Health behavior science and global public health: Transnational research collaborations to address noncommunicable diseases James F. Thrasher, MA, MS, PhD February 24, 2016 INSTITUTO NACIONAL DE SALUD PÚBLICA MÉXICO
Overview Global burden of non-communicable disease Health Behavior Science Packaging as a vehicle for communication Public health and industry strategies Direct & indirect marketing Entertainment media & Internet New products Flavor capsules & E-cigarettes Extensions to nutrition and obesity
Noncommunicable disease (NCD) mortality by country income, 2008-2030 Source: World Health Organization, Projections of Mortality and Burden of Disease, 2004-2030. Available at: http://www.who.int/healthinfo/global_burden_disease/projections/en/index.html.
WHO NCD Action Plan WHO-Targeted Risk Factors Cardiovascular disease Primary NCDs Cancers Diabetes Chronic Respiratory Diseases Tobacco Unhealthy diet Physical inactivity Alcohol World Health Organization: http://www.who.int/nmh/events/ncd_action_plan/en/
WHO s Framework Convention on Tobacco Control (WHO-FCTC)
Health warning labels (HWLs) in context Pro-tobacco environment Advertising, promotions & sponsorship PR activities Price Product design Social visibility Product environment Packaging & warning label characteristics for tobacco and other product categories Cigarette package design Size, shape & brand imagery Health warning label Relative size & location Pictorial content Execution & Design Textual content Tobacco control environment Media campaigns PR activities Tobacco control Taxes Smoke-free Ad bans Cessation services
Warning wearout study R01 CA167067 PI: Thrasher Longitudinal study sample - Online consumer panels 1000 to 1400 adult smokers in each country every 4 months 2012 2013 2014 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 Long exposure Inserts Plain packaging Fastest rotation Control
Attention to HWLs* over time 2 nd HWLs Canada 2 nd HWLs Australia Thrasher et al. Warning wearout. Preliminary results *In the last month, how often: have you noticed health warnings on cigarette packages? have you read or looked closely at the warning labels? Never; Rarely; Sometimes; Often; Very often
Interpersonal communication about HWLs, last month 2 nd HWLs Canada 2 nd HWLs Australia Thrasher JF et al. Social Science & Medicine (2016) Downstream quit attempts predicted by: Talking about HWLs in last month Family talked with you @ HWLs Non-family talked with you @ HWLs Making fun of HWLs
HWL responses & smoking cessation: Not moderated by reactance or self-efficacy Reactance: Tendency to react negatively toward threats to restrict freedom of choice. Can cause adoption or strengthening of attitude that is contrary to what was intended, increasing resistance to persuasion. Higher trait reactance of lower Self-efficacy slightly weaker or same HWL responses (unassociated with cessation) Higher state reactance stronger HWL responses (greater cessation attempts) BUT no moderation Thrasher JF et al. Health Communication (In press)
Graphic HWLs rated as more effective, especially among lowliteracy smokers Graphic Suffering Symbolic Thrasher JF, et al Cancer Causes and Control. 23:69 80. 2012 Hammond D, et al. Cancer Causes and Control. 23:69 80. 2012. Thrasher JF et al. American Journal of Preventive Medicine. 43:590 600. 2012. Thrasher JF. Salud Pública de México. 52: S206-215. 2010.
Assessing warning imagery: fmri Graphic- Rest Suffering - Rest Symbolic - Rest Newman-Norland R, Thrasher JF, et al. BMJ Open. Dec 31;4(12):e006411. 2014.
Inserts: Positively framed messages & tips for quitting Thrasher JF et al. Nicotine & Tobacco Research. 17(7): 870-875. 2015.
