Location of Graphic Images Has a Powerful Impact on the Effectiveness of Pictorial Warnings: Cross-Country Findings from the ITC Surveys

Transcription

1 Location of Graphic Images Has a Powerful Impact on the Effectiveness of Pictorial Warnings: Cross-Country Findings from the ITC Surveys Geoffrey T. Fong (gfong@uwaterloo.ca) University of Waterloo and Ontario Institute for Cancer Research European Conference on Tobacco or Health Istanbul, Turkey March 26, 2014

2 The FCTC is an evidence-based treaty that reaffirms the right of all people to the highest standard of health. Foreword to the FCTC

3 The International Tobacco Control Policy Evaluation Project (the ITC Project) Canada United States Australia United Kingdom Ireland Thailand Malaysia South Korea China Uruguay Mexico New Zealand France Germany Netherlands Bangladesh Brazil Mauritius Bhutan India Zambia Kenya 3

4 Key Objectives of the ITC Project Focus on science: International research platform (first-ever international cohort study of tobacco use) to measure policy impact, identify mechanisms of action; causes of cross-country differences; interactions with individual factors (SES, gender). Focus on dissemination: best practices in research and evaluation to promote evidence-based policies and other interventions for reducing tobacco use in the world. To provide policymakers and other health stakeholders with evidence on effectiveness of current tobacco control policies. ALSO built-in flexibility for policy >research. To evaluate the impact of new tobacco control policies when they are introduced. To build capacity (especially within LMICs) for research on tobacco control.

5 Content of the ITC Surveys Surveillance content Mixed Surveillance and policy content Unique ITC Content: 150+ Qs focusing on policy impact Throughout the policy sections there are measures relevant to monitoring Surveillance content

6 Article 11 Packaging and labelling of tobacco products 6

7 ITC Labels Report WNTD 2009 The ITC Project released a report on pictorial warnings for World No Tobacco Day (May 31, 2009): 12 page report on ITC Project 7 findings in the domain of warning labels (in English and Chinese) 7

8 Forthcoming WHO-ITC China Labels Report 8 8

9 Measures of Effectiveness for Health Warnings

10 South Korea: (30% text only and NO changes) Noticing at Wave 1 = 41.9% Noticing at Wave 3 = 36.1% DECREASE of 5.8% Forgoing cig at Wave 1 = 15.9% Forgoing cig at Wave 3 = 8.4% DECREASE of 7.5% About 20 million smokers in Republic of Korea: 1.16 million FEWER smokers noticed the warnings 1.50 million FEWER smokers reported forgoing a cigarette because of the warnings

11 New Zealand: February 2008 (30% front, 90% back) Noticing pre= 49.3% Noticing post= 67.3% Increase of 18.0% Forgoing cig pre = 10.9% Forgoing cig post = 15.8% Increase of 4.9% 650,000 smokers in New Zealand After the introduction of pictorial warnings: 117,000 more smokers noticed the warnings 30,550 more smokers reported forgoing a cigarette because of the warnings

12 Australia: March 2006 (30% front, 90% back) March 2006 Pictorial warnings on 30% of front and 90% on back Noticing pre = 43% Noticing post = 72% Increase of 29% Forgoing cig pre = 10% Forgoing cig post = 21% Increase of 11% 3 million smokers in Australia: After the introduction of pictorial warnings: 870,000 more smokers noticed the warnings 330,000 more smokers reported forgoing a cigarette because of the warnings But note the wearout after Wave 5

13 Malaysia: June 2009 (40% front, 60% back) June 2009 From text on side to pictorial warnings: 40% of front, 60% on back Noticing pre = 51.4% Noticing post = 67.2% Increase of 15.8% Forgoing cig pre = 21.2% Forgoing cig post = 54.6% Increase of 33.4% 3.6 million smokers in Malaysia After the introduction of pictorial warnings: 569,000 more smokers noticed the warnings 1,202,400 more smokers reported forgoing a cigarette because of the warnings

14 Thailand: 3 rounds of pictorial warnings March 2005: 50% of front, 50% of back

15 Thailand: 3 rounds of pictorial warnings March 2007: 50% of front, 50% of back March 2010: 55% of front, 55% of back

16 Thailand: 3 rounds of pictorial warnings Noticing at Wave 1 = 63.0% Noticing at Wave 5 = 84.6% Increase of 21.6% Forgoing cig at Wave 1 = 45.7% Forgoing cig at Wave 5 = 62.8% Increase of 17.1% About 13 million smokers in Thailand After 3 rounds of pictorial warnings: 2.81 million more smokers noticed the warnings 2.22 million more smokers reported forgoing a cigarette because of the warnings And little sign of wear-out over the 5 waves

17 China s warning labels changed in Oct 2008 OLD warning: Side of pack Only one message NEW warnings: Front/back of pack Two messages

18 China s warning labels changed in Oct 2008 Warnings appear in English on the back of every pack

19 ITC Evaluation of the Oct 2008 Text-Only Revision Noticing pre = 41.8% Noticing post = 44.6% Increase of 2.8% Forgoing cig pre = 16.8% Forgoing cig post = 22.1% Increase of 5.3% About 300 million smokers in China: 8.4 million more smokers noticed the warnings 15.9 million more smokers reported forgoing a cigarette because of the warnings Because of the enormous sample size, all of the small increases seen here are statistically significant except for avoiding 19

20 ...However, suppose China had implemented pictorial warnings... 20

21 If China implemented Malaysia s graphic warnings... Noticing warnings Warnings made them think about quitting Avoided warnings Warnings made them forgo a cigarette 8.4 million more smokers 47.1 million more Net gain = 39 million 15.9 million more smokers 98.1 million more Net gain = 82 million 21

22 United Kingdom: Oct 2008 (30% front text, 40% back pictorial) only change is pictorial on the back Oct 2008 From Text on back of 40% to pictorial of 40%: no change on front Noticing pre = 57.3% Noticing post = 58.3% Increase of 1.0% Forgoing cig pre = 8.9% Forgoing cig post = 9.0% Increase of 0.1% About 10 million smokers in the UK After the introduction of pictorial warnings: 100,000 more smokers noticed the warnings 10,000 more smokers reported forgoing a cigarette because of the warnings

23 France: Apr 2011 (30% front text, 40% back pictorial) only change is pictorial on the back Noticing pre = 57.1% Noticing post = 49.2% DECREASE of 7.9% Forgoing cig pre = 24.6% Forgoing cig post = 19.4% DECREASE of 5.2% About 16.3 million smokers in France After the introduction of pictorial warnings: 1,290,000 FEWER smokers noticed the warnings 848,000 FEWER smokers reported forgoing a cigarette because of the warnings

24 Why didn t the pictorial warnings lead to changes in effectiveness in the UK & France? 24

25 How often is the back of the pack displayed? Observational study of 2,153 packs in cafés, restaurants, and bars with outdoor seating. 81.4% were laid on tables front side up What s on the front is much more important than what s on the back.

26 Brazil s New Warnings Brazil s warnings are explicitly designed to increase negative emotional arousal. But they ONLY appear on the back of the pack: 0% Front, 100% Back

27 Measures of Effectiveness for Health Warnings Brazil = 15 th out of 21 Brazil = 5 th out of 21 Brazil = 6 th out of 21 Brazil = 8 th out of 21 The ranking of Brazil s warnings compared to 20 other ITC countries across different measures is consistent with the idea that the warnings are POTENTIALLY powerful, but they are not very noticeable because they only appear on the back.

28 Importance of Location In France and the UK (and the rest of the EU): graphic images appear only on the back, NOT on the front Converging evidence from the ITC Project highlights the importance of images on the front compared to the back Mechanisms: Increasing the salience of the pictorial images Possible weakening the branding/marketing of the brand on the front.

29 General Points Important to understand that there s (much) more to effective warnings than graphic images Content matters Location matters Research is needed to determine what matters and what doesn t matter (so much, or not at all).

30 International Tobacco Packaging Study David Hammond, James Thrasher, and colleaues

31 7 Countries Mode Timeline Mexico Face- to- face May- Aug 2010 United States Web Dec 2010 China Face- to- face May- Nov 2011 Germany Web Nov 2011 India Face- to- face March- May 2012 Bangladesh Face- to- face March- May 2012 South Korea Web Nov 2012

32 Health warning sets 5 or 6 warnings tested for each health effect Text Symbolic Lived Experience Graphic External Graphic Internal Testimonial

33 Summary and Conclusions Article 11 offers an extraordinary opportunity for governments to communicate directly with the public to educate and inform them about the harms of the product that is contained in the package. The smoker who smokes a pack a day is potentially exposed up to 20 x 365 = 7,300 times a year to the warnings. Need to make the most of this opportunity. Just like any message system or any advertising campaign, there are many dimensions of health warnings that must be carefully planned and tested. In this presentation, ITC findings demonstrate the importance of location of the warnings. Other ITC data demonstrate the importance of other dimensions of warning design.

34 Support for the ITC Project US National Cancer Institute Research Grants Canadian Institutes of Health Research Research Grant Ontario Institute for Cancer Research Senior Investigator Award Canadian Cancer Society Research Institute Prevention Scientist Award Geoffrey T. Fong:

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