Comparing Health Warnings in China to Health Warnings in Other Countries: An experimental study in four Chinese cities

Transcription

1 Comparing Health Warnings in China to Health Warnings in Other Countries: An experimental study in four Chinese cities Geoffrey T. Fong, David Hammond, Pete Driezen, & Anne C.K. Quah University of Waterloo Jiang Yuan and Li Qiang China Center for Disease Control and Prevention February 18,

2 The Importance of Package Warnings/ling Package warnings: an excellent method for informing people about the harms of tobacco use and of smoke constituents Package warnings = a health information intervention: Smoker who smokes 20 cigarettes/day: 1. Potentially exposed 7,300 times to the warnings 2. In times and situations that are relevant to the behavior: When buying cigarettes When getting a cigarette out of the pack There are probably NO other interventions in health that are delivered so often and in such an appropriate way. 2

3 FCTC Article 11 Minimal Standard: 30% on front and back, text-only Recommended: 50% on front and back, with pictures Warnings must be rotated Strong Guidelines for Article 11 adopted at the Third Conference of the Parties (Nov 2008, Durban, South Africa) 3

4 Health Warnings in China Until October 2008, China had U.S.-style warnings: on side of the pack and barely noticeable. The ITC China Survey data confirm the very low impact of the China warnings on key indicators of warning effectiveness From ITC China Summary February

5 China s warning labels changed in Oct 2008 OLD warning: Side of pack Only one message NEW warnings: Front/back of pack Two messages 5

6 Front of Pack: Two very general messages Back of Pack: Repeats the front but in English!! 6

7 Summary Table of the New Chinese Warnings With Respect to the Article 11 Guidelines Guideline YES NO 1 Should appear on both front and back? 2 Should be at the TOP of the package 3 Should be as large as possible (at least 50%) 4 Should include full colour pictures 5 Should rotate multiple messages 6 Should include a range of warnings and messages 7 Should include info on harmful effects of tobacco smoke 8 Should provide advice about cessation 9 Should list constituents without numbers Guideline #1 is a question mark because the warning on the back of the pack is in English 7

8 Study Outline Main objective: To compare the Chinese warnings (old and new) in effectiveness to those of other countries. We created high-quality photos of warnings from other countries as they might appear if they were put on Chinese packs, consistent with the Article 11 Guidelines. We showed the old and new Chinese warnings, along with 8 other possible warnings from other countries and had people from 4 cities make judgments about each of the warnings. Used established methods from psychology and from marketing research in the study Careful controls were used to be able to make strong conclusions (e.g., the same brand was used for each created warning) 8

9 Participants The study was conducted in four cities in China: Beijing, Shanghai, Kunming, and Yinchuan. In each city, there were close to 300 participants. The total number of participants by type in each of the 4 cities was: Adult Adult Youth Smoker Non-Smoker (13-17 years) TOTAL City Male Female Male Female Male Female Beijing Kunming Shanghai Yinchuan TOTALS Within each of the adult categories, the participants were approximately evenly distributed across ages: (a) years old, (b) years old, (c) years old, (d) 50+ years old. 9

10 Stimulus Materials Stimulus Materials 10 images of Chinese HWLs were created, including the OLD Chinese HWL (U.S. style: on the side of the pack and insignificant) and the NEW Chinese HWL (30% on the front of the pack, but not very distinctive). We created 8 other Chinese HWLs (through Photoshop) so that the actual Chinese HWLs could be compared to HWLs that the Chinese Government COULD HAVE put on their packs: Canadian HWL on lung cancer text + PICTURE Canadian HWL on lung cancer text only Singapore HWL on mouth disease text + PICTURE Singapore HWL on mouth disease text only Hong Kong HWL on gangrene text + PICTURE Hong Kong HWL on gangrene text only European Union HWL on clogged arteries text + PICTURE European Union HWL on clogged arteries text only 10

11 Design At the same time that the actual Chinese health warnings were being compared to these 8 alternative warnings, the composition of the 8 alternatives allowed us to explicitly test the hypothesis that adding the picture would be beneficial. The 8 warnings followed a 2 x 4 design: Text only Text + picture Canadian Lung Cancer Singapore Mouth Disease Hong Kong Gangrene EU Clogged Arteries This design allows the possibility of explicitly testing: Whether adding picture to a text warning is beneficial Whether the content domain (lung cancer vs. mouth disease...) leads to greater perceived effectiveness Whether there is an interaction between content domain and adding a picture (e.g., did adding the photo to the lung cancer warning increase its perceived effectiveness to a greater extent than adding the photo to the gangrene warning?) 11

12 The full layout of the design: 2 x 4 + China Canadian Lung Cancer Singapore Mouth Disease Hong Kong Gangrene EU Clogged Arteries and China Text Only Text + Picture Numbers = randomized order of the warnings 12