Frequency of reading inserts in the last month & future quit attempts Freq in last mo. Downstream attempt to quit More likely to read inserts if: Younger Intend to quit Recently tried to quit Stronger negative outcome expectancies Thrasher JF et al. Nicotine & Tobacco Research. 17(7): 870-875. 2015 Frequency of reading inserts OR AOR* Not at all 1 1 Once 1.46 1.17 A few times 1.95 c 1.70 a Often / very often 2.20 b 2.26 a a: p<0.05; b: p<0.01: c: p<0.001 *Adjusted for baseline age, sex, education, income, HSI, quit intention, recent quit attempt, self-efficacy to quit, risk perceptions, time in sample
Inserts with harmful constituent information Australia Canada
> 100 years of tobacco inserts Coupons Trading cards Silks
Create synergies beteween HWLs, media campaigns & cessation resources LIBRE DE TABACO Thrasher JF et al. Linking media campaigns to pictorial warning labels on cigarette packages. Tobacco Control. 2013. Thrasher JF et al. Towards informed tobacco consumption in Mexico. Mexican Journal of Public Health. 2012. Thrasher JF et al. Promoting cessation resources through cigarette package warning labels. Tobacco Control. 24(e1):e23-31. 2015. Nagelhout et al. Was the media campaign that supported Australia's new pictorial cigarette warning labels and plain packaging policy associated with more attention to and talking about warning labels? Addictive Behavior. 49:64-7. 2015
Adult smokers responses to plain packaging in Australia Before Implementation of plain packaging associated with: More awareness of harms from smoking More attention toward and use of cessation resource information (quitline & website) on HWLs More discussion & cessation-related responses to HWLs Increased support for plain packaging (28% vs 49%) After Thrasher JF et al, Promoting cessation resources through cigarette package warning labels. Tobacco Control. 24(e1):e23-31. 2015 Swayampakala et al. Pictorial health warning label content & smokers understanding of smoking-related risks. HER 30(1):35-45. 2015. Thrasher JF et al. Interpersonal communication about pictorial health warnings on cigarette packages. Social Science & Medicine. 2016. Swift E et al. Australian smokers support for plain packaging before and after implementation.. Tobacco Control (in press)
40 30 20 10 0 Warning Labels stopped you from having a cigarette. Wave 1 Wave 2 Canada Australia US UK Auction experiment among US smokers: 17% difference in demand $4.00 Second $3.52 level $3.43 $3.50 Third level $3.00 Fourth level $2.50 Fifth level $2.00 $1.50 $1.00 $0.50 $0.00 $3.11 $2.93 Control Text Pictorial Plain Thrasher JF et al. Health Policy. 102: 41 48. 2011. Rousu M, Thrasher JF. Health Education Research. 29(2):183-94. 2014. Percentage 19
Sample: 640 females; 16 to 26 years old (mean=22); 28% smokers 1 Branded (n=214) 2 Plain (n=208) 3 Plain, no descriptors (n=218) Source: White CM, Hammond D, Thrasher JF, Fong GT. The potential impact of plain packaging of cigarette products among Brazilian young women: an experimental study. BMC Public Health. 12(1):737. 2012.
Perceived Health Risk A little or A lot less harmful than other brands 24% 18% 11% (p<0.001 for branded vs. plain, no descriptors ) Source: White CM, Hammond D, Thrasher JF, Fong GT. The potential impact of plain packaging of cigarette products among Brazilian young women: an experimental study. BMC Public Health. 12(1):737. 2012.
Preference for cigarette brand variety with flavor capsule in US, Mexico & Australia, 2012-2014 Thrasher JF et al, Tobacco Control. 2015. Weighted and adjusted predicted probabilities
Market share for flavor capsules cigarettes, 2008-2014 Latin American Countries Data source: Euromonitor, 2008-2014
Product innovations: flavor capsule cigarettes Flavor capsule packaging perceived as the most attractive Greater trial (smokers) & willingness to try (never smokers) Abad-Vivero E et al. (under review)
Front of package nutrition labeling systems IOM Guiding Stars Facts Up Front
Product presentation: Cereal Blake C, Rosemond T, Kim J, Thrasher JF. (under review)
Countries where studies indicate that exposure to tobacco imagery in films promotes youth smoking Countries Germany Holand Hong Kong Iceland India Italy Mexico Norway New Zealand Poland Scotland Thailand United Kingdom USA
Percentage of US-produced films with tobacco by US rating, 2004-2012 All films
How adult-rated US films ( R ) get rated in Argentina, Brazil, and Mexico, 2002-2009 64% 49% 27% 73% Argentina Brazil México Thrasher JF et al. Are movies with tobacco, alcohol, drugs, sex, and violence rated for youth?: A comparison of Argentina, Brazil, Mexico, and the United States. International Journal of Drug Policy. 2014.
Tobacco & tobacco brands in Mexican-, Argentine- & US-produced films, 2004-2012 Films with tobacco & tobacco brands, by country of production, 2004-2012 Films with tobacco by country of production, 2004-2012 Barrientos et al. BMC Public Health. 2015. Mejía R et al. Under review.
WHO recommended policies Prohibit brand imagery No subsidies for films with tobacco imagery Films with tobacco: Adult rating Anti-smoking ad Certification of no payment from the tobacco industry
Percent of videogames with tobacco rated for ages 13 and older, 1994-2011 Any tobacco content Starcraft Barrientos-Gutierrez T, Barrientos-Gutierrez I, Lazcano-Ponce E, Thrasher JF. Tobacco content in video games: 1994-2011. Lancet Oncology. 2012. Barrientos-Gutierrez T, Barrientos-Gutierrez I, Thrasher JF. Videogames and the next tobacco frontier: Smoking in the Starcraft Universe. Tobacco Control. 2012
Trial of e-cigarettes and conventional cigarettes amongst secondary school youth in Mexico, 2015 n=10,068 E-cig trial almost as high as for adult smokers E-cig trial independently associated with traditional cigarette risk factors. Novel risk factors, including risk for e-cig only vs cigarette only: Use of media technologies Internet advertising exposure Thrasher JF et al. Journal of Adolescent Health. 2016.
Thanks! Jim Thrasher thrasher@sc.edu INSTITUTO NACIONAL DE SALUD PÚBLICA MEXICO Funding: Collaborating Institutions: