Differences in smokers' awareness of the health risks of smoking before and after introducing pictorial tobacco health warnings: findings from the 2012-2017 international tobacco control (ITC) Netherlands surveys.

BACKGROUND: As of May 2016, pictorial health warnings (PHWs) showing the harms of smoking were implemented in the European Union. After one year they had to be fully implemented. We studied changes in awareness of the health risks of smoking after implementation of PHWs among smokers from the Netherlands, whether the trend before the implementation changed after the implementation, and whether there were differences between subgroups. METHODS: We used survey data from six yearly waves of the International Tobacco Control (ITC) Netherlands Survey from 2012 to 2017. The number of participating smokers ranged between 1236 and 1604 per wave. Data were analyzed using Generalized Estimating Equations (GEE) analyses. RESULTS: Indicators of awareness of the health risks of smoking that did not change between 2015 and 2017 were perceived susceptibility (ß = 0.043, p = 0.059) and perceived severity (ß = - 0.006, p = 0.679) regarding lung problems. Perceived susceptibility, however, was more pronounced between 2015 and 2017 than between 2012 and 2015(p value of interaction: p = 0.044). Noticing information about the dangers of smoking (ß = 0.119, p < 0.001) and knowledge about the health risks of smoking (ß = 0.184, p < 0.001) increased between 2015 and 2017. These increases were both more pronounced when compared to 2012-2015 (p values of interactions: p = 0.002 and p < 0.001 respectively). Compared to high educated smokers, low educated smokers (ß = - 1.137, p < 0.001) and moderate educated smokers (ß = - 0.894, p < 0.001) were less knowledgeable about the health risks of smoking in 2016 and 2017. CONCLUSIONS: Introducing PHWs coincided with an increase in smokers' knowledge about the health risks of smoking. Dutch tobacco control policy and campaigns should focus on improving Dutch smokers' awareness of the health risks of smoking even more, especially among low educated smokers.

Systematic Review of Factors Influencing Smoking Following Release From Smoke-Free Prisons.

INTRODUCTION: Given the current proliferation of prison smoke-free policies internationally, and the multiple benefits of continued smoking abstinence for correctional populations, improved understanding of factors influencing postrelease smoking abstinence is required to inform support strategies aimed at individuals exiting smoke-free prisons. METHODS: We systematically searched health, social science, and criminal justice databases for studies relating to smoking behaviors among people released from smoke-free prisons. Studies were included if: they were published between January 1, 2000 and July 26, 2017; they were published in English; the population was people who were incarcerated or formerly incarcerated in prisons with total smoke-free policies; and the reported outcomes included measures of: (1) prerelease intention to smoke or remain abstinent from smoking following release, (2) smoking relapse or abstinence following release, or (3) quit attempts following postrelease smoking relapse. Both authors independently screened returned citations to assess eligibility and reviewed studies for methodological quality using the Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies. RESULTS: Fifteen of 121 publications were included. The evidence base in this area is small, almost exclusively US-based, and is mostly methodologically weak. Interventions delivered both pre and postrelease, that strengthen intention to quit, integrate with other substance-use treatment, and facilitate social support for quitting may help maintain postrelease smoking abstinence. CONCLUSIONS: There is an urgent need for high-quality research to inform interventions to reduce high smoking relapse rates upon release from smoke-free prisons, to extend the multiple benefits of continued smoking abstinence into the community. IMPLICATIONS: Interventions designed to help people remain abstinent from tobacco following release from smoke-free prisons are an important opportunity to improve the health, finances, and well-being of this vulnerable population.

Stillbirth Among Women Prescribed Nicotine Replacement Therapy in Pregnancy: Analysis of a Large UK Pregnancy Cohort.

