Perceptions of Health Warnings in China: Survey and experimental evidence from the International Tobacco Control Policy Evaluation Project (the ITC Project) Geoffrey T. Fong, Ph.D. Department of Psychology University of Waterloo and Ontario Institute for Cancer Research Symposium at the World Cardiology Congress Beijing, China June 18, 2010 1
The Importance of Package Warnings/Labelling Package warnings: an excellent method for informing people about the harms of tobacco use and of smoke constituents and to motivate quitting Package warnings = a health information intervention: Smoker who smokes 20 cigarettes/day: 1. Potentially exposed 7,300 times/year to the warnings 2. Exposed at the right situations: 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
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Guidelines for Implementation of Article 11 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, but NO numbers just qualitative statements about the harms 4
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The International Tobacco Control Policy Evaluation 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 6
ITC Surveys are being conducted in: Over 50% of the world s population Over 60% of the world s smokers Over 70% of the world s tobacco users 7 7
The International Tobacco Control Policy Evaluation Project (ITC Project) Mission: to measure the impact of key policies of the Framework Convention on Tobacco Control (FCTC) health warnings, taxes, advertising/promotion bans, smoke-free laws, education, cessation. Main design feature: natural experiments compare impact of a policy in one country to other control countries in which the policy has not changed. Longitudinal cohort survey: same individuals surveyed over time. Evaluation of FCTC policies: at the individual level. Use of mediation models to trace the impact of policies: how did policies have their impact? Example: if graphic pictures on health warnings are effective, are they effective because they scare people or because they increase people s knowledge about the harms of smoking, or both? 8 8
Content of the ITC Surveys (average # of questions) Surveillance content Mixed Surveillance and policy content Unique ITC Content: 170-200 Qs focusing on policy impact Surveillance content 9 9
ITC Evaluation of FCTC Policies (Partial List) Warning labels UK (2003): Text Mauritius (2009): Graphic UK (2009): Graphic Thailand (2006): Graphic Australia (2006): Graphic Canada (2010): Graphic, Round 2 China (2008): Text Mexico (2008): Graphic Uruguay (2006,09): Graphic Brazil (2008/09): Graphic, Round 3 Malaysia (2008): Graphic India (2009): Graphic Taxation All countries Product policies UK (EU): 10-1-10 regulation US/Canada: Reduced ignition propensity All countries: product; product x behavior Illicit trade China (2008): prevalence Additional in Canada/U.S.: close to reserves Bhutan (2009+): total ban on sales in country Advertising/Promotion UK (2003): Comprehensive Canada (2003): Last part of Comp. Thailand (2006): POS bans Mexico (2008): Comprehensive Canada (2008+): Re-emergence of descriptive ads & possible new ban China (2011): Comprehensive Many other countries: Partial Smoke-free Ireland (2004) Mexico (2008+) Scotland (2005) Brazil (2008+) England (2007) Bangladesh (2009+) Uruguay (2006) Bhutan (2009+) France (2007/08) India (partial) Germany (2007/08+) China (partial in 2008+ & Olympics) Netherlands (Part 2 2008/09) Light/mild bans UK (2003) Australia (2005) Canada (2006) Brazil + others (2009+) 10 10
ITC China Project Collaboration between the ITC Project and the Chinese Office of Tobacco Control (China CDC) Cohort survey in 7 cities: Beijing, Shanghai, Changsha, Guangzhou, Yinchuan, Shenyang, Kunming Total N = 5,600 smokers + 1,400 non-smokers Wave 1: May Nov 2006 Wave 2: Nov 2007 Mar 2008 Wave 3: May Oct 2009 11
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Warning Labels in China: Findings from the ITC Project 13
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Noticing warning labels China is close to the bottom of 16 ITC countries in warning label salience 15 15
Warning labels: think about health risks Only 6.9% of Chinese smokers say that the warning labels make them think of the health risks of smoking a lot 16 16
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 gfong@uwaterloo.ca http://www.itcproject.org 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
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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 55 40 39 47 51 45 277 Kunming 50 50 46 50 50 50 296 Shanghai 51 52 47 50 50 50 300 Yinchuan 50 48 48 50 50 50 296 TOTALS 206 190 180 197 201 195 1169 Within each of the adult categories, the participants were approximately evenly distributed across ages: (a) 18-29 years old, (b) 30-39 years old, (c) 40-49 years old, (d) 50+ years old. 21
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 2 6 3 10 5 Text + Picture 9 8 1 4 7 Numbers = randomized order of the warnings 22
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The Role of Emotions in Label Effectiveness Hypothesis: graphic warning labels are more effective because they create emotions that are: Highly negative (valence is negative) Highly arousing (arousal is high) There is very sound research from neuropsychological studies in social psychology to support this hypothesis. 25
Brazil s New Warnings 26
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China Labels Study: Label Effectiveness Average within subject correlation between VALENCE and... Rated effectiveness in motivating smokers to quit: r = +.45 Rated effectiveness in convincing youth not to start: r = +.46 Average within subject correlation between AROUSAL and... Rated effectiveness in motivating smokers to quit: r = +.49 Rated effectiveness in convincing youth not to start: r = +.49 Strong support for the hypothesis that label effectiveness is linked to negative valence and high arousal 29
Summary Table of the New Chinese Warnings 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 30
China warnings will be more effective if they... Follow the Article 11 Guidelines include images that are very negative and highly arousing include concrete information about the effects of smoking: cigarettes CAUSE cancer ; cigarettes CAUSE COPD include some NEW information about what cigarettes do: NOT just lung cancer, but heart disease, stroke, COPD, impotence, etc. include information about the effects of secondhand smoke: smoking doesn t just affect the smoker, but others as well include information that helps them with quitting and/or tells them where they can get help (although China has very limited resources for cessation) 31
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These numbers are NOT useful as a guide for how harmful these cigarettes are 34
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Chinese tobacco control efforts should move toward... removal of ALL methods of implying that this brand is less harmful Other words besides light/mild Colours that are lighter Claims of technology Plain packaging this may be in the distant future for China, but it would satisfy the goals of reducing the ways in which the industry misleads people to thinking that a brand is somehow safer. 37
There is NO such thing as a safer cigarette 38