Effectiveness of warning graphic labels on cigarette packs in enhancing late-teenagers’ perceived fear of smoking-related harms in Bangkok, Thailand
Background: This study investigated the level of fear of smoking-related harms for teenagers of different gender, different levels of smoking behaviour, and difference in smoking levels of friends and family members, as influenced by warning graphic images on cigarette packs. The study also compared levels of this fear in categories based on participants’ perception (e.g., scarier or less scary images).
Design and Methods: The sample group was 353 undergraduate students at King Mongkut’s University of Technology Thonburi in Bangkok, Thailand. Questionnaires containing 21 warning graphic images, aimed at measuring levels of fear of smoking-related harms, were conducted. Both descriptive statistics and inferential statistics, such as independent and dependent t-test, were used to analyse the data.
Results: The results showed that warning graphic images exhibiting patients suffering from cancers (e.g., lung cancer or laryngeal cancer) and images of damaged body parts were perceived as the scariest warning images. In contrast, images that did not illustrate serious disease suffered by smokers were perceived as the least scary images. The scariest images generated a significant higher level of fear of smoking-related harms than the least scary images. In addition, non-smoking participants were more sensitive to scary warning images than smoking participants. It was also found that the level of fear of smoking-related harms was significantly based on individual cognitive judgment, and it was not affected by the influence of social groups such as friends and family members.
Conclusions: Developing effective warning graphic images could directly contribute to individuals’ perceived health risks and danger associated with smoking.
Committee on the Public Health Implications of Raising the Minimum Age for Purchasing Tobacco Products, Board on Population Health and Public Health Practice, Institute of Medicine, et al. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington DC: National Academies Press (US). 2015. Available from: https://www.ncbi.nlm.nih.gov/books/NBK310413/
World Health Organization. WHO report on the global tobacco epidemic, 2017: monitoring tobacco use and prevention policies. World Health Organization. Available from: https://apps.who.int/iris/handle/10665/255874
Tobacco Control Research and Knowledge Management Center. Report on Tobacco Use in Thailand, Mahidol University, Thailand. 2018. Available form: http://www.trc.or.th/th/media/attachments/2562/01/29/2561.pdf
Hammond D. Health warning messages on tobacco products: A review. Tob Control 2011;20:327-37. DOI: https://doi.org/10.1136/tc.2010.037630
Wakefield M, Morley C, Horan JK. The cigarette pack as image: new evidence from tobacco industry documents. Tob Control 2002;11:73-80. DOI: https://doi.org/10.1136/tc.11.suppl_1.i73
Noar SM, Hall MG, Francis DB, et al. Pictorial cigarette pack warnings: A meta-analysis of experimental studies. Tob Control 2016;25:34-54. DOI: https://doi.org/10.1136/tobaccocontrol-2014-051978
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. DOI: https://doi.org/10.1016/j.socscimed.2016.06.011
Thrasher JF, Swayampakala K, Hammond D, et al. 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 2016;31:1517-26. DOI: https://doi.org/10.1080/10410236.2015.1089456
Mutti-Packer S, Reid JL, Thrasher JF, et al. The role of negative affect and message credibility in perceived effectiveness of smokeless tobacco health warning labels in Navi Mumbai, India and Dhaka, Bangladesh: A moderated-mediation analysis. Addict Behav 2017;73:22-9. DOI: https://doi.org/10.1016/j.addbeh.2017.04.002
WHO. WHO Framework Convention on Tobacco Control (WHO FCTC) Framework Convention on Tobacco Control. Elaboration of Guidelines for Implementation of Article 11 of the Convention. 2008. Available from: http://apps.who.int/gb/fctc/PDF/cop3/FCTC_COP3_7-en.pdf DOI: https://doi.org/10.1186/1617-9625-4-3
World Health Organization. WHO Framework Convention on Tobacco Control (WHO FCTC). 2020. Available at: https://www.euro.who.int/en/health-topics/disease-prevention/tobacco/publications/key-policy-documents/who-framework-convention-on-tobacco-control-who-fctc
Hammond D, Thrasher J, Reid JL, et al. Perceived effectiveness of pictorial health warnings among Mexican youth and adults: a population-level intervention with potential to reduce tobacco-related inequities. Cancer Causes Control 2012;23:57-67. DOI: https://doi.org/10.1007/s10552-012-9902-4
World Health Organization. WHO Report on the Global Tobacco Epidemic, Warning about the Dangers of Tobacco. 2011. Available from: https://www.who.int/tobacco/global_report/2011/implementation_effective_measures.pdf?ua=1
Tobacco Control Laws [Internet]. Legislation by Country. Available from: www.tobaccocontrollaws.org
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. DOI: https://doi.org/10.1001/jamainternmed.2016.2621
Yzer MC, Southwell BG, Stephenson MT. Inducing fear as a public communication campaign strategy. In: RE Rice and CK Atkin, editors. Public communication campaigns. Thousand Oaks: Sage; 2012. p. 163-76. DOI: https://doi.org/10.4135/9781544308449.n11
Engelbrecht R. Choose Life or Death: Guarding the Gates. Lulu.com; 2019.
