Understanding Why Pictorial Cigarette Pack Warnings Increase Quit Attempts

Abstract

Background Our randomized trial found that pictorial cigarette pack warnings elicited more quit attempts than text-only warnings. Purpose In the current study, we sought to identify psychological mechanisms that explain why pictorial cigarette pack warnings change behavior. Methods In 2014 and 2015, we recruited 2,149 adult smokers in North Carolina and California, US. We randomly assigned smokers to receive on their cigarette packs for 4 weeks either a text-only warning (one of the US’s current warnings on the side of cigarette packs) or a pictorial warning (one of the US’s proposed text warnings with pictures on the top half of the front and back of cigarette packs). Results Pictorial warnings increased attention to, reactions to, and social interactions about cigarette pack warnings (all p<.05). However, pictorial warnings changed almost no belief or attitude measures. Mediators of the impact of pictorial warnings included increased attention, negative affect, social interactions, thinking about the warning and harms of smoking, and intentions to quit (all p<.05). Analyses also found that pictorial warnings led to greater avoidance of the warnings, which was associated with more quit attempts (p<.05). Conclusions Pictorial warnings increased quit attempts by eliciting aversive reactions and by keeping the message vividly in smokers’ minds. Contrary to predictions from several theories of health behavior, the warnings exerted little of their influence through changes in beliefs and attitudes and none of their influence through changes in risk perception. We propose the Tobacco Warnings Model based on these findings.

Avoidance of tobacco health warnings? An eye-tracking approach

“…In this context, self-reported avoidance thus indicates how effectively the warning communicates threat -an important prerequisite for effective communication of health messages (2,16,(49)(50)(51)(52). In two of the three studies, we found that avoidance and reactance are positively correlated, and recent research suggests that warnings can simultaneously increase avoidance (which is related to increased quit intentions (15)) and reactance (which is related to decreased quit intentions (53)). We suggest that these simultaneous effects of warnings on both adaptive (i.e., self-reported avoidance) and defensive (i.e., reactance) measures may explain, at least in part, the current lack of consensus in the literature regarding the effectiveness of threatening health warnings (45,46).…”

“…In contrast, longitudinal studies have found that self-reported avoidance of warnings is related to increased quit attempts (15,16). It is thus possible that visual avoidance of warnings indicates a lack of low-level engagement with warnings (and thus a maladaptive response), while self-reported avoidance (characterised by higher-order cognitive processes) may be a marker of warning engagement, with those individuals most affected by the negative emotions evoked by the warnings most likely to employ strategies to avoid them.…”

Public support for pictorial warnings on cigarette packs: an experimental study of US smokers

“…Message reactance, in turn, was associated with lower support for pictorial warnings. Prior research has focused on whether message reactance hinders the effectiveness of pictorial warnings on intentions and behavior (Brewer et al, Under Review; Hall et al, In Press). However, our study suggests that reactance may also partially undermine support for pictorial warnings on cigarette packs.…”

Improving Knowledge that Alcohol Can Cause Cancer is Associated with Consumer Support for Alcohol Policies: Findings from a Real-World Alcohol Labelling Study

“…Alcohol container labels are one potentially effective information-based strategy for increasing consumer knowledge about the negative consequences of alcohol and are recommended by the World Health Organization [40,41]. Labels influence behaviour by attracting consumers' attention and keeping the message in consumers' minds through repeated exposure at key points of contact-the point-of-purchase and the point-of-pour [42]. Labels are appealing because of their low cost to regulators and unparalleled reach among drinkers, with the heaviest drinkers exposed most often [43].…”