INTRODUCTION: We aimed to compare risk of stillbirth between maternal smokers and those prescribed nicotine replacement therapy (NRT) during pregnancy. AIMS AND METHODS: We conducted a cross-sectional analysis on a pregnancy cohort of 220,630 singleton pregnancies ending in live or stillbirth between 2001 and 2012 from The Health Improvement Network UK general practice database. Women were categorized into three groups: NRT (prescribed during pregnancy or 1 month before conception); smokers; and controls (nonsmokers without a pregnancy NRT prescription). We calculated Odds ratios (OR) and corresponding 95% confidence intervals (CI) for stillbirth in the NRT group and smokers compared to controls. RESULTS: A total of 805 pregnancies ended in stillbirth (3.6/1000 births). Absolute risks of stillbirth in NRT and smoker groups were both 5/1000 births compared with 3.5/1000 births in the control group. Compared with the control group, the adjusted odds of stillbirth in the NRT group was not statistically significant (OR = 1.35, 95% CI 0.91 to 2.00), although it was similar in magnitude to that in the smokers group (OR = 1.41, 95% CI 1.13 to 1.77). CONCLUSIONS: We found no evidence of a statistically significant association between being prescribed NRT during pregnancy and odds of stillbirth compared with nonsmoking women. Although our study had much larger numbers than any previously, an even larger study with biochemically validated smoking outcome data and close monitoring of NRT use throughout pregnancy is required to exclude effects on findings of potential exposure misclassification.

Lesbian, Gay, Bisexual, and Transgender (LGBT) View it Differently Than Non-LGBT: Exposure to Tobacco-related Couponing, E-cigarette Advertisements, and Anti-tobacco Messages on Social and Traditional Media.

BACKGROUND: LGBT populations use tobacco at disparately higher rates nationwide, compared to national averages. The tobacco industry has a history targeting LGBT with marketing efforts, likely contributing to this disparity. This study explores whether exposure to tobacco content on traditional and social media is associated with tobacco use among LGBT and non-LGBT. METHODS: This study reports results from LGBT (N = 1092) and non-LGBT (N = 16430) respondents to a 2013 nationally representative cross-sectional online survey of US adults (N = 17522). Frequency and weighted prevalence were estimated and adjusted logistic regression analyses were conducted. RESULTS: LGBT reported significantly higher rates of past 30-day tobacco media exposure compared to non-LGBT, this effect was strongest among LGBT who were smokers (p < .05). LGBT more frequently reported exposure to, searching for, or sharing messages related to tobacco couponing, e-cigarettes, and anti-tobacco on new or social media (eg, Twitter, Facebook, etc.) than did non-LGBT (p < .05). Non-LGBT reported more exposure from traditional media sources such as television, most notably anti-tobacco messages (p = .0088). LGBT had higher odds of past 30-day use of cigarettes, e-cigarettes, and cigars compared to non-LGBT, adjusting for past 30-day media exposure and covariates (p ≤ .0001). CONCLUSIONS: LGBT (particularly LGBT smokers) are more likely to be exposed to and interact with tobacco-related messages on new and social media than their non-LGBT counterparts. Higher levels of tobacco media exposure were significantly associated with higher likelihood of tobacco use. This suggests tobacco control must work toward reaching LGBT across a variety of media platforms, particularly new and social media outlets. IMPLICATIONS: This study provides important information about LGBT communities tobacco-related disparities in increased exposure to pro-tobacco messages via social media, where the tobacco industry has moved since the MSA. Further, LGBT when assessed as a single population appear to identify having decreased exposure to anti-tobacco messages via traditional media, where we know a large portion of tobacco control and prevention messages are placed. The study points to the need for targeted and tailored approaches by tobacco control to market to LGBT using on-line resources and tools in order to help reduce LGBT tobacco-related health disparities. Although there have been localized campaigns, only just recently have such LGBT-tailored national campaigns been developed by the CDC, FDA, and Legacy, assessment of the content, effectiveness, and reach of both local and national campaigns will be important next steps.

Prevalence and Determinants of Susceptibility to Tobacco Smoking Among Students in The Gambia.

INTRODUCTION: Smoking is the biggest preventable cause of death and kills about seven million people annually. As smoking prevalence is falling in developed countries, tobacco businesses are turning to low- and middle-income countries (LMICs) to generate new tobacco markets. To prevent young people from initiating smoking and becoming regular smokers, it is important to understand the causes of susceptibility to smoking. In this study, we report a nationwide survey of the prevalence and risk factors of smoking susceptibility among students aged 12-20 years in The Gambia. METHODS: We used two-stage cluster random sampling to select students in secondary schools throughout The Gambia and questionnaire to collect data on demographic characteristics and indicators on susceptibility to initiating smoking. RESULTS: Among the total sample of 10289 students, 9831 (96%; 55.6% girls and 44.4% boys, aged 12-20 years) nonsmokers were included in the analysis. Of these, 3333 (33.9%) were found to be susceptible to smoking. Smoking susceptibility was more common among students attending grant-aided schools, non-Muslims, who had smoking allowed at home, had family members or friends who smoke, were sent to purchase cigarettes, had poor knowledge of the harmful effects of smoking, noticed point-of-sale tobacco advertisements, and who had positive attitudes towards smoking. CONCLUSIONS: This study shows that susceptibility to smoking is common among students and associated with preventable exposures. Although based on cross-sectional data, these findings suggest that raising students' awareness of the harmful effects of smoking and reducing the prevalence of adult smoking, extending tobacco advertising restrictions to include point-of-sale, are all important to preventing the uptake of smoking among students. IMPLICATIONS: This is the first study to provide detailed data on smoking susceptibility and risk factors in a nationally representative sample of young people in The Gambia. Our findings show that susceptibility to smoking is relatively high and associated with preventable measures. Our results also identify an urgent need to broaden the ban on tobacco advertising to explicitly include point-of-sale advertisements. These findings provide valuable information for tobacco control policies and evidence to enable targeted intervention for young people most at risk of initiating smoking.

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.

Electronic cigarettes in physician practice: a complex debate.

E-cigarettes, or electronic nicotine delivery systems (ENDS), have been suggested as a potential aid for smoking cessation, but many questions about their efficacy and safety remain unanswered. Until very recently, the evidence for ENDS in smoking cessation was largely based on observational studies or randomised controlled trials with methodological flaws and did not provide adequate evidence to support strongly ENDS for smoking cessation. Concerns about the uptake of ENDS by nonsmoking populations (such as adolescents) remain. More recent evidence may indicate the effect of ENDS in smoking cessation, but many questions remain unanswered. In this article, we address recent claims that failure to recommend ENDS for smoking cessation represents unethical practice. We strongly dispute this claim, analysing the many complex issues that clinicians working in smoking cessation should consider.

One size fits all? Disentangling the effects of tobacco taxes, laws, and control spending on adult subgroups in the United States.

Background: To determine the relative impact of each of the 3 state-level tobacco control policies (cigarette taxation, tobacco control spending, and smoke-free air [SFA] laws) on adult smoking rate overall and separately for adult subgroups in the United States. Methods: A difference-in-differences analysis was conducted with generalized propensity scores. State-level policies were merged with the individual-level Behavioral Risk Factor Surveillance System in 1995-2009. Results: State cigarette taxation was the only policy that significantly impacted smoking among the general adult population, with a 1-standard deviation increase in taxes (i.e., $0.68 in constant 2014 dollars) lowering the adult smoking rate by about a quarter of a percentage point. The taxation impact was consistent, regardless of the presence of, or interactions with, other policies. Taxation was also the only policy that significantly reduced smoking for some adult subgroups, including females, non-Hispanic whites, adults aged 51 or older, and adults with more than a high school education. However, other adult subgroups responded to the other 2 types of policies, either by mediating the taxation effect or by reducing smoking independently. Specifically, tobacco control spending reduced smoking among young adults (ages 18-25 years) and Hispanics. SFA laws affected smoking among men, young adults, non-Hispanic blacks, and Hispanics. Conclusions: State cigarette taxation is the single most important policy for reducing smoking among the general adult population. However, adult subgroups' reactions to taxes are diverse and mediated by tobacco control spending and SFA laws.

Tobacco control in Mexico: a decade of progress and challenges.

Mexico was the first country in the Americas to sign and ratify the World Health Organization's (WHO) Framework Convention on Tobacco Control (FCTC) in 2004. More than a decade later, it is appropriate to evaluate legislative and regulatory progress and the associated challenges; and also, to propose a roadmap to prioritize the problems to be addressed to achieve long-term sustainable solutions. Mexico has made substantial progress in tobacco control. However, regulations have been only weakly enforced. The tobacco industry continues to interfere with full implementation of the WHO-FCTC. As a result, tobacco consumption remains stable at about 17.6%, with a trend upwards among vulnerable groups: adolescents, women and low-income groups. The growing popularity of new tobacco products (electronic cigarettes or e-cigs) among young Mexicans is an increasing challenge. Our review reveals the need to implement all provisions of the WHO-FCTC in its full extent, and that laws and regulations will not be effective in decreasing the tobacco epidemic unless they are strictly enforced.

