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, Hua H Yong, Warwick Hosking

2

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

8

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

10

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

1111

Summary

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

• Or processed differently

• ? Artifact of larger change in prominence

12

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

13

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

14

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

2121

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

2222

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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