Cigarette pack messages about toxic chemicals: a randomised clinical trial

Noel T Brewer, Michelle Jeong, Jennifer R Mendel, Marissa G Hall, Dongyu Zhang, Humberto Parada Jr, Marcella H Boynton, Seth M Noar, Sabeeh A Baig, Jennifer C Morgan, Kurt M Ribisl, Noel T Brewer, Michelle Jeong, Jennifer R Mendel, Marissa G Hall, Dongyu Zhang, Humberto Parada Jr, Marcella H Boynton, Seth M Noar, Sabeeh A Baig, Jennifer C Morgan, Kurt M Ribisl

Abstract

Background: The USA can require tobacco companies to disclose information about harmful and potentially harmful chemicals in cigarette smoke, but the impact of these messages is uncertain. We sought to assess the effect of placing messages about toxic chemicals on smokers' cigarette packs.

Methods: Participants were 719 adult cigarette smokers from California, USA, recruited from September 2016 through March 2017. We randomly assigned smokers to receive either factual messages about chemicals in cigarette smoke and their health harms (intervention) or messages about not littering cigarette butts (control) on the side of their cigarette packs for 3 weeks. The primary trial outcome was intention to quit smoking.

Results: In intent-to-treat analyses, smokers whose packs had chemical messages did not have higher intentions to quit smoking at the end of the trial than those whose packs had control messages (P=0.56). Compared with control messages, chemical messages led to higher awareness of the chemicals (28% vs 15%, P<0.001) and health harms (60% vs 52%, P=0.02) featured in the messages. In addition, chemical messages led to greater negative affect, thinking about the chemicals in cigarettes and the harms of smoking, conversations about the messages and forgoing a cigarette (all P<0.05).

Discussion: Chemical messages on cigarette packs did not lead to higher intentions to quit among smokers in our trial. However, chemical messages informed smokers of chemicals in cigarettes and harms of smoking, which directly supports their implementation and would be critical to defending the messages against cigarette company legal challenges.

Trial registration number: NCT02785484.

Keywords: carcinogens; packaging and labelling; prevention; public policy; smoking caused disease.

Conflict of interest statement

Competing interests: None of the authors have received funding from tobacco product manufacturers. NTB and KMR have served as paid expert consultants in litigation against tobacco companies. The other authors declare no conflicts of interest.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Figures

Figure 1
Figure 1
Labels placed on smokers’ cigarette packs in intervention arm (A) and control arm (B).
Figure 2
Figure 2
Flow diagram of trial enrollment, randomisation and retention.

