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  1. 1. Health warningsCurrent internationalPractices.David Hammond PhDMarch 21, 2012
  2. 2. International standards Pictures Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 2 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  3. 3. Health Warning Labels Implementation of pictorial warnings Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 3 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2 Source: Cigarette health warnings: International status report. Canadian Cancer Society. October 2010.
  4. 4. Health Warning LabelsCountries with pictorial warnings  Second level  Third level  Fourth level  Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 4 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  5. 5. Health Warning LabelsCountries with pictorial warnings  Second levelLatvia 2010 Mexico 2010 Mongolia 2010 Pakistan 2010 Switzerland 2010  Third level  Fourth levelTurkey France Malta 2011 Spain 2011* Norway 2011*  Fifth level 2010 2011Philippines 2011* Urkraine 2012* Warning Labels stopped you from having a cigarette. 40 Canada 5 Australia *Proposed implementation date at time of publication. US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  6. 6.  Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 6 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  7. 7. Size 82% Australia* 80% Uruguay Second level 75% Canada Third level 65% Madagascar Fourth level 65% Mauritius Fifth level 65% Mexico 60% Philippines 60% New Zealand 60% Cook Islands 56% Belgium 40 Warning Labels stopped you from having a cigarette. Canada 7 Australia US 30 UK Percentage 20 10 Source: Cigarette health warnings: International status report. Canadian Cancer Society. October 2011. 0 Wave 1 Wave 2
  8. 8. PositionFront vs. Back Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 8 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  9. 9.  Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 9 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  10. 10.  Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 10 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  11. 11.  Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 11 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  12. 12. Message “rotation”  Second level2002  Third level  Fourth level  Fifth level20042008 Warning Labels stopped you from having a cigarette. 40 Canada 12 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  13. 13. Number of messages in rotation  Second level  Third level  Fourth level  Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 13 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  14. 14. What types of messages are most effective?
  15. 15. Health Warning ThemesGraphic Health Effects
  16. 16. ContentLimits of “graphic” content?
  17. 17. Health Warning ThemesLived experience
  18. 18. Health Warning ThemesLived experience
  19. 19. Health Warning ThemesSymbolic and Abstract
  20. 20. Health Warning ThemesSymbolic and Abstract
  21. 21. Health Warning ThemesCartoons
  22. 22. Health Warning ThemesTestimonial
  23. 23. Testimonials
  24. 24. Testimonials Australia 2012
  25. 25. Text Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 25 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  26. 26. Health Warning ContentQuit lines Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 26 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  27. 27.  Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 27 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  28. 28. Content Cessation Inserts Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 28 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  29. 29. Health Warning Content Pack inserts Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 29 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  30. 30.  Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 30 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  31. 31. Legal challengesUnited States Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 31 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  32. 32. Preliminary injunctionFactual?“…the evidence here overwhelmingly suggests that the Second level requirements are not….purely factualRules graphic-imageand uncontroversial disclosures…. Indeed, the fact alone Third levelthat some of the graphic images here appear to be Fourth levelcartoons, and others appear to be digitally enhanced or Fifth levelmanipulated, would seem to contravene the very definitionof "purely factual.” page 14 Warning Labels stopped you from having a cigarette. 40 Canada 32 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2Source: Richard J. Leon. Memorandum of Opinion. Nov 7 2011. Civil Case No. 11-1482 (RJL) United States District Court for the District of Columbia.
  33. 33. Factual Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 33 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  34. 34. Credibility Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 34 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  35. 35. ContentCredibility  Second level  Third level  Fourth level  Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 35 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  36. 36. Implementation & Legal challengesIndia Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 36 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  37. 37. Implementation challenges“Little” tobacco  Second level  Third level  Fourth level  Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 37 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  38. 38. Implementation challengesContraband tobacco Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 38 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  39. 39.  Second level Third level Fourth level Fifth level“Other” tobacco products 40 30 Warning Labels stopped you from having a 39 cigarette. Canada Australia US UK Percentage 20 10 0 Wave 1 Wave 2
  40. 40. “Other” tobacco productsWaterpipe Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 40 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  41. 41. Links with other media Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 41 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  42. 42. Summary• Warning labels should be regarded as a communication campaign.• Policy evolution: “First” vs. “second” generation.• Importance of international collaboration.• Role of research & evidence.
