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James F. Thrasher, Edna Arillo-Santillán, Marta Caballero, David Hammond
ITC-Mexico: An update & example of research to select
effective pictorial warning label content
Mexican health warnings labels (HWLs) 3rd largest in the world (65% of pack)
30% of the front (picture & text) 100% of the back and one side
(text only) 2 new HWLs every 3 months,
fastest rotation in the world
50% of the back (text only)
4 messages
(2004-2010) (2010-present)
1st round of Mexican Pictorial Health Warning Labels (HWLs)
4
Phase 1Objective: Most effective HWL imagery
Method: Field experiments
Phase 2Objective: Most effective HWL textual content
Method: Field experiments
Phase 3Objective: Confirm findings about HWL imagery & text
Method: Focus groups
3-stage process to select second round of HWLs
Warning Labels stopped you from having a cigarette.
0
10
20
30
40
Wave 1 Wave 2
Per
cen
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CanadaAustraliaUSUK
Second level Third level Fourth level Fifth level
5Warning Labels stopped you from having a
cigarette.
0
10
20
30
40
Wave 1 Wave 2
Per
cen
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CanadaAustraliaUSUK
International Pack Study
Parallel studies in 7 diverse countries:
Examine effective content for pictorial warnings
Examine individual differences in responses
Examine cultural, national level differences
P01 CA138389, Tobacco packaging and labeling policies: Expanding the evidence on novel policies
Mexico
US
China
India
Germany
Bangladesh
South Korea
Health Warning Topics & Stimuli
Health warning topic “sets”5 or 6 warnings tested for each topic
Text Symbolic Human suffering
Graphic External Graphic Internal Testimonial
Field experiments
Random assignment
Addiction
Stroke
Toxicity
Rate 5 to 7 warnings from
selected block in random order
Evaluate for each warning:
• Attention
• Credibility
• Relevance
• Negative emotional arousal
• Impact
Brief Survey• Sociodemographics• Smoking-related
perceptions & behavior
• Warning labels
Rank warnings
within a block:
• Which most motivates you to stop smoking?
• Which most motivates you to not start smoking?
Throat cancer
Mouth cancerDeath
Heart attack
Enphysema
Premature aging
Impotence
Lung cancerGangrene
Premature birth
SHS in children
Topics
Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.
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.
Warning Labels stopped you from having a cigarette.
0
10
20
30
40
Wave 1 Wave 2
Per
cen
tag
e
CanadaAustraliaUSUK
Second level Third level Fourth level Fifth level
10Warning Labels stopped you from having a
cigarette.
0
10
20
30
40
Wave 1 Wave 2
Per
cen
tag
e
CanadaAustraliaUSUK
Graphic & human suffering rated as more effective than symbolic warnings (p<.001)
Graphic & human
sufferingvs. Symbolic
Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.
Warning Labels stopped you from having a cigarette.
0
10
20
30
40
Wave 1 Wave 2
Per
cen
tag
e
CanadaAustraliaUSUK
Second level Third level Fourth level Fifth level
11Warning Labels stopped you from having a
cigarette.
0
10
20
30
40
Wave 1 Wave 2
Per
cen
tag
e
CanadaAustraliaUSUK
Warnings with graphic content rated more effective than with human suffering (p<.001)
Graphic vs. Human suffering
Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.
Warning Labels stopped you from having a cigarette.
0
10
20
30
40
Wave 1 Wave 2
Per
cen
tag
e
CanadaAustraliaUSUK
Second level Third level Fourth level Fifth level
12Warning Labels stopped you from having a
cigarette.
0
10
20
30
40
Wave 1 Wave 2
Per
cen
tag
e
CanadaAustraliaUSUK
Testimonial Non-Testimonial
Adding testimonial information increased effectiveness (p<.001)
Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.
Warning Labels stopped you from having a cigarette.
0
10
20
30
40
Wave 1 Wave 2
Per
cen
tag
e
CanadaAustraliaUSUK
Second level Third level Fourth level Fifth level
13Warning Labels stopped you from having a
cigarette.
0
10
20
30
40
Wave 1 Wave 2
Per
cen
tag
e
CanadaAustraliaUSUK
Warnings depicting suffering of OTHERS rated as more effective than suffering of SELF (p<.001)
Self sufferingvs.Other suffering
Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.
Impact on knowledge
Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.Mutti S, Hammond D, Reid J, Thrasher JF. Jnl Health Communicaiton. In press.
Images with the greatest impact in study 1
Topic ImageThroat cancer
Mouth cancer
Lung cancer
Emphysema
Adiction
Topic Image
Heart disease
Stroke
Gangrene
SHS & children
Fetus & Premature birth
Phase 1Objective: Most effective HWL imagery
Method: Field experiments
Phase 2Objective: Most effective HWL textual content
Method: Field experiments
Phase 3Objective: Confirm findings about HWL imagery & text
Method: Focus groups
2nd phase: Selection of textual content for pictorial HWLs
Characteristics of Mexican pictorial HWLs
30% of front with image and text
100% of one side, reinforcing the central message
“Qualitative” focus on toxic
constituents
Call to action with 1800 number
Didactic/scientific vs. testimonial content
Breathing tobacco smoke causes the arteries of your heart to clog. The clogging damages your heart and can kill you.