References

    1. Hecht SS. Research opportunities related to establishing standards for tobacco products under the Family Smoking Prevention and Tobacco Control Act. Nicotine Tob Res 2012;14:18–28. 10.1093/ntr/ntq216
    1. Jamal A, Homa DM, O’Connor E, et al. . Current cigarette smoking among adults - United States, 2005-2014. MMWR Morb Mortal Wkly Rep 2015;64:1233–40. 10.15585/mmwr.mm6444a2
    1. U.S. Department of Health and Human Services. The health consequences of smoking 5 50 years of progress: A report of the Surgeon General. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Atlanta, GA: U.S, 2014.
    1. International Agency for Research on Cancer. Tobacco smoke and involuntary smoking. Lyon, France, 2004.
    1. Parada H, Hall MG, Boynton MH, et al. . Trajectories of responses to pictorial cigarette pack warnings. Nicotine Tob Res 2017. doi: 10.1093/ntr/ntx182 [Epub ahead of print 18 Aug 2017]. 10.1093/ntr/ntx182
    1. Brewer NT. Goals : Fischoff B, Brewer NT, Downs JS, Communicating risks and benefits: An evidence-based user’s guide. Washington, D.C: Food and Drug Administration, 2011:3–10.
    1. Centers for Disease Control and Prevention (CDC). Health warnings on tobacco products - worldwide, 2007. MMWR Morb Mortal Wkly Rep 2009;58:528–9.
    1. Noar SM, Francis DB, Bridges C, et al. . Effects of strengthening cigarette pack warnings on attention and message processing: A systematic review. Journal Mass Commun Q 2017;94:416–442.
    1. Noar SM, Francis DB, Bridges C, et al. . The impact of strengthening cigarette pack warnings: Systematic review of longitudinal observational studies. Soc Sci Med 2016;164:118–29. 10.1016/j.socscimed.2016.06.011
    1. Noar SM, Hall MG, Francis DB, et al. . Pictorial cigarette pack warnings: a meta-analysis of experimental studies. Tob Control 2016;25:341–54. 10.1136/tobaccocontrol-2014-051978
    1. Canadian Cancer Society. Cigarette package health warnings: International status report. 5th ed Canada: Ontario Canadian Cancer Society, 2016.
    1. Brewer NT, Hall MG, Noar SM, et al. . Effect of Pictorial Cigarette Pack Warnings on Changes in Smoking Behavior: A Randomized Clinical Trial. JAMA Intern Med 2016;176:905–12. 10.1001/jamainternmed.2016.2621
    1. United States Public Laws. Family smoking prevention and tobacco control act of 2009. 111th Congress, 1st Session. Public Law 111531 [H.R. 1256]. 2009.
    1. Kraemer JD, Baig SA. Analysis of legal and scientific issues in court challenges to graphic tobacco warnings. Am J Prev Med 2013;45:334–42. 10.1016/j.amepre.2013.05.004
    1. National Cancer Institute. Risks associated with smoking cigarettes with low machine-measured yields of tar and nicotine. Smoking and Tobacco Control Monograph 13. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 2001.
    1. Morgan JC, Byron MJ, Baig SA, et al. . How people think about the chemicals in cigarette smoke: a systematic review. J Behav Med 2017;40:553–64. 10.1007/s10865-017-9823-5
    1. Gilpin EA, Emery S, White MM, et al. . Does tobacco industry marketing of ’light' cigarettes give smokers a rationale for postponing quitting? Nicotine Tob Res 2002;4:147–55. 10.1080/1462220021000032870
    1. Salloum RG, Louviere JJ, Getz KR, et al. . Evaluation of strategies to communicate harmful and potentially harmful constituent (HPHC) information through cigarette package inserts: a discrete choice experiment. Tob Control 2018;27:677–83. 10.1136/tobaccocontrol-2016-053579
    1. Hammond D, White CM. Improper disclosure: tobacco packaging and emission labelling regulations. Public Health 2012;126:613–9. 10.1016/j.puhe.2012.03.012
    1. Cho YJ, Thrasher JF, Swayampakala K, et al. . Does Adding Information on Toxic Constituents to Cigarette Pack Warnings Increase Smokers' Perceptions About the Health Risks of Smoking? A Longitudinal Study in Australia, Canada, Mexico, and the United States. Health Educ Behav 2018;45:32–42. 10.1177/1090198117709884
    1. Hammond D. Tobacco labelling and packaging toolkit. 2009. (accessed 10 Dec 2012).
