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David Hammond PhD
March 21, 2012
Health warnings
Current international Practices.
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International standards
Pictures
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Source: Cigarette health warnings: International status report. Canadian Cancer Society. October 2010.
Health Warning Labels
Implementation of pictorial warnings
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Health Warning Labels
Countries with pictorial warnings
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Latvia 2010 Mexico 2010 Mongolia 2010 Pakistan 2010 Switzerland 2010
Turkey 2010 France 2011 Malta 2011 Spain 2011* Norway 2011*
Philippines 2011* Urkraine 2012*
*Proposed implementation date at time of publication.
Health Warning Labels
Countries with pictorial warnings
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Warning Labels stopped you from having a
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Source: Cigarette health warnings: International status report. Canadian Cancer Society. October 2011.
Size
82% Australia*
80% Uruguay
75% Canada
65% Madagascar
65% Mauritius
65% Mexico
60% Philippines
60% New Zealand
60% Cook Islands
56% Belgium
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Position
Front vs. Back
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Warning Labels stopped you from having a
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2002
2004
2008
Message “rotation”
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Number of messages in rotation
What types of messages are most effective?
Health Warning Themes
Graphic Health Effects
Content
Limits of “graphic” content?
Health Warning Themes
Lived experience
Health Warning Themes
Lived experience
Health Warning Themes
Symbolic and Abstract
Health Warning Themes
Symbolic and Abstract
Health Warning Themes
Cartoons
Health Warning Themes
Testimonial
Testimonials
Australia 2012
Testimonials
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Text
Warning Labels stopped you from having a
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Health Warning Content
Quit lines
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Content
Cessation Inserts
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Health Warning Content
Pack inserts
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Legal challenges
United States
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“…the evidence here overwhelmingly suggests that the
Rule's graphic-image requirements are not….purely factual
and uncontroversial disclosures…. Indeed, the fact alone
that some of the graphic images here appear to be
cartoons, and others appear to be digitally enhanced or
manipulated, would seem to contravene the very definition
of "purely factual.” page 14
Preliminary injunction
Factual?
Source: Richard J. Leon. Memorandum of Opinion. Nov 7 2011. Civil Case No. 11-1482 (RJL) United States District Court for the District of Columbia.
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Factual
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Credibility
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Content
Credibility
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Implementation & Legal challenges
India
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Implementation challenges
“Little” tobacco
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Implementation challenges
Contraband tobacco
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“Other” tobacco products
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“Other” tobacco products
Waterpipe
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Links with other media
Summary
• Warning labels should be regarded as a communication campaign.
• Policy evolution: “First” vs. “second” generation.
• Importance of international collaboration.
• Role of research & evidence.
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Contact
David Hammond PhD
School of Public Health & Health Systems
University of Waterloo
Tel. 519 888 4567 ext.36462
Email [email protected]
Web www.davidhammond.ca
Evidence from low and middle income
countries: 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
VENEZUELA (2005)
URUGUAY (2006)
BRAZIL (2002)
MEXICO (2010)
PANAMA (2008)
CHILE (2006)
PERU (2010)
Pictorial Health Warning Labels in LAC
COLOMBIA (2010)
BOLIVIA (2012)
HONDURAS (2011)
1. Caribbean Study:
• Jamaica, Barbados, Trinidad & Tobago,
Guyana
2. Central America Study:
• Nicaragua, Honduras (Guatemala,
Panama, El Salvador)
3. South America Study:
• Bolivia
Cigarette Labeling Studies in Latin
America & the Caribbean:
GOALS 1.To determine the most effective content of pictorial
HWLs related to 3 themes: • Health effects
• Environmental effects/ social & economic impact
• SHS & Smokefree support
2.To determine if greater credibility is attributed to the
message from the Minister of Health compared to
other agencies
3.To determine which “marker word” is most effective
in attracting attention and increasing credibility of
the message presented
DATA COLLECTION
Mall intercept recruitment technique
• Subjects were recruited from 2 different local public
venues (e.g., mall, market, or equivalent) in the
capital 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
14 countries: population ~ 16 million
English-Speaking Caribbean Study
Members States of the CARICOM
ANTIGUA &
BARBUDA
GRENADA ST. KITTS & NEVIS
BAHAMAS GUYANA ST. LUCIA
BARBADOS HAITI ST. VINCENT & THE
GRENADINES
BELIZE JAMAICA SURINAME
DOMINICA MONTSERRAT TRINIDAD &
TOBAGO
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?