  43. 43.  Second level Third level Fourth level Fifth level www.tobaccolabels.ca Warning Labels stopped you from having a cigarette. 40 Canada 43 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  44. 44. ContactDavid Hammond PhDSchool of Public Health & Health SystemsUniversity of WaterlooTel. 519 888 4567 ext.36462Email dhammond@uwaterloo.caWeb www.davidhammond.ca
  45. 45. Evidence from low and middle incomecountries: Latin America & the Caribbean Ernesto M Sebrié, MD MPH Department of Health Behavior, Roswell Park Cancer Institute Buffalo, New York 15 th World Conference on Tobacco OR Health Singapore, March 21, 2012
  46. 46. Pictorial Health Warning Labels in MEXICO (2010) LACHONDURAS (2011) VENEZUELA (2005) PANAMA (2008)COLOMBIA (2010) PERU (2010) BRAZIL (2002) BOLIVIA (2012) CHILE (2006) URUGUAY (2006)
  47. 47. Cigarette Labeling Studies in Latin America & the Caribbean:1. Caribbean Study: • Jamaica, Barbados, Trinidad & Tobago, Guyana2. Central America Study: • Nicaragua, Honduras (Guatemala, Panama, El Salvador)3. South America Study: • Bolivia
  48. 48. GOALS1. To determine the most effective content of pictorial HWLs related to 3 themes: • Health effects • Environmental effects/ social & economic impact • SHS & Smokefree support2. To determine if greater credibility is attributed to the message from the Minister of Health compared to other agencies3. To determine which “marker word” is most effective in attracting attention and increasing credibility of the message presented
  49. 49. DATA COLLECTIONMall intercept recruitment technique• Subjects were recruited from 2 different local publicvenues (e.g., mall, market, or equivalent) in thecapital city of each of the countries.• Eligible subjects answered a 20 minutes face-to-face survey (paper or computer based).• Inclusion Criteria: • Legal resident • Able to talk and read English or Spanish • Smokers (18 & over)/ Non-smokers (18-24) • Male & Female
  50. 50. English-Speaking Caribbean Study 14 countries: population ~ 16 million
  51. 51. Members States of the CARICOMANTIGUA & GRENADA ST. KITTS & NEVIS BARBUDABAHAMAS GUYANA ST. LUCIA ST. VINCENT & THEBARBADOS HAITI GRENADINESBELIZE JAMAICA SURINAME TRINIDAD &DOMINICA MONTSERRAT TOBAGO
  52. 52. PROTOCOL Respondents were shown a series of 24 cigarette mock-ups and asked questions following each one. Respondents were asked:  On a scale of 1 to 10, with 1 being “NOT AT ALL” and 10 being “EXTREMELY”, please tell me whether this warning message… • … grabs your attention • … is believable • … would make smokers want to quit • … would help prevent young people from starting to smoke  Overall, on a scale of 1 to 10, how effective is this health warning?
  53. 53. HIGHEST Rated TOTAL SMOKERS NON SMOKERSTheme /TypeHealth effect: Mouth Cancer /GRAPHICHealth effect: Mouth Disease/GRAPHICHealth effect: Mouth Cancer /GRAPHICHealth effect: Stillbirth /GRAPHIC
  54. 54. LOWEST RATED TOTAL SMOKERS NON SMOKERSTheme /TypeCessation/ Economic effect /SYMBOLICHealth effect: Aesthetic /GRAPHICCessation /SYMBOLICCessation /SYMBOLIC
  55. 55. MARKER WORDRespondents were asked to focus on the word in CAPITAL letters and differentcolor that appears at the beginning of these messages. 100 80 63 62 63 Warning 60 % Caution 40 29 29 30 Danger 20 11 12 10 0 Overall (n=1,441) Smokers (n=712) Non-smokers (n=729) Which pack is most effective at getting people to think about the dangers of smoking?