    1. Moracco KE, Morgan JC, Mendel J, et al. . "My First Thought was Croutons": Perceptions of Cigarettes and Cigarette Smoke Constituents Among Adult Smokers and Nonsmokers. Nicotine Tob Res 2016;18:1566–74. 10.1093/ntr/ntv281
    1. Kelley DE, Boynton MH, Noar SM, et al. . Effective Message Elements for Disclosures about Chemicals in Cigarette Smoke. Nicotine Tob Res 2017. doi: 10.1093/ntr/ntx109 [Epub ahead of print 17 May 2017]. 10.1093/ntr/ntx109
    1. Baig SA, Byron MJ, Boynton MH, et al. . Communicating about cigarette smoke constituents: an experimental comparison of two messaging strategies. J Behav Med 2017;40:352–9. 10.1007/s10865-016-9795-x
    1. Baig SA, Gottfredson NC, Noar SM, et al. . UNC Perceived Message Effectiveness Scale: Development and Validation. In Preparation.
    1. Noar SM, Kelley DE, Boynton MH, et al. . Identifying principles for effective messages about chemicals in cigarette smoke. Prev Med 2018;106:31–7. 10.1016/j.ypmed.2017.09.005
    1. Baig SA, Moracco KE, Agans RP, et al. . Testing message about cigarette smoke constituents: A mixed methods study. In Preparation.
    1. Brewer NT, Hall MG, Lee JG, et al. . Testing warning messages on smokers' cigarette packages: a standardised protocol. Tob Control 2016;25:153–9. 10.1136/tobaccocontrol-2014-051661
    1. Klein WM, Zajac LE, Monin MM. Worry as a moderator of the association between risk perceptions and quitting intentions in young adult and adult smokers. Ann Behav Med 2009;38:256–61. 10.1007/s12160-009-9143-2
    1. Borland R, Yong HH, Wilson N, et al. . How reactions to cigarette packet health warnings influence quitting: findings from the ITC Four-Country survey. Addiction 2009;104:669–75. 10.1111/j.1360-0443.2009.02508.x
    1. Hammond D, Fong GT, McDonald PW, et al. . Impact of the graphic Canadian warning labels on adult smoking behaviour. Tob Control 2003;12:391–5. 10.1136/tc.12.4.391
    1. Fong GT, Cummings KM, Borland R, et al. . The conceptual framework of the International Tobacco Control (ITC) Policy Evaluation Project. Tob Control 2006;15:iii3–iii11. 10.1136/tc.2005.015438
    1. IARC. Handbooks of cancer prevention. Tobacco control: Methods for evaluating tobacco control policies. Lyon, France: International Agency for Research on Cancer, 2009.
    1. Yong HH, Borland R, Thrasher JF, et al. . Mediational pathways of the impact of cigarette warning labels on quit attempts. Health Psychol 2014;33:1410–20. 10.1037/hea0000056
    1. Sheeran P, Harris PR, Epton T. Does heightening risk appraisals change people’s intentions and behavior? A meta-analysis of experimental studies. Psychol Bull 2014;140:511–43. 10.1037/a0033065
    1. Cho YJ, Thrasher JF, Yong HH, et al. . Path analysis of warning label effects on negative emotions and quit attempts: A longitudinal study of smokers in Australia, Canada, Mexico, and the US. Soc Sci Med 2018;197 10.1016/j.socscimed.2017.10.003
    1. Thrasher JF, Abad-Vivero EN, Huang L, et al. . Interpersonal communication about pictorial health warnings on cigarette packages: Policy-related influences and relationships with smoking cessation attempts. Soc Sci Med 2016;164:141–9. 10.1016/j.socscimed.2015.05.042
    1. Nonnemaker J, Farrelly M, Kamyab K, et al. ; Experimental study of graphic cigarette warning labels: Final results report. Research Triangle Park, NC: RTI International, 2010.
    1. Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol 1988;54:1063–70. 10.1037/0022-3514.54.6.1063
    1. Keller PA, Block LG. Increasing the Persuasiveness of Fear Appeals: The Effect of Arousal and Elaboration. J Consum Res 1996;22:448–59. 10.1086/209461
    1. Hall MG, Peebles K, Bach LE, et al. . Social Interactions Sparked by Pictorial Warnings on Cigarette Packs. Int J Environ Res Public Health 2015;12:13195–208. 10.3390/ijerph121013195
    1. Morgan JC, Southwell BG, Noar SM, et al. . Frequency and Content of Conversations about Pictorial Warnings on Cigarette Packs. Nicotine Tob Res 2017. [Epub ahead of print 17 August 2017] 10.1093/ntr/ntx180
    1. Borland R, Hill D. Initial impact of the new Australian tobacco health warnings on knowledge and beliefs. Tob Control 1997;6:317–25. 10.1136/tc.6.4.317