13 Rating Task: motivating smokers to quit Rate each of the 10 labels on how effective each label would be in motivating smokers to quit #1 Extremely Effective Very Effective Somewhat Effective A little bit Effective Not at all Effective #2 #3 #4 #5 #6 #7 #8 #9 #10 13

14 Rating Task: convincing youth not to start Rate each of the 10 labels on how effective each label would be in convincing youth not to start smoking. #1 Extremely Effective Very Effective Somewhat Effective A little bit Effective Not at all Effective #2 #3 #4 #5 #6 #7 #8 #9 #10 14

15 Results 15

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18 Ranking Task All participants also RANKED the 10 labels on effectiveness on 4 dimensions: Motivating smokers to quit Convincing youth not to start smoking Informing the public about the harms of smoking Chinese Government is serious about reducing smoking 18

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22 Comparing rankings and ratings: nearly identical findings 22

23 Correlations Between Ratings and Rankings Average within-person correlation = +.73 Aggregate correlation (bar charts) >

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26 Ranking data show the enormous difference in effectiveness between China and warnings from other countries Over 80% ranked the China warning as least effective or 2nd least effective 60% ranked the Singapore picture warning as most effective or 2nd most effective Clear differences: China label is worst Singapore text is much better Singapore picture is best of all 26

27 Summary of Findings from the Ratings & Rankings The two actual Chinese warnings were the lowest rated and ranked of all 10 warnings The mean ratings and rankings of the new Chinese warning (30% on front and back) are barely higher than the old Chinese warning (side of pack) The new Chinese warnings are rated/ranked much lower than each of the other text warnings from other countries. The new Chinese warnings are rated/ranked much much lower than the warnings with pictures Picture warnings are superior to text warnings: All of the picture warnings were rated/ranked higher than their corresponding text warnings (and every one of the picture warnings had a better rating/ranking than every other text warnings) 27

28 Do these findings differ by...? Participant type: Adult Smokers, Adult Non-Smokers, Youth City: Beijing, Shanghai, Kunming, Yinchuan Participant gender 28

29 Participant Type: Smokers, Non-Smokers, Youth 29

30 Gender: Males and Females 30

31 City: Beijing, Shanghai, Kunming, Yinchuan 31

32 Summary of Findings on Pictures vs. Text Only Picture warnings are superior to text warnings All of the picture warnings were rated higher than their corresponding text warnings (and every one of the picture warnings had a higher rating than every one of the text warnings) Pictures vary in their strength (and so does text) The Singapore mouth disease text warning was the lowest rated of the four non-china text warnings. But when the picture was added, it jumped to 2nd of the four non-china picture warnings. One explanation is that the mouth photo was particularly dramatic and thus led to a greater enhancement in the ratings. But it is also possible that the text was particularly poor. So we can t strictly tell where the effect is. This could easily be assessed by adding conditions in which the pictures were varied with same text and text was varied with same pictures. 32

33 Using English on the Warnings on the Back Each respondent was asked BEFORE the warning rating and ranking tasks to translate two phrases in English (so they were not prompted about the presence of these phrases on cigarette packs): 1. Smoking is harmful to your health. The main warning appears on ALL packs. 2. Quit smoking early is good for your health. This is the second line of the warning appears on half of the packs; rotated with a VERY similar phrase: Quitting smoking is good for your health What % of participants could understand the English text of the Chinese warnings? 33

34 % of Participants who correctly translated the two English-language warnings by type of participant Translation phrase Smoking is harmful to your health. Quit smoking early is good for your health. Adult Smoker Adult Non-Smoker Youth Total 26.8% 51.5% 90.4% 56.3% 10.1% 24.7% 47.7% 27.5% 73% and 90% of adult smokers do not understand the English warnings! 34

35 % of Participants who correctly translated the two English-language warnings by city Translation phrase Smoking is harmful to your health. Quit smoking early is good for your health. Beijing Kunming Shanghai Yinchuan Total 58.8% 57.1% 50.3% 59.1% 56.3% 37.9% 27.4% 18.0% 27.7% 27.5% 35

36 % of Participants who correctly translated the two English-language warnings by gender Translation phrase Smoking is harmful to your health. Quit smoking early is good for your health. Males Females Total 59.1% 53.4% 56.3% 30.0% 25.1% 27.5% 36

37 Conclusions Very strong evidence that the new Chinese warnings are much lower in effectiveness than the warnings from other countries, especially the picture warnings. Enormous gap between Chinese warnings and the recommended picture warnings. The results are the same for adult smokers and non-smokers and for youth, in all four cities, for males and females, whether rankings or ratings are used. Results are remarkably consistent. The majority of participants could not understand the English warnings on the back of the pack. Absolutely clear that the new Chinese warnings are ineffective and that they should be revised to conform with the Article 11 guidelines. There are MANY examples of strong warnings from other countries that could easily be used in China. Strong and effective warnings are absolutely essential for China to educate the people on the harms of smoking: to motivate smokers to quit and to convince youth not to start. 37

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