Perceived Effectiveness of Pictorial versus Textual Health Warning Labels on Waterpipe Tobacco Packages (Tumbac packages)

Transcription

1 Perceived Effectiveness of Pictorial versus Textual Health Warning Labels on Waterpipe Tobacco Packages (Tumbac packages) NELLY LAYOUN, PhD, MPH Epidemiologist

2 Misperceived as less harmful than cigarette smoking Every study to date has found that waterpipe tobacco smoke contains extensive quantities of the toxicants admitted to cause diseases in cigarette smokers, including cancer. One WTS session consistently exposes users to higher levels of tobacco toxicants nicotine, tar, and CO compared with one cigarette. Accordingly, Scientific premise Waterpipe use has damaging effects on the respiratory and cardiovascular systems. Shihadeh A et al Brian A et al Layoun N et al. 2014

3 Waterpipe and chronic cough & chronic phlegm? Chronic cough and phlegm are important indicators of respiratory morbidity with significant association of these symptoms with mortality due to COPD. It has been demonstrated that these chronic symptoms motivated cigarette smokers to quit smoking because they were afraid of getting sick in the future. Even light-use waterpipe only smokers have more cough and sputum, lower lung diffusion capacity, abnormalities in multiple lung related biologic and clinical parameters. Annesi I et al Albayrak S et al Strulovici-Barel et al. 2016

4 Execution of relevant tobacco control policies in Lebanon? It is the main problem in developing countries

5 Price-based policies? Although most price-based policies have been efficient in reducing the demand for cigarettes, raising the price of waterpipe tobacco might not have the same effect. Waterpipe smokers may be less susceptible to price than cigarette smokers.

6 Ban on smoking in public places?

7 Advertising and promotion bans? Wp specificities can render them ineffective even if they are enforced. In addition to health messages to market narguileh products ex: natural, 100% coconut shell, free of chemicals much of the advertisement is done indirectly through the promotion of establishments serving the wp. For examples many coffee shops display wp in their windows as a decoration.

8 Education about smoking related illnesses: Health warnings? Health warnings on tobacco packages are a typical population-level intervention: 1. They have broad reach 2. They cost little to implement 3. Are feasible over time In addition, smokers have little knowledge about tobacco product ingredients and most of them are unaware of the specific harms caused by waterpipe use; they underestimate the risks they take to themselves and their surroundings.

9 Pictorial versus textual warnings? Therefore, replacing those positive associations with negative associations by using shocking graphic pictures could be a powerful technique to convey the devastating impact of tobacco products on global health, in several low- and middle-income countries in particular. Evidence suggests that pictorial HWLs on cigarette packages outperform textonly HWLs on a range of outcomes, including : 1. Increasing awareness of health risks 2. Perceived effectiveness 3. Negative effect 4. Motivation to quit.

10 Objective of the study: Perceived effectiveness of health warnings on waterpipe tobacco packages Evaluate the impact of shocking pictures versus textual health warnings in Lebanon on quitting tobacco-smoking or on reducing the number of waterpipe smoked weekly; Shocking pictures Assess the motivation factors to quit waterpipe smoking. WARNINGS Textual Health WARNINGS

11 Participants and design: o A cross-sectional study was conducted between March 2014 and April 2015, in 5 outpatient clinics located in 5 Hospitals in Lebanon. o Adults aged 18 years, current exclusive waterpipe smokers defined as current smoking of 1 waterpipe per week ; o Visiting the clinic for an ordinary check-up, an acute respiratory disease including pneumonia, bronchitis or a chronic obstructive pulmonary disease; o Healthy individuals were also included; o Patients seeking advice for a smoking cessation program were also eligible to participate.

12 Participants and design: o Sociodemographic characteristics: age categorized into ( 45 and 45 years) and gender. o Chronic respiratory problems: chronic cough, chronic expetorations, chronic bronchitis, chronic wheezing. o Smoking behaviour: number of WP smoked weekly categorized into 1-2, 3-6, 7. o Dependence scale LWDS11 for WP categorized into >10. o Motivation scale (Mondor scale) categorized into >12.

13 Participants and design:

14 Outcome measures: Evaluation of the actual effect of currently used textual warnings on packages: Have you ever stopped smoking for at least one month after reading the textual warnings on tumbac packages? Are you or have you been influenced by the health warnings in a way that lead you to (reduce the number of waterpipe smoked weekly)? After showing participants a group of shocking pictures about negative smoking consequences on some body organs (black teeth, dirty lungs, ): If these shocking images were used on tobacco boxes, would they have greater effect than simple warning text currently used? Yes/no; If your favorite tumbac brand decides to change its look by using these pictorial warnings on tobacco packaging, would you think of buying another tumbac brand? Yes/no;

15 Table1: Description of the sample of waterpipe smokers Results? Variables N % Gender male Age 45 years Number of weekly waterpipe > LWDS11 scale (nicotine dependence) High Mondor's scale (motivation to quit) High Are you Aware of the damage caused by smoking? Yes breathlessness What is the consequence that in the immediate worries you? (Multiple answer question) bad breath bad smelling clothes Mean Age: 30 years IQR = [23-40] Median duration: 5 years IQR = [3-14]

16 Variables N % Have you ever stopped smoking due to the warnings? Yes Are you or have you been influenced by the health warnings on tumbac packages (the weekly number of WP smoked)? If shocking images were used on tumbac boxes, would they have greater and Thailand effect than simple warning text currently used? If you could choose the types of warning labels on tumbac packs, which one do you feel asmore effective in helping to stop smoking? If your favorite tumbac brand decided to change look of its tumbac warnings. boxes with shocking pictures, would you think of changing it? Yes Similar association has also been demonstrated in Australia 2008 A Canadian study found that approximately half of the smokers reported at least some fear, disgust, anger and subsequently an increase in cessation behavior in response to the pictorial health Yes textual graphic Both Yes Results?

17 Results? Table2: Description and comparison by motivation score and dependance score for waterpipe smokers Variables What is the consequence that in the immediate worries you? Have you ever stopped smoking due to the warnings? If your favorite tumbac brand decided to change look of its tumbac boxes with shocking pictures, would you think of changing it? If shocking images were used on tumbac boxes, would they have greater effect than simple warning text currently used? low mot N (%) high mot N(%) p-value low dep N (%) high dep N (%) p- value breathlessness 38 (50.7) 43 (86) (61.4) 46 (67.6) 0.47 yes 4 (5.3) 9 (18) (15.8) 4 (5.9) 0.07 yes 28 (37.3) 31 (62) (50.9) 30 (44.1) 0.45 Coherent with a study done among cigarette smokers. yes 42 (56) 42 (84) (75.4) 41 (60.3) 0.07

18 Results? According to several studies, younger people are more sensitive to warnings (Hammond et al. 2012; Thrasher et al. 2012); However in our findings, there is no association between younger age and the impact of pictorial and textual warning. This might be due to the high percentage of young people in our sample (86.6%). In our study, 73.9% of female smokers were more hypothetically affected by pictorial warnings in comparison with 58.9% of males. Similar to other research (Koval et al. 2005; Hammond et al. 2012; Mannocci et al. 2012).

19 Table3: Multivariate logistic models to evaluate the effect of the pictorial shocking warnings for waterpipe smoking. Results? Independents variables Agree with the fact that the shocking images used on tumbac packs have greater effect Agree to change your favorite tumbac brand if a new look with shocking images on smoking health damage was adopted by the tumbac company Ora CI 95% p-value ORa CI 95% p-value 45 versus <45* years Female versus male* High versus Low* motivation to quit High versus Low* nicotine dependence

20 Table4: Multivariate logistic models to evaluate the motivation to quit waterpipe smoking. Results? Independents variables Mondor scale Ora CI 95% p-value Female versus male* versus <45* years High versus Low* nicotine dependence Chronic cough (yes/no*) Cough and exp more than 3 weeks (yes/no*) Chronic wheezing (Yes/no*)

21 Summary Our study is consistent with other research on cigarettes indicating that pictorial graphic warnings are more influencing on the behavior of waterpipe smokers than textual warning. Females and more motivated smokers are more hypothetically influenced by shocking pictures. Operational features. It provides further reasons to policymakers in Lebanon to incorporate more tobacco labeling policies in order to help: 1. in reducing the widespread of cigarette and waterpipe tobacco smoking 2. in increasing the awareness concerning the health symptoms effect of smoking. The implementation of tobacco labeling policies concerning pictorial warnings should be explored on other parts of waterpipe devices in future design.

22 At operational level. All health professionals should inform waterpipe users about the potential health risks; They are in an excellent position to provide information and effective advice, particularly on cessation, for waterpipe users.

23 Have you written your will???

24 THANK YOU!!!!