México fue el primer país de América en firmar y ratificar el Convenio Marco de la OMS para el Control del Tabaco (CMCT-OMS) en 2004. Un poco más de una década después, es relevante evaluar aspectos legislativos, regulatorios, avances y desafíos, además de proponer una ruta crítica con soluciones sustentables a largo plazo. México ha avanzado en el control del tabaco; sin embargo, las medidas se han implementado parcialmente y la industria del tabaco continúa interfiriendo con la implementación completa del CMCTOMS. Como resultado, el consumo de tabaco se mantiene estable alrededor de 17.6%, con una tendencia ascendente entre los más vulnerables: adolescentes, mujeres y grupos de bajos ingresos. La creciente popularidad de uso de los e-cig entre los jóvenes mexicanos trae nuevos y complejos desafíos. Es perentorio implementar al más alto nivel todas las disposiciones del CMCT-OMS: las leyes y los reglamentos no serán eficaces para abatir la epidemia de tabaquismo si no se aplican adecuadamente.

[Current and emerging issues in tobacco prevention and control]. / Estado actual y desafíos emergentes en la prevención y el control del tabaco.

OBJECTIVE: To review the implementation of the WHO Framework Convention onTobacco Control in theAmericas, describe two national case studies and analyze the evidence on electronic cigarettes from a public health perspective. MATERIALS AND METHODS: Revision of the tobacco control legislation and the scientific evidence regarding electronic cigarettes. RESULTS: Implementation of tobacco control policies is not homogeneous, with important advances in smoke-free environments, pictorial health warnings, and epidemiological surveillance, but challenges that remain for the implementation of a total ban of tobacco advertising, increases in tobacco taxes, and tobacco cessation programs. Tobacco industry interference is one of the main obstacles for advancing and novel products create uncertainty about their regulation. CONCLUSIONS: There is a need for political will for a comprehensive implementation of the Convention, with evidence-based decisions to confront challenges and to defend the achievements from tobacco industry interference.

OBJETIVO: Revisar la aplicación del Convenio Marco de la OMS para el Control del Tabaco en las Américas, describir dos estudios de caso nacionales y analizar la evidencia sobre los cigarrillos electrónicos desde la perspectiva de salud pública. MATERIAL Y MÉTODOS: Revisión de la legislación de control de tabaco y la evidencia científica sobre los cigarrillos electrónicos. RESULTADOS: La aplicación de políticas no es homogénea, con avances importantes en ambientes libres de humo, advertencias sanitarias gráficas y vigilancia epidemiológica, pero desafíos pendientes en la prohibición total de la publicidad, incremento de impuestos y cesación tabáquica.La interferencia de la industria tabacalera es uno de los principales obstáculos para avanzar y los nuevos productos crean incertidumbre sobre su regulación. CONCLUSIONES: Se necesita revitalizar la voluntad política para aplicar integralmente el Convenio, tomando decisiones basadas en evidencia ante los nuevos desafíos y defendiendo los logros de la interferencia de la industria.

Salience and Impact of Health Warning Label on Cigarette Packs in Vietnam: Findings From the Global Adult Tobacco Survey 2015.

Viet Nam is among the countries having highest rate of male smokers in the world. The country has joined the Global Tobacco Surveillance System since 2010. Under this system, two rounds of Global Adult Tobacco Survey (GATS) were conducted in 2010 and 2015. Those two surveys provide excellent comparable data on tobacco usage and its related aspects in Vietnam. This study using the data from GATS 2015 to examine the salience and impact of cigarette pack health warnings on quitting intention in Vietnam. The Vietnam GATS 2015 was a nationally representative survey in which 9,513 households were selected using two-stage random systematic sampling method. Results of multivariate analysis showed that the strongest predictor for quit intention because of health warnings was "ever made a quit attempt in the past 12 months" followed by "believes that tobacco smoking causes serious illness". Compared to GATS 2010, GATS 2015 observed the increase in salience of cigarette health warnings. However, the current pictorial health warnings are losing their impact on motivating intention to quit. The results highlight that it is time to start the rotation cycle to refresh the current health warning set. Actions to select a new and more impressive set of pictorial health warnings should be developed as soon as possible.

Survey on the Status of Smoking Inside Eating Establishments in the Cities of Kobe and Amagasaki.

