Recent legislation provides the US Food and Drug Administration (FDA) with regulatory authority over tobacco, including the selection of pictorial imagery for new health warning labels (HWLs) that will cover 50% of the front and back of cigarette packs starting in 2012. US HWL policy is aligned with research that has clearly demonstrated that the most effective HWLs are prominent, cover the front and back of the pack, and include imagery that depicts the consequences of smoking. However, the effects of pictorial HWLs "wear out", and the specific characteristics of pictorial HWLs that promote a sustained impact have not been carefully studied. Between-country variation in key characteristics of pictorial HWL policies allows for a natural experiment to determine their relative impact over time. We propose to conduct quasi-experimental and experimental studies among adult smokers in four countries with pictorial HWL policies that differ along key dimensions and that involve implementation of new pictorial HWL content and design in 2012: 1. The US will introduce pictorial HWLs for the first time;2. Canada will change pictorial HWLs for the first tim after the longest period of exposure in the world (i.e., 11 years);3. Mexico will continue rotatin new HWLs at the highest frequency in the world (i.e., every three months);and 4. Australia will change its pictorial HWLs while simultaneously implementing the innovative policy of prohibiting brand imagery on cigarette packs (i.e., "plain" packaging). This project would capitalize on the unprecedented opportunity to systematically examine the over-time effects of changes to HWL policies in four countries that will introduce novel pictorial HWLs in the same year. We will do this by pursuing the following specific aims:
Specific Aim 1 : We will use a quasi-experimental design with rolling panels of adult smokers in these four countries, in order to determine whether pictorial HWL characteristics that are easiest to process have a more sustained impact on smoking cessation-related cognitions, affect and behaviors than HWL characteristics that require greater cognitive effort to process.
Specific Aim 2 : We will conduct a series of controlled randomized experiments among adult smokers in the same four countries, systematically varying their exposure to pictorial HWL content and design that is novel relative to existing HWLs, in order to determine the cognitive and affective impact of these manipulations. This project brings together the world's leading experts on tobacco HWL policy to extend the foundation for evidence-based policy development, so that it encompasses the effectiveness and sustainability of different HWL policy options. Results will be disseminated to key decision-makers around the world, including the US FDA and the US Secretary of Health and Human Services, who have the authority to revise HWLs to ensure adequate public understanding of the harms of tobacco use.

Public Health Relevance

In 2012, the United States (US) will implement prominent pictorial health warning labels (HWLs) on cigarette packaging in order to reduce tobacco use, which is the leading cause of preventable death in the US. The proposed study will examine the effects and wear out of this policy, comparing the results with those from three other countries (i.e., Canada, Australia, and Mexico) whose pictorial HWL policies contrast with US policy in important ways. Results from this research will increase understanding of the characteristics of pictorial HWL policies that are most effective and sustainable, so that regulators in the US and other countries can design HWL policies that better address the substantial public health burden of tobacco use.

National Institute of Health (NIH)
National Cancer Institute (NCI)
Research Project (R01)
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Community Influences on Health Behavior (CIHB)
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Vollinger, Robert
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University of South Carolina at Columbia
Schools of Public Health
United States
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Thrasher, James F; Abad-Vivero, Erika N; Moodie, Crawford et al. (2016) Cigarette brands with flavour capsules in the filter: trends in use and brand perceptions among smokers in the USA, Mexico and Australia, 2012-2014. Tob Control 25:275-83
Riddle Jr, Philip J; Newman-Norlund, Roger D; Baer, Jessica et al. (2016) Neural response to pictorial health warning labels can predict smoking behavioral change. Soc Cogn Affect Neurosci 11:1802-1811
Thrasher, James F; Abad-Vivero, Erika N; Huang, Liling et al. (2016) Interpersonal communication about pictorial health warnings on cigarette packages: Policy-related influences and relationships with smoking cessation attempts. Soc Sci Med 164:141-9
Huang, Li-Ling; Thrasher, James F; Reid, Jessica L et al. (2016) Predictive and External Validity of a Pre-Market Study to Determine the Most Effective Pictorial Health Warning Label Content for Cigarette Packages. Nicotine Tob Res 18:1376-81
Thrasher, James F; Swayampakala, Kamala; Cummings, K Michael et al. (2016) Cigarette package inserts can promote efficacy beliefs and sustained smoking cessation attempts: A longitudinal assessment of an innovative policy in Canada. Prev Med 88:59-65
Osman, Amira; Thrasher, James F; Cayir, Ebru et al. (2016) Depressive symptoms and responses to cigarette pack warning labels among Mexican smokers. Health Psychol 35:442-53
Thrasher, James F; Swayampakala, Kamala; Borland, Ron et al. (2016) Influences of Self-Efficacy, Response Efficacy, and Reactance on Responses to Cigarette Health Warnings: A Longitudinal Study of Adult Smokers in Australia and Canada. Health Commun 31:1517-26
Nagelhout, Gera E; Osman, Amira; Yong, Hua-Hie et al. (2015) Was the media campaign that supported Australia's new pictorial cigarette warning labels and plain packaging policy associated with more attention to and talking about warning labels? Addict Behav 49:64-7
Swayampakala, Kamala; Thrasher, James F; Hammond, David et al. (2015) Pictorial health warning label content and smokers' understanding of smoking-related risks-a cross-country comparison. Health Educ Res 30:35-45
Huang, Li-Ling; Thrasher, James F; Abad, Erika Nayeli et al. (2015) The U.S. National Tips From Former Smokers Antismoking Campaign: Promoting Awareness of Smoking-Related Risks, Cessation Resources, and Cessation Behaviors. Health Educ Behav 42:480-6

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