James F. Thrasher, Edna Arillo-Santillán, Marta Caballero, David Hammond

ITC-Mexico: An update & example of research to select

effective pictorial warning label content

Mexican health warnings labels (HWLs) 3rd largest in the world (65% of pack)

30% of the front (picture & text) 100% of the back and one side

(text only) 2 new HWLs every 3 months,

fastest rotation in the world

50% of the back (text only)

4 messages

(2004-2010) (2010-present)

1st round of Mexican Pictorial Health Warning Labels (HWLs)

4

Phase 1Objective: Most effective HWL imagery

Method: Field experiments

Phase 2Objective: Most effective HWL textual content

Method: Field experiments

Phase 3Objective: Confirm findings about HWL imagery & text

Method: Focus groups

3-stage process to select second round of HWLs

Warning Labels stopped you from having a cigarette.

0

10

20

30

40

Wave 1 Wave 2

Per

cen

tag

e

CanadaAustraliaUSUK

Second level Third level Fourth level Fifth level

5Warning Labels stopped you from having a

cigarette.

0

10

20

30

40

Wave 1 Wave 2

Per

cen

tag

e

CanadaAustraliaUSUK

International Pack Study

Parallel studies in 7 diverse countries:

Examine effective content for pictorial warnings

Examine individual differences in responses

Examine cultural, national level differences

P01 CA138389, Tobacco packaging and labeling policies: Expanding the evidence on novel policies

Mexico

US

China

India

Germany

Bangladesh

South Korea

Health Warning Topics & Stimuli

Health warning topic “sets”5 or 6 warnings tested for each topic

Text Symbolic Human suffering

Graphic External Graphic Internal Testimonial

Field experiments

Random assignment

Addiction

Stroke

Toxicity

Rate 5 to 7 warnings from

selected block in random order

Evaluate for each warning:

• Attention

• Credibility

• Relevance

• Negative emotional arousal

• Impact

Brief Survey• Sociodemographics• Smoking-related

perceptions & behavior

• Warning labels

Rank warnings

within a block:

• Which most motivates you to stop smoking?

• Which most motivates you to not start smoking?

Throat cancer

Mouth cancerDeath

Heart attack

Enphysema

Premature aging

Impotence

Lung cancerGangrene

Premature birth

SHS in children

Topics

Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.

Samples• Mexico:• Sample

– 535 16 to 18 years old, smokers and nonsmokers– 527 adult smokers

• Mode– Intercept surveys in Mexico City (July 2010)– In-person administration– Stimulus presentation by laptop

Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.

Warning Labels stopped you from having a cigarette.

0

10

20

30

40

Wave 1 Wave 2

Per

cen

tag

e

CanadaAustraliaUSUK

Second level Third level Fourth level Fifth level

10Warning Labels stopped you from having a

cigarette.

0

10

20

30

40

Wave 1 Wave 2

Per

cen

tag

e

CanadaAustraliaUSUK

Graphic & human suffering rated as more effective than symbolic warnings (p<.001)

Graphic & human

sufferingvs. Symbolic

Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.

Warning Labels stopped you from having a cigarette.

0

10

20

30

40

Wave 1 Wave 2

Per

cen

tag

e

CanadaAustraliaUSUK

Second level Third level Fourth level Fifth level

11Warning Labels stopped you from having a

cigarette.

0

10

20

30

40

Wave 1 Wave 2

Per

cen

tag

e

CanadaAustraliaUSUK

Warnings with graphic content rated more effective than with human suffering (p<.001)

Graphic vs. Human suffering

Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.

Warning Labels stopped you from having a cigarette.

0

10

20

30

40

Wave 1 Wave 2

Per

cen

tag

e

CanadaAustraliaUSUK

Second level Third level Fourth level Fifth level

12Warning Labels stopped you from having a

cigarette.

0

10

20

30

40

Wave 1 Wave 2

Per

cen

tag

e

CanadaAustraliaUSUK

Testimonial Non-Testimonial

Adding testimonial information increased effectiveness (p<.001)

Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.

Warning Labels stopped you from having a cigarette.

0

10

20

30

40

Wave 1 Wave 2

Per

cen

tag

e

CanadaAustraliaUSUK

Second level Third level Fourth level Fifth level

13Warning Labels stopped you from having a

cigarette.

0

10

20

30

40

Wave 1 Wave 2

Per

cen

tag

e

CanadaAustraliaUSUK

Warnings depicting suffering of OTHERS rated as more effective than suffering of SELF (p<.001)

Self sufferingvs.Other suffering

Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.

Impact on knowledge

Hammond D, Thrasher JF, Reid J et al. Cancer Causes & Control. 2012.Mutti S, Hammond D, Reid J, Thrasher JF. Jnl Health Communicaiton. In press.

Images with the greatest impact in study 1

Topic ImageThroat cancer

Mouth cancer

Lung cancer

Emphysema

Adiction

Topic Image

Heart disease

Stroke

Gangrene

SHS & children

Fetus & Premature birth

Phase 1Objective: Most effective HWL imagery

Method: Field experiments

Phase 2Objective: Most effective HWL textual content

Method: Field experiments

Phase 3Objective: Confirm findings about HWL imagery & text

Method: Focus groups

2nd phase: Selection of textual content for pictorial HWLs

Characteristics of Mexican pictorial HWLs

30% of front with image and text

100% of one side, reinforcing the central message

“Qualitative” focus on toxic

constituents

Call to action with 1800 number

Didactic/scientific vs. testimonial content

Breathing tobacco smoke causes the arteries of your heart to clog. The clogging damages your heart and can kill you.

You can quit smoking. Call us01800 966 3863

“My husband was a smoker, and while he was still young, he died from a heart attack. I was left stranded to take care of the family all by myself.”

Celia Juárez

You can quit smoking. Call us

01800 966 3863

“Tobacco smoke is a silent killer. Without thinking, I breathed it in, unable to feel the damage it had done…until it gave me a heart attack.”

César Guerrero

You can quit smoking. Call us01800 966 3863

Didactic /scientific Testimonial - other Testimonial - self

Contains particles that enter your blood stream, form blood clots and can block your arteries

Contains particles that enter your blood stream, form blood clots and can block your arteries

Contains particles that enter your blood stream, form blood clots and can block your arteries

Thrasher JF, Arillo-Santillán E, Villalobos V, et al. Cancer Causes & Control. 2012.

Field experiments in 8 public places

Randomization

Condition 1: 4 blocks of packs on same health outcome

Condition 2:4 blocks of packs on same health outcome

Condition 3: 4 blocks of packs on same health outcome

Condition 4: 4 blocks of packs on same health outcome

Random presentation of packs within each block

Assessment of each HWL:

• Attention

• Credibility

• Relevance

• Emotional arousal

• Impact

Brief survey• Sociodemographics• Smoking perceptions & behavior

• HWL

Ranking task of HWLs within block:

• Which motivates you most to quit?

• Which motivates you most to not start smoking?

Thrasher JF, Arillo-Santillán E, Villalobos V, et al. Cancer Causes & Control. 2012.

Sample characteristicsCharacteristics

Youth sample% (n)

Adult smoker sample% (n)

Age (average) 20.6 (range 18 – 24) 32.8 (range 25 – 80)

Sex Male

Female50% (266)50% (263)

62% (330)38% (199)

Education Secondary or less

Technical schoolHigh schoolUniversity +

28% (146)8% (44)

57% (302)7% (37)

18% (100)14% (76)42% (223)25% (130)

Smoking behaviorNonsmoker

Non-daily smokerDaily smoker, < 5 /dayDaily smoker, 5+ / day

49% (258)30% (159)12% (63)10% (53)

N/A43% (225)25% (131)33% (173)

Intend to quit in next 6 months 31% (77 / 252) 31% (165)

Overall impact of scientific vs. testimonial

7.2

6.8 6.8 6.8

6.3

6.6

6.8

6.5

6.6

6.8

6.4 6.4

6.26.2

6.3

6.5

6.36.2

5.0

5.5

6.0

6.5

7.0

7.5

Lung cancer Heart disease Prematurebirth

Stroke Addiction Throatcancer

Scientific

Testimonial 1

Testimonial 2

Thrasher JF, Arillo-Santillán E, Villalobos V, et al. Cancer Causes & Control. 2012.

Adjusted ORs* of selecting a testimonial as most influential, lowest vs. highest educational attainment

2.0

1.3

1.9

3.0

1.7

2.9

0.5

1

1.5

2

2.5

3

3.5

4

Lungcancer

Heartdisease

Prematurebirth

Stroke Addiction Throatcancer

*adjusted for age, sex, smoking status, level of consumption, perceived risk, and quit intentions

Phase 1Objective: Most effective HWL imagery

Method: Field experiments

Phase 2Objective: Most effective HWL textual content

Method: Field experiments

Phase 3Objective: Confirm findings about HWL imagery & text

Method: Focus groups

3rd phase: confirm best combination of imagery and textual content

Population characteristics

Mexico City Guadalajara Monterrey

SmokersNon-

smokersSmokers

Non-smokers

SmokersNon-

smokers18 - 24

25 - 65

18 - 24

25 - 65

18 - 24

25 - 65

18 - 2418 - 24

25 - 65

18 - 24

25 - 65

Female (n=80) 7 17 4 0 6 14 6 5 16 5 0

Male (n=67) 4 11 9 1 6 10 5 6 8 6 1

Total (n=147) 11 28 13 1 12 24 11 11 24 11 1

Focus groups

Mixed methodsIndividual ratings

Group discussion

Callback two days later

12 groups, 4 in each city:

Versión: 3A Versión: 3B

TEMA 3: CÁNCER DE BOCA

New Health Warning Labels

Future research•Every 4 months in Mx, Canada, Australia, US•Define and measure real world outcomes

• “Understanding of risks”• Cessation behavior

•Targeted messages - Which features matter?:• Perceived credibility and relevance?• Matching of social identity characteristics?• Message complexity?

•Define & explain patterns of “wear out”

Survey Mode: Face-to-Face (F2F)Respondent Types: Smoker

29

2011/12 New pictorial warning rotations

MEXICOTimeline of Tobacco Control Policies and ITC Surveys

2004 2005 2006 2007 2008 2009 2010 2011 2012

Wave 1Sept-Nov 2006

N= 1080

Wave 2Oct-Dec 2007

N= 1080

Wave 3Nov-Dec 2008

N= 2000

Wave 4Jan-Feb 2010

N= 2100

Wave 5Apr-May 2011

N=2100

29