Lang PJ. Cognition in emotion: Concept and action. In: CE Izard, J Kagan and RB Zajonc, editors. Emotions, cognition, and behavior. Cambridge: Cambridge University Press; 1984. p. 192-226.
Borland R. Understanding hard to maintain behaviour change: a dual process approach. J. Wiley & Sons; 2014. DOI: https://doi.org/10.1002/9781118572894
Peters E, Evans AT, Hemmerich N, Berman M. Emotion in the law and the lab: the case of graphic cigarette warnings. Tob Regul Sci 2016;2:404-13. DOI: https://doi.org/10.18001/TRS.2.4.10
Evans AT, Peters E, Shoben AB, et al. Cigarette graphic warning labels increase both risk perceptions and smoking myth endorsement. Psychol Health 2018;33:213-34. DOI: https://doi.org/10.1080/08870446.2017.1310864
Evans AT, Peters E, Strasser AA, et al. Graphic warning labels elicit affective and thoughtful responses from smokers: Results of a randomized clinical trial. PLoS One 2015;10:e0142879. DOI: https://doi.org/10.1371/journal.pone.0142879
Borgatta EF, Evans RR. Smoking Health and Behavior. Aldine: Chicago; 1968.
Sutton S. Shock tactics and the myth of the inverted U. Br J Addict 1992;87:517-9. DOI: https://doi.org/10.1111/j.1360-0443.1992.tb01953.x
Cho YJ, Thrasher JF, Yong H-H, 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;197:226-34. DOI: https://doi.org/10.1016/j.socscimed.2017.10.003
Macy JT, Chassin L, Presson CC, Yeung E. Exposure to graphic warning labels on cigarette packages: Effects on implicit and explicit attitudes towards smoking among young adults. Psychol Health, 2015;31:349-63. DOI: https://doi.org/10.1080/08870446.2015.1104309
Canada Cancer Society [Internet]. Evaluation of new warning on cigarette packages highlight. 2002. Accessed: 12 Apr 2018. Available from: http://www.cancer.ca
Szklo AS, Volchan E, Thrasher JF, et al. Do more graphic and aversive cigarette health warning labels affect Brazilian smokers' likelihood of quitting? Addict Behav 2016;60:209-12. DOI: https://doi.org/10.1016/j.addbeh.2016.04.021
Yong H-H, Borland R, Thrasher JF, et al. Mediational pathways of the impact of cigarette warning labels on quit attempts. Health Psychol 2014;33:1410-20. DOI: https://doi.org/10.1037/hea0000056
Hammond D, Fong GT, McDonald PW, et al. Graphic Canadian cigarette warning labels and adverse outcomes: Evidence from Canadian smoker. Am J Public Health 2004;94:1442-5. DOI: https://doi.org/10.2105/AJPH.94.8.1442
Morgan JC, Golden SD, Noar SM, et al. Conversations about pictorial cigarette pack warnings: Theoretical mechanisms of influence. Soc Sci Med 2018;218:45-51. DOI: https://doi.org/10.1016/j.socscimed.2018.09.063
Chalearnchatri P. Effects of smoking warning images on cigarette packs on perception and intention to smoke among people with the age of fifteen years old and above in Nakornsritammarat Province. 2007. [Thesis in Thai]. Master’s Thesis, Mahidol University, Thailand.
Positioning Magazine [Internet]. Thai people’s smoking behavior. New World No Tobacco Day. 2005. [In Thai]. Accessed: 12 Dec 2018. Available from: http://www.positioningmag.com/prnews/prnews.aspx?id=33539
Action on Smoking and Health [Internet]. Smoking warning statement on cigarette packs in Thailand. 2008. [In Thai]. Accessed: 12 Dec 2018. Available from: http://dpc9.ddc.moph.go.th/group/ncd/TOBAC%20ALC/thaiwarninghealth.doc
The ABAC Social Innovation in Management and Business Analysis. Survey on Teenagers’ opinion on smoking warning images and smoking behaviors. [In Thai]. Assumption University: Bangkok; 2008.
Wannasirorat T. Effects of smoking warning labels on health perception of vocational students in Bangkok city. [in Thai]. Master’s Thesis, Mahidol University, Thailand: 2010.
Tobacco Control Research and Knowledge Management Center. Changes of smoking warning images on cigarette packs and outcome evaluation. 2009. [In Thai]. Accessed: 15 Dec 2018. Available from: http://www.trc.or.th/th/research_knowledge/knowledge/knowledge_02.php#data
Evans WD, Powers A, Hersey J, Renaud J. The influence of social environment and social image on adolescent smoking. Health Psychol 2006;25:26. DOI: https://doi.org/10.1037/0278-622.214.171.124
Lim KH, Sumarni MG, Amal NM, et al. Tobacco use, knowledge and attitude among Malaysians age 18 and above. Trop Biomed 2009;26:92-9.
Flay B, Phil D, Hu F, Richardson J. Psychosocial predictors of different stages of cigarette smoking among high school students. Prev Med 1998;27:9-18. DOI: https://doi.org/10.1006/pmed.1998.0380
Hale WJ, Perrotte JK, Baumann MR, Garza RT. Low self-esteem and positive beliefs about smoking: a destructive combination for male college students. Addict Behav 2015;46:94-9. DOI: https://doi.org/10.1016/j.addbeh.2015.03.007
Hermalin AI, Lowry D. The age prevalence of smoking among Chinese women: A Case of arrested diffusion? Population Studies Center, University of Michigan Ann Arbor; 2010. Available from: https://www.psc.isr.umich.edu/pubs/pdf/rr10-718.pdf
Sherman S, Chassin L, Sherman J, et al. Social psychological factors in adolescent and adult smoking: Findings and conclusions from a 30-year longitudinal study. Health Commun 2016;3:1517-26.
Indonesia Ministry of Public Health. Announcement No.8 B.E. 2547 on rules, procedures and conditions of cigarette labelling and label content according to the Tobacco Products Control Act B.E. 2535. 2004. Available from: https://www.tobaccocontrollaws.org/files/live/Thailand/Thailand%20-%202004%20P%26L%20Rules.pdf
Kapook.com [Internet]. Smoking Warning Images. 2004. [In Thai]. Accessed: 17 Apr 2018. Available from: https://hilight.kapook.com/view/116940
Indonesia Ministry of Public Health. Notification No. 13 2550 (A.D. 2007) Re: Criteria, procedures and conditions for displaying pictorial labels and statements of warning on harm of cigars issued under the Tobacco Products Control Act B.E. 2535 (A.D. 1992). 2007-02-27. Available from: https://www.tobaccocontrollaws.org/files/live/Thailand/Thailand%20-%20Cigar%20Label%20Regs%202007.pdf
Jitsomwang S. How mandatory warning images on cigarette packages affect health perceptions and smoking avoidance in the Bangkok area. [Thesis in Thai]. Master’s Thesis. Bangkok: Thammasat University; 2016. Available from: http://ethesisarchive.library.tu.ac.th/thesis/2016/TU_2016_5804010212_6424_4480.pdf
Indonesia Ministry of Public Health. Notice of rules, procedures and conditions for the display and content of cigarette labels. 2009. Tobacco Products Control Act B.E. 2535 (A.D. 1992). Available from: https://www.tobaccocontrollaws.org/files/live/Thailand/Thailand%20-%20Cigarette%20Label%20Regs%202009.pdf