You can quit smoking. Call us01800 966 3863
“My husband was a smoker, and while he was still young, he died from a heart attack. I was left stranded to take care of the family all by myself.”
Celia Juárez
You can quit smoking. Call us
01800 966 3863
“Tobacco smoke is a silent killer. Without thinking, I breathed it in, unable to feel the damage it had done…until it gave me a heart attack.”
César Guerrero
You can quit smoking. Call us01800 966 3863
Didactic /scientific Testimonial - other Testimonial - self
Contains particles that enter your blood stream, form blood clots and can block your arteries
Contains particles that enter your blood stream, form blood clots and can block your arteries
Contains particles that enter your blood stream, form blood clots and can block your arteries
Thrasher JF, Arillo-Santillán E, Villalobos V, et al. Cancer Causes & Control. 2012.
Field experiments in 8 public places
Randomization
Condition 1: 4 blocks of packs on same health outcome
Condition 2:4 blocks of packs on same health outcome
Condition 3: 4 blocks of packs on same health outcome
Condition 4: 4 blocks of packs on same health outcome
Random presentation of packs within each block
Assessment of each HWL:
• Attention
• Credibility
• Relevance
• Emotional arousal
• Impact
Brief survey• Sociodemographics• Smoking perceptions & behavior
• HWL
Ranking task of HWLs within block:
• Which motivates you most to quit?
• Which motivates you most to not start smoking?
Thrasher JF, Arillo-Santillán E, Villalobos V, et al. Cancer Causes & Control. 2012.
Sample characteristicsCharacteristics
Youth sample% (n)
Adult smoker sample% (n)
Age (average) 20.6 (range 18 – 24) 32.8 (range 25 – 80)
Sex Male
Female50% (266)50% (263)
62% (330)38% (199)
Education Secondary or less
Technical schoolHigh schoolUniversity +
28% (146)8% (44)
57% (302)7% (37)
18% (100)14% (76)42% (223)25% (130)
Smoking behaviorNonsmoker
Non-daily smokerDaily smoker, < 5 /dayDaily smoker, 5+ / day
49% (258)30% (159)12% (63)10% (53)
N/A43% (225)25% (131)33% (173)
Intend to quit in next 6 months 31% (77 / 252) 31% (165)
Overall impact of scientific vs. testimonial
7.2
6.8 6.8 6.8
6.3
6.6
6.8
6.5
6.6
6.8
6.4 6.4
6.26.2
6.3
6.5
6.36.2
5.0
5.5
6.0
6.5
7.0
7.5
Lung cancer Heart disease Prematurebirth
Stroke Addiction Throatcancer
Scientific
Testimonial 1
Testimonial 2
Thrasher JF, Arillo-Santillán E, Villalobos V, et al. Cancer Causes & Control. 2012.
Adjusted ORs* of selecting a testimonial as most influential, lowest vs. highest educational attainment
2.0
1.3
1.9
3.0
1.7
2.9
0.5
1
1.5
2
2.5
3
3.5
4
Lungcancer
Heartdisease
Prematurebirth
Stroke Addiction Throatcancer
*adjusted for age, sex, smoking status, level of consumption, perceived risk, and quit intentions
Phase 1Objective: Most effective HWL imagery
Method: Field experiments
Phase 2Objective: Most effective HWL textual content
Method: Field experiments
Phase 3Objective: Confirm findings about HWL imagery & text
Method: Focus groups
3rd phase: confirm best combination of imagery and textual content
Population characteristics
Mexico City Guadalajara Monterrey
SmokersNon-
smokersSmokers
Non-smokers
SmokersNon-
smokers18 - 24
25 - 65
18 - 24
25 - 65
18 - 24
25 - 65
18 - 2418 - 24
25 - 65
18 - 24
25 - 65
Female (n=80) 7 17 4 0 6 14 6 5 16 5 0
Male (n=67) 4 11 9 1 6 10 5 6 8 6 1
Total (n=147) 11 28 13 1 12 24 11 11 24 11 1
Focus groups
Mixed methodsIndividual ratings
Group discussion
Callback two days later
12 groups, 4 in each city:
Versión: 3A Versión: 3B
TEMA 3: CÁNCER DE BOCA
New Health Warning Labels
Future research•Every 4 months in Mx, Canada, Australia, US•Define and measure real world outcomes
• “Understanding of risks”• Cessation behavior
•Targeted messages - Which features matter?:• Perceived credibility and relevance?• Matching of social identity characteristics?• Message complexity?
•Define & explain patterns of “wear out”
Survey Mode: Face-to-Face (F2F)Respondent Types: Smoker
29
2011/12 New pictorial warning rotations
MEXICOTimeline of Tobacco Control Policies and ITC Surveys
2004 2005 2006 2007 2008 2009 2010 2011 2012
Wave 1Sept-Nov 2006
N= 1080
Wave 2Oct-Dec 2007
N= 1080
Wave 3Nov-Dec 2008
N= 2000
Wave 4Jan-Feb 2010
N= 2100
Wave 5Apr-May 2011
N=2100
29
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