Theme /
Type
TOTAL
SMOKERS
NON SMOKERS
Health effect: Mouth Cancer /
GRAPHIC
Health effect: Mouth Disease
/
GRAPHIC
Health effect: Mouth Cancer /
GRAPHIC
Health effect: Stillbirth /
GRAPHIC
HIGHEST Rated
Theme /
Type
TOTAL
SMOKERS
NON SMOKERS
Cessation/ Economic effect /
SYMBOLIC
Health effect: Aesthetic /
GRAPHIC
Cessation /
SYMBOLIC
Cessation /
SYMBOLIC
LOWEST RATED
Respondents were asked to focus on the word in CAPITAL letters and different
color that appears at the beginning of these messages.
29 29 30
11 12 10
63 62 63
0
20
40
60
80
100
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?
%
Warning
Caution
Danger
MARKER WORD
Respondents were asked to focus on the word in CAPITAL letters and different
color that appears at the beginning of these messages.
27 27 27
11 12 10
68 69 66
0
20
40
60
80
100
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?
%
Warning
Caution
Danger
Respondents were asked to focus on the word in CAPITAL letters and different
color that appears at the beginning of these messages.
27 27 27
11 12 10
68 69 66
0
20
40
60
80
100
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?
%
Warning
Caution
Danger
MARKER WORD
Respondents were asked to focus on the last words print in smaller font at the end of
the warning.
11 12 10
43 404646 45 45
2 3 1
0
15
30
45
60
75
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?
%
Minister of Health
Ministry of Health
Chief Medical Officer
None
Respondents were asked to focus on the last words print in smaller font at the end of
the warning.
11 12 10
43 404646 45 45
2 3 1
0
15
30
45
60
75
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?
%
Minister of Health
Ministry of Health
Chief Medical Officer
None
ATTRIBUTION
Respondents were asked to focus on the last words print in smaller font at the end of
the warning.
11 13 10
43 404645 44 46
3 4 2
0
15
30
45
60
75
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?
%
Minister of Health
Ministry of Health
Chief Medical Officer
None
Respondents were asked to focus on the last words print in smaller font at the end of
the warning.
11 13 10
43 404645 44 46
3 4 2
0
15
30
45
60
75
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?
%
Minister of Health
Ministry of Health
Chief Medical Officer
None
ATTRIBUTION
7 countries: population ~ 42 million
Central America Cigarette Labeling Study
Central America Cigarette Labeling Study
SOCIOECONOMIC
IMPACT:
CHILD LABOR &
POVERTY
ENVIRONMENTAL
IMPACT:
AGROTOXICS &
DEFORESTATION
HIGHEST Rated
TONG & MOUTH
CANCER
LUNG CANCER
LARINX CANCER
PREGNANCY
LOWEST Rated
POVERTY &
CHILD LABOR
DEFORESTATION
& AGROTOXICS
SHS CHILDREN
STROKE
Population: ~ 11 million
Bolivia Cigarette Labeling Study
NEW WARNINGS (2012)
Bolivia Cigarette Labeling Study
Examples of 4 types of pictorial HWLs on SHS & lung cancer to be tested
Aim: To pre-test the effectiveness of pictorial-based HWLs printed on
cigarette packages to raise awareness on SHS and to increase support
for 100% smokefree policies in Bolivia (synergy of policies)
ACKNOWLEDGEMENTS
RPCI Dep. Health Behavior
• Michael Cummings
• Mark Travers
• Maansi Travers
• Richard O’Connor
• Andrew Hyland
• Cheryl Rivard
• Essie Torres
Univ. of Waterloo
• David Hammond
Univ. of South Carolina • James Thrasher
International Partners
• Center for Tobacco Epidemic
Research of Uruguay
• InterAmerican Heart Foundation
• Ministry of Health of Panama
• National Cancer Institute of Brazil
• National Institute of Public Health of
Mexico
• Smokefree Alliance of Argentina
• Heart Foundation of Jamaica
• Heart & Stroke Foundation of
Barbados
• Trinidad & Tobago Cancer Society
• Guyana Chest Society
James F. Thrasher
How to design the content of
pictorial warning labels:
A case study of Mexico
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 1
Objective: Most
effective HWL imagery
Method: Field
experiments
Phase 2
Objective: Most
effective HWL textual content
Method: Field
experiments
Phase 3
Objective: Confirm
findings about HWL imagery & text
Method: Focus groups
3-stage process to select HWL content
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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
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Adaptation of Health Warnings
Health warning topic “sets” 5 or 6 warnings tested for each topic
Text Symbolic Human suffering
Graphic External Graphic Internal Testimonial
Health Warning Topics & Stimuli
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 cancer
Death
Heart attack
Enphysema
Premature aging
Impotence
Lung cancer
Gangrene
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
Perc
en
tag
e
Canada
Australia
US
UK
Second level
Third level
Fourth level
Fifth level
11 Warning Labels stopped you from having a
cigarette.
