Ron Borland, David Hammond, Geoffrey T Fong,

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The relative effectiveness 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

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Constrain tobacco

marketing

Tobacco use

Regulate tobacco products

Elements of tobacco control

Consequences of use

Smoke-free rules

Programs to prevent

uptake

Cessation programs and aids

Information:• Mandated,• Campaigns

Norms for use

Tobacco use controlTobacco industry control

Biology

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Mediational Model(s) of Policy Effects

Proximal Variables(Policy-Specific)

Distal Variables(Psychosocial Mediators)

Policy Behavior

Warning labels

LabelsLabel Salience Perc EffectivenessDepth of Processing

Intentionsto Quit

QuitAttempt

Perceived risk Perceived severity

Immediate reactions: foregoing cigarettes

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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

5

OLD

NEW

USA UK Australia Canada

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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

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Scale:1 = never2 = rarely3 = sometimes4 = often5 = very often

How often have you noticed WL in the last month?

1

1.5

2

2.5

3

3.5

4

4.5

2002 2003 2004 2005 2006

Canada

USA

UK

Australia

Processing of Warning Labels (current smokers at each wave)

UK AUST

UK peak and increase higher than Aust

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Scale:1 = never2 = rarely3 = sometimes4 = often5 = very often

How often have you read or looked closely at WL in the last month?

1

1.5

2

2.5

3

3.5

4

2002 2003 2004 2005 2006

Canada

USA

UK

Australia

Processing of Warning Labels (current smokers at each wave)

UK AUST

UK peak and increase higher than Aust

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Summary

Text warnings processed more often• ? Graphic taken in more quickly

• Or processed differently

• ? Artifact of larger change in prominence

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Scale:1 = not at all2 = a little3 = somewhat4 = a lot

To what extent do WL make you think about health risks of smoking?

1

1.2

1.4

1.6

1.8

2

2.2

2.4

2.6

2003 2004 2005 2006

Canada

USA

UK

Australia

Cognitive reactions to Warning Labels (current smokers)

UK AUST

Australian peak higher than UK

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Scale:1 = not at all2 = a little3 = somewhat4 = a lot

To what extent do WL make you more likely to quit smoking?

1

1.2

1.4

1.6

1.8

2

2.2

2003 2004 2005 2006

Canada

USA

UK

Australia

Cognitive reactions to Warning Labels (current smokers)

UK AUST

Australian peak higher than UK

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Scale:1 = not at all2 = somewhat3 = very much

In last 6 months, how much have WL made you think about quitting?

1

1.1

1.2

1.3

1.4

1.5

1.6

1.7

2002 2003 2004 2005 2006

Canada

USA

UK

Australia

Cognitive reactions to Warning Labels (current smokers)

UK AUST

No diffs, Aust vs UK)

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Summary

Graphic warnings stimulate more appropriate thoughts (ie more intense thoughts)• ? Graphic more emotionally salient

• No clear effect for frequency over time

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Avoidance of WL in last month (composite measure on a 4-point scale, where 0 = no avoidance, 4 = avoid WL in all 4 ways)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

2002 2003 2004 2005 2006

Canada

USA

UK

Australia

Behavioral reactions to Warning Labels (current smokers)

UK AUST

Australian peak and increase greater than UK

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Scale:1 = never2 = once3 = a few times4 = many times

Have WL stopped you from smoking in the last month?

1

1.05

1.1

1.15

1.2

1.25

1.3

1.35

1.4

2002 2003 2004 2005 2006

Canada

USA

UK

Australia

Behavioral reactions to Warning Labels (current smokers at each wave)

UK AUST

No clear diffs Aust vs UK

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Comparisons with Canada

Slower decline in effects in Canada than UK, especially to cognitive and behavioral reactions

• See also Hammond et al, 2007

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Impacts of Warning labels Australia 2006

Current plans to quit

Notice them

Read them

Think about risk

More likely to quit

Forego cigs

Avoid them

In next month 90% 67% 70% 55% 28% 40%

< 6 months 88% 67% 68% 47% 18% 44%

> 6 months 86% 65% 49% 33% 12% 36%

Not planning 81% 51% 29% 14% 5% 31%

NB: Impacts of Warning labels at least sometimes

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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

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Predictors of making quit attempts by the next survey wave

Predictor W1W2 W2W3 W3W4W4W5

Notice WL 1.02 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

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Predictors of making quit attempts by the next survey wave

Predictor W1W2 W2W3 W3W4 W4W5

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.

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Predictors of making quit attempts by the next survey wave

Predictor W1W2 W2W3 W3W4 W4W5

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 1.04warnings (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.

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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)

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Reactions to warnings and concerns about future health

Worried about future health

Not at all Very

Forego cigarettes 2004 2% 13%

2005 4% 25%

Think of risks 2004 12% 52%

2005 16% 76%

Increase quit prob 2004 4% 35%

2005 8% 55%

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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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