BACKGROUND: The Hyogo Prefectural Government has been enforcing a smoking ban ordinance since April 2013. The present survey was conducted to determine the extent to which the smoking ban has been successfully implemented in eating establishments in Kobe City and Amagasaki City.Methods and Results:The Health and Welfare Department of the Hyogo Prefectural Government provided a list of eating establishments in Kobe and Amagasaki City. From these, we chose 1,300 from each city using random number generation. Responses were obtained from 310 establishments in Kobe City (response rate: 23.8%) and 297 in Amagasaki City (22.8%). Overall, 58.1% of the establishments surveyed in Kobe City were aware of the ordinance, a recognition rate significantly higher than that of Amagasaki City, where only 45.5% of eateries were aware of the ordinance (P=0.003). Of the Kobe City eateries, 31.7% had succeeded in implementing a complete ban on smoking. In Amagasaki City, the rate was significantly lower, at just 13.4% (P<0.001). A logistic regression analysis showed that coffee shops, Japanese-style taverns, bars, and eating establishments that served alcohol were the independent significant predictors of low compliance. Kobe City restaurants, women, and families were the independent significant predictors of high compliance with the complete smoking ban. CONCLUSIONS: The rates of recognition and implementation of the complete smoking ban were significantly lower in Amagasaki City than in Kobe City. There needs to be a strong and continuous socialization campaign to promote the ordinance.

Predictors of Postpartum Return to Smoking: A Systematic Review.

Background: Finding effective ways to help pregnant women quit smoking and remain abstinent is a major public health issue. Approximately half of UK women who smoke attempt cessation after conception; unfortunately, up to 75% return to smoking within 12 months postpartum. Interventions for preventing postpartum return to smoking (PPRS) have not been found to be effective. It is important to identify factors associated with PPRS, to inform development of alternative interventions. Aim: Identify by systematic review factors associated with PPRS. Methods: Systematic searches of electronic databases (MEDLINE, EMBASE, PsychINFO, CINAHL), trials registers, and conference proceedings were conducted to November 2016. Studies statistically examining factors associated with PPRS were included. Modified versions of the Newcastle Ottawa Quality Assessment Scale were used to assess studies' quality and a narrative synthesis focused on those judged of high quality. Results: Thirty-nine studies (12 trials, 27 observational studies) were included. Thirty-one (79.5%) studies were high-quality. Among these, the most common significant predictors of PPRS were being less well educated, younger, multiparous, living with a partner or household member who smoked, experiencing higher stress, depression or anxiety, not breastfeeding, intending to quit only for pregnancy and low confidence to remain abstinent postpartum. Conclusions: Of the factors found to be associated with PPRS, intending to quit smoking only for the duration of pregnancy, partner/household member smoking and confidence to remain abstinent are those most likely to have a direct, causal impact on smoking behavior after childbirth, and need to be considered when designing interventions to prevent PPRS. Implications: This is the first systematic review of factors that may facilitate or inhibit PPRS. Considering how having a partner or household member who smokes, intending to quit smoking only for pregnancy, having self-efficacy to quit long term, breastfeeding and depression exert direct or indirect impacts on women's relapse to smoking and how such impacts could successfully be manipulated will inform development of new interventions to prevent PPRS.

E-cigarette Use Among US Adults: Population Assessment of Tobacco and Health (PATH) Study.

Introduction: In 2011 the US Food and Drug Administration launched the Population Assessment of Tobacco and Health (PATH) Study to gather information for regulatory activities authorized by the Family Smoking Prevention and Tobacco Control Act (TCA). Methods: Data were drawn from the first wave of the PATH survey, involving interviews of 32 320 civilian and non-institutionalized adults. In addition to conventional classifications for current, former and never smoking and e-cigarette use, we used PATH questions to classify former and current triers of these products. Descriptive statistics were used to describe the prevalence, patterns of, and reasons for e-cigarette use, and the perceptions of nicotine and e-cigarettes among user groups, according to smoking status. Results: The prevalence of current smoking was 18%; an additional 3.1% of participants were current triers. The prevalence of current e-cigarette use was 2.4% (1.0% every day, 1.4% some days), with another 3.2% as current triers. The majority of nonsmokers who were current e-cigarette users were already current (56%) or former (34%) cigarette triers. Reasons for e-cigarette use were similar across subgroups, but patterns of use were different. Majorities of participants believed that nicotine is the main substance driving tobacco use, that nicotine causes most cancers, and that e-cigarettes were less harmful than cigarettes. Conclusions: E-cigarettes were used primarily by current smokers and recent former smokers. The main reasons for use center around perceptions that e-cigarettes are less harmful than cigarettes to users and others. Implications: This study reports detailed information about the prevalence, patterns of, and reasons for e-cigarette use in the first (baseline) wave of the PATH Study in 2014. In addition to conventional categories for current, former and never smoking and e-cigarette use, the PATH questionnaire facilitated classification of new usage groups consisting of current and former triers of these products, which may impact prevalence estimates.