    1. Li L, Borland R, Fong GT, et al. . Smoking-related thoughts and microbehaviours, and their predictive power for quitting: findings from the International Tobacco Control (ITC) China Survey. Tob Control 2015;24:354–61.
    1. Centers for Disease Control and Prevention. Adult Tobacco Survey (ATS, 2008.
    1. Population Assessment of Tobacco and Health Study. PATH: Population Assessment of Tobacco and Health, 2014. (accessed April 3 2014).
    1. Brody T. Intent to treat analysis vs. per protocol analysis. Clinical trials: study design, endpoints and biomarkers, drug safety, and FDA and ICH guidelines. Cambridge, MA: Academic Press, 2011.
    1. Peters E, Lipkus I, Diefenbach MA. The Functions of Affect in Health Communications and in the Construction of Health Preferences. J Commun 2006;56(suppl_1):S140–S162. 10.1111/j.1460-2466.2006.00287.x
    1. Goodman EP. Visual gut punch: persuasion, emotion, and the constitutional meaning of graphic disclosure. Cornell Law Rev 2014;99:513–70.
    1. Witte K. Putting the fear back into fear appeals: The extended parallel process model. Commun Monogr 1992;59:329–49. 10.1080/03637759209376276
    1. Wang AL, Lowen SB, Romer D, et al. . Emotional reaction facilitates the brain and behavioural impact of graphic cigarette warning labels in smokers. Tob Control 2015;24:225–32. 10.1136/tobaccocontrol-2014-051993
    1. Partos TR, Borland R, Thrasher JF, et al. . The predictive utility of micro indicators of concern about smoking: findings from the International Tobacco Control Four Country study. Addict Behav 2014;39:1235–42. 10.1016/j.addbeh.2014.04.001
    1. Li L, Borland R, Fong GT, et al. . Smoking-related thoughts and microbehaviours, and their predictive power for quitting. Tob Control 2015;24:354–61. 10.1136/tobaccocontrol-2013-051384
    1. Hall MG, Sheeran P, Noar SM, et al. . Negative affect, message reactance and perceived risk: how do pictorial cigarette pack warnings change quit intentions? Tob Control 2018;27:e136–e142. 10.1136/tobaccocontrol-2017-053972
    1. Crawford MA, Balch GI, Mermelstein R. Tobacco Control Network Writing Group. Responses to tobacco control policies among youth. Tob Control 2002;11:14–19. 10.1136/tc.11.1.14
    1. Brennan E, Durkin SJ, Cotter T, et al. . Mass media campaigns designed to support new pictorial health warnings on cigarette packets: evidence of a complementary relationship. Tob Control 2011;20:412–8. 10.1136/tc.2010.039321
    1. Duke JC, Alexander TN, Zhao X, et al. . Youth’s Awareness of and Reactions to The Real Cost National Tobacco Public Education Campaign. PLoS One 2015;10:e0144827 10.1371/journal.pone.0144827
    1. Huang LL, Lazard AJ, Pepper JK, et al. . Impact of The Real Cost Campaign on Adolescents' Recall, Attitudes, and Risk Perceptions about Tobacco Use: A National Study. Int J Environ Res Public Health 2017;14:42 10.3390/ijerph14010042
    1. American Meat Institute vs United States Department of Agriculture. Case No. 13-5281: United States Court of Appeals, District of Columbia Circuit, 2014.
    1. Hammond D, Fong GT, Borland R, et al. . Text and graphic warnings on cigarette packages: findings from the international tobacco control four country study. Am J Prev Med 2007;32:202–9. 10.1016/j.amepre.2006.11.011
    1. Hitchman SC, Driezen P, Logel C, et al. . Changes in effectiveness of cigarette health warnings over time in Canada and the United States, 2002-2011. Nicotine Tob Res 2014;16:536–43. 10.1093/ntr/ntt196
    1. Swayampakala K, Thrasher J, Carpenter MJ, et al. . Level of cigarette consumption and quit behavior in a population of low-intensity smokers--longitudinal results from the International Tobacco Control (ITC) survey in Mexico. Addict Behav 2013;38:1958–65. 10.1016/j.addbeh.2012.12.007
    1. Kowitt S, Sheeran P, Jarman KL, et al. . Cigarette constituent health communications for smokers: impact of chemical, imagery, and source. Nicotine Tob Res 2017. doi: 10.1093/ntr/ntx226 [Epub ahead of print 3 Oct 2017]. 10.1093/ntr/ntx226
    1. Lakens D. Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and ANOVAs. Front Psychol 2013;4:863 10.3389/fpsyg.2013.00863

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera