Research articleText and Graphic Warnings on Cigarette Packages: Findings from the International Tobacco Control Four Country Study
Introduction
Tobacco use remains the second leading cause of death in the world.1, 2, 3 Accordingly, cigarette packages in almost every jurisdiction in the world carry health warnings to inform consumers about the risks of smoking. Health warnings on packages are appealing both because of their low cost to regulators and their unparalleled reach among smokers. However, the effectiveness of package warnings depends on their size, position, and design: whereas obscure warnings have been shown to have relatively little impact, more comprehensive warnings, including picture-based warnings, have been associated with greater recall, increased motivation to quit smoking, and greater attempts to quit.4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 Previous research also indicates that health warnings are subject to “wear-out,” such that newly implemented warnings are most likely to be noticed and rated as effective by smokers.15, 16, 17, 18
In recognition of the health and economic burden from tobacco use, more than 140 countries have ratified the Framework Convention on Tobacco Control (FCTC)—the first international treaty devoted to public health.3 Countries that ratify the FCTC are required to implement health warnings on cigarette packages that cover at least 30% of the surface and are “large, clear, visible, and legible.”3 Beyond these minimum requirements, the FCTC also recommends that warnings “should” cover 50% or more of a package’s principal surfaces, and “may” be in the form of pictures.3
Although several countries, such as Canada, already meet the recommended international guidelines, health warnings in the majority of countries, including the United States, fall short of the minimum FCTC standards. Some jurisdictions, such as the European Union, have recently revised their labeling policies to meet the FCTC guidelines.19
The “effectiveness” of graphic warnings can be measured in various ways, including (1) measures of salience, such as noticing and reading the warnings, (2) changes in health knowledge and perceptions of risk, (3) intentions/motivation to quit, and (4) behavioral changes, including changes in consumption, attempts to quit, and successful cessation. Measures of salience have previously been shown to predict future cessation behavior in previous research11; however, each of these downstream outcomes, including changes in perceived risk and motivation to quit, is also mediated by individual factors, such as a smoker’s socioeconomic background, as well as environmental variables including other sources of health information and pro-tobacco marketing.18
The purpose of the current study was to evaluate the effectiveness of health warnings in four countries—United States, Canada, UK, and Australia—including the impact of new warnings implemented in the UK, which were enhanced in 2003 to meet the minimum FCTC standard. The present study used data from the International Tobacco Control (ITC) Four Country Survey, a cohort survey of representative samples of adult smokers in the UK, Canada, United States, and Australia. Survey waves were conducted in each country approximately 2 months before the UK warnings were implemented, and at 6, 18, and 32 months after implementation. Figure 1 shows the health warnings in each of the four ITC countries over the course of the survey waves. At baseline, Canadian packages featured 16 graphic warnings covering half of the outside of packages, as well as additional health and cessation information on the inside of packages. Australian packages featured six text warnings covering 25% and 35% of the front and back of the package, respectively, whereas the six text warnings on UK packages covered only 6% of the package face. In the United States, four warnings were printed on the side of packages. Thus, the current study evaluated warnings that were (1) well below the minimum FCTC standard (U.S. and UK at baseline), (2) slightly below the FCTC minimum (Australian warnings), (3) enhanced to the FCTC standard (UK at follow-up), and (4) at the recommended FCTC standard (Canada).
Section snippets
Sample
Respondents in the ITC Four Country Survey were aged ≥18 years, smoked more than 100 cigarettes in their life, and smoked at least once in the past 30 days at recruitment.
Procedure
The cohort was constructed from probability sampling methods with telephone numbers selected at random from the population of each country, within strata defined by geographic region and community size. Eligible households were identified by asking a household informant the number of adult smokers. The next birthday method20
Sample Characteristics
Table 1 presents the demographic profile of the samples for each country.
Responses to Health Warnings—Wave 1
Figure 3 shows responses to health warnings across four survey waves. At Wave 1, Canadian smokers were significantly more likely to report noticing health warnings compared to smokers in the other three countries: 60% of Canadian smokers noticed the warning “often” or “very often,” compared to 52% of Australians (odds ratio [OR]=1.42, 95% confidence interval (CI)=1.25–1.63, p<0.001), 44% of UK smokers (OR=1.95,
Discussion
This study suggests that more prominent health warnings are associated with greater levels of awareness and perceived effectiveness among smokers. In particular, the findings provide strong support for the effectiveness of new health warnings implemented on UK packages that were enhanced to meet the minimum international standards. The new UK warnings were significantly more likely to be noticed and read than the previous set of UK warnings, as well as the U.S. and Australian warnings, neither
Limitations
Although the prospective quasi-experimental design used in this study offers considerable advantages over previous research evaluating product warnings, this research nevertheless has important limitations common to survey research, including bias from nonresponse and attrition. The data were weighted to help account for nonresponse and potential sample bias. In order to assess the threat of bias due to attrition and to examine any “time-in-sample” effects, each of the analyses was run with (1)
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