Trajectories of Responses to Pictorial Cigarette Pack Warnings.

Background: Pictorial warnings on cigarette packs are a cost-effective policy-level intervention for smoking cessation; however, little research has examined changes in the impact of warnings over time, especially shortly following the first exposure to pictorial warnings. We sought to characterize the trajectories of responses to pictorial cigarette pack warnings soon after first exposure. Methods: Participants were 2149 adult smokers in North Carolina and California, United States. In 2014-2015, we randomized smokers to have pictorial (intervention) or text-only (control) warnings on their cigarette packs for 4 weeks. Weekly surveys assessed psychosocial and behavioral outcomes. Results: After 1 week, smokers in the intervention arm reported higher levels of most outcomes, compared with the control arm. Over subsequent weeks, smokers in both trial arms had decreases in thinking about the harms of smoking (ß = -0.046), positive (ß = -0.036), and negative (ß = -0.042) smoking reinforcement attitudes, and increases in quit intentions (ß = 0.070) and cigarette forgoing (ß = 0.137) (all p < .05). Only negative affective reactions decreased more in the intervention versus control condition (pinteraction < .01). Conclusions: The impact of pictorial cigarette pack warnings on emotions and cognitions may wane over time. In contrast, quit intentions and cigarette forgoing may continue to increase, at least during the initial period after introduction. Rotation of pictorial warnings may help prevent warning wear-out. Implications: Cigarette smoking is the leading cause of preventable morbidity and mortality and warnings on cigarette packs are a cost-effective policy-level intervention. Prior studies reporting on cigarette pack warning "wear out" have been limited by being short-term single-session experimental studies. Ours are the first study to experimentally examine the trajectories of several outcomes after first exposure and report that the impact of pictorial cigarette pack warnings on emotions and cognitions may wane over time while quit intentions and cigarette forgoing may continue to increase. Trials Registration: ClinicalTrials.gov identifier: NCT02247908; https://clinicaltrials.gov/ct2/show/NCT02247908.

Frequency and Content of Conversations About Pictorial Warnings on Cigarette Packs.

Introduction: Social interactions are a key mechanism through which health communication efforts, including pictorial cigarette pack warnings, may exert their effects. We sought to better understand social interactions elicited by pictorial cigarette pack warnings. Methods: A controlled trial randomly assigned US adult smokers (n = 2149) to have their cigarette packs labeled with pictorial or text-only warnings for 4 weeks. Smokers completed surveys during the baseline visit and each of the subsequent 4 weekly visits. Results: Smokers with pictorial warnings on their packs had more conversations throughout the trial compared to those with text-only warnings (8.2 conversations vs 5.0, p<.01). The highest number of conversations occurred during the first week. Smokers with pictorial warnings were more likely than those with text-only warnings to discuss the health effects of smoking, whether the warnings would make them want to quit and whether the warnings would make others want to quit (all p < .05). Smokers were more likely to describe pictorial warnings as scary, gross, or depressing and gloomy during conversations than text-only warnings (all p < .05). Conclusions: Pictorial warnings sparked more conversations about the warnings, the health effects of smoking, and quitting smoking than text-only warnings. These social interactions may extend the reach of pictorial warnings beyond the targeted smoker and may be one of the processes by which pictorial warnings have impact. Implications: Health communication can influence behavior by changing social interactions. Our trial characterized social interactions about pictorial cigarette pack warnings with a large longitudinal sample in a real-world setting. Understanding these conversations can inform the United States and other countries as they improve existing warnings and help tobacco control policy makers and health communication theorists understand how social interactions triggered by warnings affect smoking.