0
10
20
30
40
Wave 1 Wave 2
Perc
en
tag
e
Canada
Australia
US
UK
Graphic more effective than human suffering,
which is more effective than symbolic warnings (p<.001)
Graphic
vs.
Symbolic
Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.
Human
suffering
vs.
Warning Labels stopped you from having a
cigarette.
0
10
20
30
40
Wave 1 Wave 2
Perc
en
tag
e
Canada
Australia
US
UK
Second level
Third level
Fourth level
Fifth level
12 Warning Labels stopped you from having a
cigarette.
0
10
20
30
40
Wave 1 Wave 2
Perc
en
tag
e
Canada
Australia
US
UK
Testimonial Non-Testimonial
Adding testimonial information
increased effectiveness (p<.001)
Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.
vs.
Rankings in experimental sample consistent
with rankings in a representative sample
Health Beliefs
Does smoking cause impotence in male smokers? % “Yes”
Mutti S, Hammond D, Reid J, Thrasher JF. Jnl of Health Communicaiton. In press.
Images with the greatest impact in study 1
Phase 1
Objective: Most
effective HWL imagery
Method: Field
experiments
Phase 2 Objective: Most
effective HWL textual content
Method: Field
experiments
Phase 3 Objective: 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 us
01800 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 us
01800 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 characteristics
Characteristics Youth sample
% (n)
Adult smoker sample
% (n)
Age (average) 20.6 (range 18 – 24) 32.8 (range 25 – 80)
Sex
Male
Female
50% (266)
50% (263)
62% (330)
38% (199)
Education
Secondary or less
Technical school
High school
University +
28% (146)
8% (44)
57% (302)
7% (37)
18% (100)
14% (76)
42% (223)
25% (130)
Smoking behavior
Nonsmoker
Non-daily smoker
Daily smoker, < 5 /day
Daily smoker, 5+ / day
49% (258)
30% (159)
12% (63)
10% (53)
N/A
43% (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
6.3
6.2
5.0
5.5
6.0
6.5
7.0
7.5
Lung cancer Heart disease Premature
birth
Stroke Addiction Throat
cancer
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
effective, 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
Lung
cancer
Heart
disease
Premature
birth
Stroke Addiction Throat
cancer
*adjusted for age, sex, smoking status, level of consumption, perceived risk, and quit intentions
Phase 1
Objective: Most
effective HWL imagery
Method: Field
experiments
Phase 2
Objective: Most
effective HWL textual content
Method: Field
experiments
Phase 3
Objective: Confirm
findings about HWL imagery & text
Method: Focus groups
3rd phase: confirm best combination of
imagery & textual content
Population
characteristics
Mexico City Guadalajara Monterrey
Smokers Non-
smokers Smokers
Non-
smokers Smokers
Non-
smokers
18 -
24
25 -
65
18 -
24
25 -
65
18 -
24
25 -
65 18 - 24
18 -
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 methods
Individual ratings
Group discussion
Callback two days later
12 groups, 4 in each city:
Second round of pictorial HWLs
Conclusions
Graphic imagery was rated as more effective than other types of imagery
Consistent across samples and countries
Didactic / scientific textual content was more effective 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 media
Textual content on toxic constituents effective
Quantitative and focus group results were consistent
What do we need?
A role for positively framed quit messages?
People who intend to quit have strongest responses
Habituation and “wear out”
Wear out quicker for some imagery than others
Cycles of wearin and wearout?
Matching/targeting of messages?
Industry responses
Image banks and sharing of high-quality pictorial imagery among countries
