Aims Among three eye‐tracking studies, we examined how cigarette pack features affected visual attention and self‐reported avoidance of and reactance to warnings. Design Study 1: smoking status × warning immediacy (short‐term versus long‐term health consequences) × warning location (top versus bottom of pack). Study 2: smoking status × warning framing (gain‐framed versus loss‐framed) × warning format (text‐only versus pictorial). Study 3: smoking status × warning severity (highly severe versus moderately severe consequences of smoking). Setting University of Bristol, UK, eye‐tracking laboratory. Participants Study 1: non‐smokers (n = 25), weekly smokers (n = 25) and daily smokers (n = 25). Study 2: non‐smokers (n = 37), smokers contemplating quitting (n = 37) and smokers not contemplating quitting (n = 43). Study 3: non‐smokers (n = 27), weekly smokers (n = 26) and daily smokers (n = 26). Measurements For all studies: visual attention, measured as the ratio of the number of fixations to the warning versus the branding, self‐reported predicted avoidance of and reactance to warnings and for study 3, effect of warning on quitting motivation. Findings Study 1: greater self‐reported avoidance [mean difference (MD) = 1.14; 95% confidence interval (CI) = 0.94, 1.35, P < 0.001, ηp2 = 0.64] and visual attention (MD = 0.89, 95% CI = 0.09, 1.68, P = 0.03, ηp2 = 0.06) to long‐term warnings, but not for reactance (MD = 0.14, 95% CI = –0.04, 0.32, P = 0.12, ηp2 = 0.03). Increased visual attention to warnings on the upper versus lower half of the pack (MD = 1.8; 95% CI = 0.33, 3.26, P = 0.02, ηp2 = 0.08). Study 2: higher self‐reported avoidance of (MD = 0.70; 95% CI = 0.59,0.80, P < 0.001, ηp2 = 0.61) and reactance to (MD = 0.37; 95% CI = 0.27, 0.47, P < 0.001, ηp2 = 0.34) loss‐framed warnings but little evidence of a difference for visual attention (MD = 0.52; 95% CI = –0.54, 1.58, P = 0.30, ηp2 = 0.01). Greater visual attention, avoidance and reactance to pictorial versus text‐only warnings (all Ps < 0.001, ηp2 > 0.25). Study 3: greater self‐reported avoidance of (MD = 0.37; 95% CI = 0.25, 0.48, P < 0.001, ηp2 = 0.33) and reactance to (MD = 0.14; 95% CI = 0.05, 0.23, P = 0.003, ηp2 = 0.11) highly severe warnings but findings were inconclusive as to whether there was a difference in visual attention (MD = –0.55; 95% CI = –1.5, 0.41, P = 0.24, ηp2 = 0.02). Conclusions Subjective and objective (eye‐tracking) measures of avoidance of health warnings on cigarette packs produce different results, suggesting these measure different constructs. Visual avoidance of warnings indicates low‐level disengagement with warnings, while self‐reported predicted avoidance reflects higher‐level engagement with warnings.
BackgroundPictorial tobacco health warning labels (HWLs) have been shown to be more effective than text-only HWLs in changing smoking attitudes and intentions. However, there is contradictory evidence regarding how the severity of the content of HWLs influences responses to them.MethodsWe examined the perceived believability and effectiveness of HWLs in an online study using a convenience sample of non-smokers (N = 437) and smokers (N = 436). HWLs were in one of three presentation formats: (text-only, a moderately severe image or highly severe image) and focussed on three disease outcomes (lung cancer, blindness or tooth and gum disease). Participants rated the effectiveness and believability of each HWL and also rated their perceived susceptibility to each disease.ResultsA 2 (smoking status) × 3 (presentation format) × 3 (disease outcome) ANOVA was run for both believability and effectiveness ratings. The most severe pictorial HWLs received the highest believability and effectiveness ratings and as expected, the text-only HWLs received the lowest. Lung cancer HWLs were rated most believable and effective, with the blindness HWLs receiving the lowest scores. A 2 (smoking status) × 3 (disease outcome) ANOVA was conducted on the ratings of perceived susceptibility to the three diseases. Smokers considered themselves to be more susceptible to all three diseases, and among smokers, perceived susceptibility to the diseases was positively correlated with effectiveness and believability ratings of the HWLs.ConclusionOur findings support previous evidence that pictorial HWLs are rated as more effective and believable than text-only warnings, and provide some support for the use of severe or ‘grotesque’ HWLs on tobacco products. Our data also suggest that HWLs should aim to increase perceived susceptibility to disease, as this was positively related to perceived message effectiveness and believability.Electronic supplementary materialThe online version of this article (10.1186/s12889-018-5385-x) contains supplementary material, which is available to authorized users.
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