  56. 56. MARKER WORDRespondents were asked to focus on the word in CAPITAL letters and differentcolor that appears at the beginning of these messages. 100 80 68 69 66 60 Warning % Caution 40 27 27 27 Danger 20 11 12 10 0 Overall (n=1,441) Smokers (n=712) Non-smokers (n=729) Which pack is most effective at getting people to think about the dangers of smoking?
  57. 57. ATTRIBUTIONRespondents were asked to focus on the last words print in smaller font at the end ofthe warning. 75 60 46 45 46 45 Minister of Health 43 40 45 Ministry of Health % 30 Chief Medical Officer 11 12 10 None 15 2 3 1 0 Overall (n=1,441) Smokers (n=712) Non-smokers (n=729) Which is MOST effective at getting people to think about the dangers of smoking?
  58. 58. ATTRIBUTIONRespondents were asked to focus on the last words print in smaller font at the end ofthe warning. 75 60 45 46 46 Minister of Health 43 44 45 40 Ministry of Health % 30 Chief Medical Officer 11 13 10 None 15 4 3 2 0 Overall (n=1,441) Smokers (n=712) Non-smokers (n=729) Which is MOST effective at getting people to think about the dangers of smoking?
  59. 59. Central America Cigarette Labeling Study 7 countries: population ~ 42 million
  60. 60. Central America Cigarette Labeling StudySOCIOECONOMICIMPACT:CHILD LABOR &POVERTYENVIRONMENTALIMPACT:AGROTOXICS &DEFORESTATION
  61. 61. HIGHEST RatedTONG & MOUTH CANCERLUNG CANCERLARINX CANCER PREGNANCY
  62. 62. LOWEST Rated POVERTY & CHILD LABORDEFORESTATION & AGROTOXICSSHS CHILDREN STROKE
  63. 63. Bolivia Cigarette Labeling Study Population: ~ 11 million
  64. 64. NEW WARNINGS (2012)
  65. 65. Bolivia Cigarette Labeling StudyAim: To pre-test the effectiveness of pictorial-based HWLs printed oncigarette packages to raise awareness on SHS and to increase supportfor 100% smokefree policies in Bolivia (synergy of policies)Examples of 4 types of pictorial HWLs on SHS & lung cancer to be tested
  66. 66. ACKNOWLEDGEMENTSRPCI Dep. Health Behavior International Partners• Michael Cummings • Center for Tobacco Epidemic Research of Uruguay• Mark Travers • InterAmerican Heart Foundation• Maansi Travers • Ministry of Health of Panama• Richard O’Connor • National Cancer Institute of Brazil• Andrew Hyland • National Institute of Public Health of• Cheryl Rivard Mexico• Essie Torres • Smokefree Alliance of ArgentinaUniv. of Waterloo • Heart Foundation of Jamaica• David Hammond • Heart & Stroke Foundation of BarbadosUniv. of South Carolina • Trinidad & Tobago Cancer Society• James Thrasher • Guyana Chest Society
  67. 67. Ernesto Sebrie, MD MPH ernesto.sebrie@roswellpar k.orgRoswell Park Cancer Institute
  68. 68. How to design the content of pictorial warning labels: A case study of Mexico James F. Thrasher
  69. 69. Mexican health warnings labels (HWLs) 3rd largest in the world (65% of pack) (2004-2010) (2010-present) 50% of the back (text only)  30% of the front (picture & text) 4 messages  100% of the back and one side (text only)  2 new HWLs every 3 months, fastest rotation in the world
  70. 70. 1st round of MexicanPictorial Health Warning Labels (HWLs)
  71. 71. 3-stage process to select HWL contentPhase 1 Phase 2 Phase 3 Objective: Objective: Objective:  Most  Most  Confirm effective effective findings HWL imagery HWL textual about HWL content imagery & Method: text  Field Method: experiments  Field Method: experiments  Focus groups 4
  72. 72. International Pack Study Parallel studies in 7 diverse countries: Second level Mexico India South Korea Third level US Germany Fourth level China Bangladesh Fifth level Examine effective content for pictorial warnings Examine individual differences in responses Examine cultural, national level differences P01 CA138389, Tobacco packaging and labeling policies: 40 30 Warning Labels stopped you from having a 5 cigarette. Canada Australia US UK Percentage Expanding the evidence on novel policies 20 10 0 Wave 1 Wave 2