Indonesia Ministry of Public Health. Notice of rules, procedures, and conditions for the display of images, warning statements, and contact channels for smoking cessation on cigarette labels. 2013. Tobacco Products Control Act B.E. 2535 (A.D. 1992). Available from: https://www.tobaccocontrollaws.org/files/live/Thailand/Thailand%20-%20P%26L%20Rules%202013.pdf
Family Network Foundation [Internet]. 10 warning pictures on cigarette packs. 2010. [In Thai]. Accessed: 19 Apr 2018. Available from: http://www.familynetwork.or.th/content/10-ภาพคำเตือนบนซองบุหรี่
Isranews Agency [Internet]. Ministry of Public Health has issued a warning for the world's largest cigarette pack. 2013. Accessed: 20 Apr 2018. Available from: https://www.isranews.org/isranews-news/20463-สธ-คลอดประกาศคำเตือนซองบุหรี่ใหญ่ที่สุดในโลกแล้ว-sp-690588681.html
Gendall P, Hoek J, Gendall K. Evaluating the emotional impact of warning images on young adult smokers and susceptible non-smokers. J Health Commun 2018;23:291-8. DOI: https://doi.org/10.1080/10810730.2018.1440332
Popova L, So J, Sangalang A, et al. Do emotions spark interest in alternative tobacco products? Health Educ Behav 2017;44:598-612. DOI: https://doi.org/10.1177/1090198116683169
Yamane T. Statistics, an introductory analysis. New York: Harper and Row; 1967.
Physicians for a Smoke-Free Canada [Internet]. Picture based cigarette health warnings: Research. Accessed: 21 Nov 2018. Available from: http://www.smoke-free.ca
Brown SL, Smith Z. The inhibitory effect of a distressing anti-smoking message on risk perceptions in smokers. Psychol Health 2007;22:255-68. DOI: https://doi.org/10.1080/14768320600843127
Keller PA, Block LG. Increasing the persuasiveness of fear appeals: the effect of arousal and elaboration. J Consumer Res 1996;22:448–59. DOI: https://doi.org/10.1086/209461
Kees J, Burton S, Andrews JC, et al. Understanding how graphic pictorial warnings work on cigarette packaging. J Public Policy Marketing 2010;29:265-76. DOI: https://doi.org/10.1509/jppm.29.2.265
Farrelly M, Choiniere C. Experimental study of graphic cigarette warning labels. Contract No. HHSF-223-2009-10135G. Rockville: Food and Drug Administration; 2010. Available from: https://www.fda.gov/tobacco-products/research/research-experimental-study-graphic-cigarette-warning-labels
Cameron LD, Pepper JK, Brewer NT. Responses of young adults to graphic warning labels for cigarette packages. Tob Control 2015;24:14–22. DOI: https://doi.org/10.1136/tobaccocontrol-2012-050645
Berg CJ, Thrasher JF, Westmaas JL, et al. College student reactions to health warning labels: Socio-demographic and psychosocial factors related to perceived effectiveness of different approaches. Prev Med 2011;53:427-30. DOI: https://doi.org/10.1016/j.ypmed.2011.09.006
Pepper JK, Cameron LD, Reiter PL, et al. Non-smoking male adolescents' reactions to cigarette warnings. PLoS One 2013;8:e65533. DOI: https://doi.org/10.1371/journal.pone.0065533
HFocus [Internet]. Investigations on Health Systems. 2017. [In Thai]. Accessed: 19 Aug 2018. Available from: https://www.hfocus.org/content/2017/05/13944
Li HCW, Chan SS, Lam TH. Smoking among Hong Kong Chinese women: behavior, attitudes and experience. BMC Public Health 2015;15:183. DOI: https://doi.org/10.1186/s12889-015-1529-4
Smith SY, Curbow B, Stillman FA. Harm perception of nicotine products in college freshman. Nicotine Tob Res 2007;9:977-82. DOI: https://doi.org/10.1080/14622200701540796
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