Are the Same Health Warnings Effective Across Different Countries? An Experimental Study in Seven Countries.

INTRODUCTION: More than 100 countries have implemented pictorial health warnings on cigarette packages. However, few studies have compared how consumers from different geographic and cultural contexts respond to health warning content. The current study compares perceptions of warnings among adult smokers and youth in seven countries, to examine the efficacy of different health warning themes and images. METHODS: Between 2010 and 2012, online and face-to-face surveys were conducted with ~500 adult smokers and ~500 youth (age 16-18) smokers and nonsmokers in each of Mexico, United States, China, Germany, India, Bangladesh, and Republic of Korea (total N = 8182). Respondents were randomized to view and rate sets of 5-7 health warnings (each set for a different health effect); each set included a text-only warning and various types (ie, themes) of pictorial warnings, including graphic health effects, "lived experience," symbolic images, and personal testimonials. Mixed-effects models were utilized to examine perceived effectiveness of warning themes, and between-country differences in responses. RESULTS: Overall, pictorial warnings were rated as more effective than text-only warnings (p < .001). Among pictorial themes, "graphic" health effects were rated as more effective than warnings depicting "lived experience" (p < .001) or "symbolic" images (p < .001). Pictorial warnings with personal testimonials were rated as more effective than the same images with didactic text (p < .001). While the magnitude of differences between warning themes varied across countries, the pattern of findings was generally consistent. CONCLUSIONS: The findings support the efficacy of graphic pictorial warnings across diverse geographic and cultural contexts, and support sharing health warning images across jurisdictions. IMPLICATIONS: Although over 100 countries have implemented pictorial health warnings on cigarette packages, there is little research on the most effective types of message content across geographic and cultural contexts. The current study examined perceived effectiveness of text and pictorial health warnings featuring different message content-graphic health effects, "lived experience," personal testimonials, and symbolic imagery-among more than 8000 adults and youth in Mexico, United States, China, Germany, India, Bangladesh, and Korea. Across countries, "graphic" pictorial messages were rated as most effective. Consistencies across countries in rating message content suggests there may be "globally effective" themes and styles for designing effective health warnings.

Perceptions of branded and plain cigarette packaging among Mexican youth.

Plain cigarette packaging, which seeks to remove all brand imagery and standardize the shape and size of cigarette packs, represents a novel policy measure to reduce the appeal of cigarettes. Plain packaging has been studied primarily in high-income countries like Australia and the UK. It is unknown whether the effects of plain packaging may differ in low-and-middle income countries with a shorter history of tobacco regulation, such as Mexico. An experimental study was conducted in Mexico City to examine perceptions of branded and plain cigarette packaging among smoking and non-smoking Mexican adolescents (n = 359). Respondents were randomly assigned to a branded or plain pack condition and rated 12 cigarette packages for appeal, taste, harm to health and smoker-image traits. As a behavioral measure of appeal, respondents were offered (although not given) four cigarette packs (either branded or plain) and asked to select one to keep. The findings indicated that branded packs were perceived to be more appealing (ß = 3.40, p < 0.001) and to contain better tasting cigarettes (ß = 3.53, p < 0.001), but were not perceived as less harmful than plain packs. Participants rated people who smoke the branded packs as having relatively more positive smoker-image traits overall (ß = 2.10, p < 0.001), with particularly strong differences found among non-smokers for the traits 'glamorous', 'stylish', 'popular' and 'sophisticated' (p < 0.001). No statistically significant difference was found for the proportion of youth that accepted when offered branded compared with plain packs. These results suggest that plain packaging may reduce brand appeal among Mexican youth, consistent with findings in high-income countries.

If it looks like a duck and quacks like a duck : Energy "shots" should be regulated as energy drinks in Canada.

In 2012, Health Canada transitioned caffeinated energy drinks from Natural Health Product to Food and Drug classification and regulations, implementing temporary guidelines with requirements such as caffeine content limits, mandatory cautionary labelling, and restrictions on health claims. "Energy shots" often contain as much or more caffeine compared to energy drinks and have been associated with a similar number of adverse health events. However, current requirements for energy drinks do not apply to energy shots, which remain classified as "natural health products" on the basis that they are "not consumed or perceived as foods" in the same way as energy drinks. An online survey was conducted with Canadian youth and young adults aged 12-24 years (N = 2040) in October 2014 to examine perceptions of energy shots. Respondents viewed an image of a popular energy shot and were asked which term best described it, with six randomly-ordered options. The vast majority (78.8%) perceived the energy shot as an "energy drink" (vs. "supplement", "vitamin drink", "natural health product", "soft drink" or "food product"). Given consumer perceptions and the similarity in product constituents, there is little basis for regulating energy shots differently from energy drinks; these products should be subject to similar labelling and health warning requirements.