  73. 73. Adaptation of Health Warnings Second level Third level Fourth level Fifth level Warning Labels stopped you from having a cigarette. 40 Canada 6 Australia US 30 UK Percentage 20 10 0 Wave 1 Wave 2
  74. 74. Health warning topic “sets” 5 or 6 warnings tested for each topic Text Symbolic Human sufferingGraphic External Graphic Internal Testimonial
  75. 75. HealthWarningTopics &Stimuli
  76. 76. Field experiments TopicsBrief Survey Rate 5 to 7 Rank Addiction• Sociodemographics warnings from warnings• Smoking-related Throat cancer selected block within a block: perceptions & Mouth cancer in random order behavior • Which Death Evaluate for most• Warning labels Premature aging each warning: motivates Stroke you to stop • Attention Random smoking? Impotence • Credibilityassignment Lung cancer • Which • Relevance most Gangrene motivates • Negative Heart attack you to not emotional Toxicity start arousal smoking? Enphysema • Impact Premature birth SHS in children Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.
  77. 77. Samples• Mexico:• Sample – 535 16 to 18 years old, smokers and nonsmokers – 527 adult smokers• Mode – Intercept surveys in Mexico City (July 2010) – In-person administration – Stimulus presentation by laptop Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.
  78. 78. Graphic more effective than human suffering,which is more effective than symbolic warnings (p<.001)  Second level  Third level  Fourth level  Fifth level Human Symbolic Graphic vs. vs. suffering 40 30 Warning Labels stopped you from having a 11 cigarette. Canada Australia US UK Percentage 20 10 Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012. 0 Wave 1 Wave 2
  79. 79. Adding testimonial information increased effectiveness (p<.001) Second level Third level Fourth level Fifth level  Testimonial vs.  Non-Testimonial Warning Labels stopped you from having a cigarette. 40 Canada 12 Australia US 30 UK Percentage 20 10 Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012. 0 Wave 1 Wave 2
  80. 80. Rankings in experimental sample consistent with rankings in a representative sample
  81. 81. Health BeliefsDoes smoking cause impotence in male smokers? % “Yes” Mutti S, Hammond D, Reid J, Thrasher JF. Jnl of Health Communicaiton. In press.
  82. 82. Images with the greatest impact in study 1
  83. 83. 2nd phase: Selection of textual content for pictorial HWLsPhase 1 Phase 2 Phase 3 Objective: Objective: Objective:  Most  Most  Confirm effective effective findings HWL imagery HWL textual about HWL content imagery & Method: text  Field Method: experiments  Field Method: experiments  Focus groups
  84. 84. Characteristics of Mexican pictorial HWLs 30% of front with image and text “Qualitative” focus on toxic constituents Call to action with 100% of one side, reinforcing 1800 number the central message
  85. 85. Didactic/scientific vs. testimonial content Didactic /scientific Testimonial - other Testimonial - selfBreathing tobacco “My husband was a “Tobacco smoke is a silentsmoke causes the smoker, and while he was killer. Without thinking, Iarteries of your heart to still young, he died from breathed it in, unable toclog. The clogging a heart attack. I was left feel the damage it had stranded to take care of done…until it gave me adamages your heart and the family all by myself.” heart attack.”can kill you. Celia Juárez César GuerreroContains particles that enter Contains particles that enter Contains particles that enteryour blood stream, form blood your blood stream, form blood your blood stream, form bloodclots and can block your clots and can block your clots and can block yourarteries arteries arteriesYou can quit smoking. Call us You can quit smoking. Call us You can quit smoking. Call us 01800 966 3863 01800 966 3863 01800 966 3863 Thrasher JF, Arillo-Santillán E, Villalobos V, et al. Cancer Causes & Control. 2012.
  86. 86. Field experiments in 8 public places Brief survey Condition 1: Random Ranking task • Sociodemographics 4 blocks of packs presentation of HWLs • Smoking on same health of packs within block: perceptions & outcome within each behavior • Which Condition 2: block • HWL motivates 4 blocks of packs Assessment you most on same health of each HWL: to quit?Randomization outcome • Attention • Which Condition 3: motivates • Credibility 4 blocks of packs you most on same health • Relevance to not start outcome smoking? • Emotional Condition 4: arousal 4 blocks of packs • Impact on same health outcome Thrasher JF, Arillo-Santillán E, Villalobos V, et al. Cancer Causes & Control. 2012.
  87. 87. Sample characteristics Youth sample Adult smoker sampleCharacteristics % (n) % (n)Age (average) 20.6 (range 18 – 24) 32.8 (range 25 – 80)Sex Male 50% (266) 62% (330) Female 50% (263) 38% (199)Education Secondary or less 28% (146) 18% (100) Technical school 8% (44) 14% (76) High school 57% (302) 42% (223) University + 7% (37) 25% (130)Smoking behavior Nonsmoker 49% (258) N/A Non-daily smoker 30% (159) 43% (225) Daily smoker, < 5 /day 12% (63) 25% (131) Daily smoker, 5+ / day 10% (53) 33% (173)Intend to quit in next 6 months 31% (77 / 252) 31% (165)
  88. 88. Overall impact of scientific vs. testimonial7.5 Scientific Testimonial 1 7.27.0 Testimonial 2 6.8 6.8 6.8 6.8 6.86.5 6.6 6.6 6.5 6.4 6.4 6.5 6.3 6.2 6.3 6.3 6.2 6.26.05.55.0 Lung cancer Heart disease Premature Stroke Addiction Throat birth cancer Thrasher JF, Arillo-Santillán E, Villalobos V, et al. Cancer Causes & Control. 2012.
  89. 89. Adjusted ORs* of selecting a testimonial as mosteffective, lowest vs. highest educational attainment 4 3.5 3 3.0 2.9 2.5 2 2.0 1.9 1.7 1.5 1.3 1 0.5 Lung Heart Prem ature Stroke Addiction Throat cancer disease birth cancer*adjusted for age, sex, smoking status, level of consumption, perceived risk, and quit intentions
  90. 90. 3rd phase: confirm best combination of imagery & textual contentPhase 1 Phase 2 Phase 3 Objective: Objective: Objective:  Most  Most  Confirm effective effective findings HWL imagery HWL textual about HWL content imagery & Method: text  Field Method: experiments  Field Method: experiments  Focus groups
  91. 91. Focus groupsMixed methods Individual ratings Group discussion Callback two days later12 groups, 4 in each city: Mexico City Guadalajara MonterreyPopulation Non- Non- Non- Smokers Smokers Smokerscharacteristics smokers smokers smokers 18 - 25 - 18 - 25 - 18 - 25 - 18 - 25 - 18 - 25 - 18 - 24 24 65 24 65 24 65 24 65 24 65Female (n=80) 7 17 4 0 6 14 6 5 16 5 0Male (n=67) 4 11 9 1 6 10 5 6 8 6 1Total (n=147) 11 28 13 1 12 24 11 11 24 11 1
  92. 92. Second round of pictorial HWLs
  93. 93. ConclusionsGraphic imagery was rated as more effective thanother types of imagery Consistent across samples and countriesDidactic / scientific textual content was moreeffective and credible than testimonial content Amount of testimonial content may matter Testimonials work best among lower educated smokers Testimonials may be more effective with stronger TC environment, or when complemented by other mediaTextual content on toxic constituents effectiveQuantitative and focus group results were consistent
  94. 94. What do we need?A role for positively framed quit messages? People who intend to quit have strongest responsesHabituation and “wear out” Wear out quicker for some imagery than others Cycles of wearin and wearout? Matching/targeting of messages?Industry responsesImage banks and sharing of high-quality pictorialimagery among countries

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