Does the effect go up in smoke? A randomized controlled trial of pictorial warnings on cigarette packaging

Objective

Placing a combination of a written warning and a graphic image on cigarette packaging (so called “pictorial warnings”) is one of the WHO Framework Convention on Tobacco Control's most controversial recommendations. Our randomized controlled trial investigated if pictorial warnings lead to significantly higher motivation to quit, as compared to written warnings alone.

Methods

Four pictorial warnings were selected from the EU Commission's official image catalogue. Study arm 1 (44 adult smokers) viewed only the written warnings while study arm 2 (44 adult smokers) viewed the corresponding pictorial warnings. Self-affirmation was a second randomly manipulated factor, and nicotine dependence a quasi-experimental third factor. The main outcome measured was the motivation to quit, with fear intensity as one of the secondary outcomes.

Results

Pictorial warnings were associated with a significantly higher motivation to quit. A pictorial warning was also associated with higher fear intensity. The effect of warnings appears to be independent of nicotine dependence and self-affirmation.

Conclusions

Nationwide implementation of pictorial warnings may be effective in increasing heavy smokers’ motivation to quit.

Practice implication

Due to the fact that perceived vulnerability, response and self-efficacy are not more strongly affected by pictorial warnings this effect may turn out to be short-term.     

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.     

Public support for pictorial warnings on cigarette packs: an experimental study of US smokers

Background

Understanding factors that influence public support for “nudging” policies, like pictorial cigarette pack warnings, may offer insight about how to increase such support. We sought to examine factors that influence smokers’ support for requiring pictorial warnings on cigarette packs.

Methods

In 2014 and 2015, we randomly assigned 2149 adult US smokers to receive either pictorial warnings or text-only warnings on their cigarette packs for 4 weeks. The outcome examined in the current study was support for a policy requiring pictorial warnings on cigarette packs in the US.

Results

Support for pictorial warnings was high at baseline (mean: 3.2 out of 4). Exposure to pictorial warnings increased policy support at week 4 (β = .05, p = .03). This effect was explained by increases in perceived message effectiveness (p < .001) and reported conversations about policy support (p < .001). Message reactance (i.e., an oppositional reaction to the warning) partially diminished the impact of pictorial warnings on policy support (p < .001).

Conclusions

Exposing people to a new policy through implementation could increase public support for that policy by increasing perceived effectiveness and by prompting conversations about the policy. Reactance may partially weaken the effect of policy exposure on public support.

     

A brief measure of reactance to health warnings

Reactance to persuasive messages involves perceived threat to freedom, anger, and counterarguing that may undermine the impact of health warnings. To understand reactance’s effects, reliable and valid assessment is critical. We sought to develop and validate a brief Reactance to Health Warnings Scale (RHWS). Two independent samples of US adults completed the brief RHWS in studies that presented warnings on cigarette packs that smokers carried with them for 4 weeks (Study 1; n = 2149) or as digital images of cigarette packs that participants viewed briefly (Study 2; n = 1413). The three-item Brief RHWS had good internal consistency and test–retest reliability. The scale correlated with higher trait reactance and exposure to pictorial warnings, supporting its convergent validity. With respect to predictive validity, the Brief RHWS predicted perceived message effectiveness, quit intentions, avoidance of the warnings, and number of cigarettes smoked per day. The Brief RHWS can serve as an efficient adjunct to the development of persuasive messages.     

Larger and More Prominent Graphic Health Warnings on Plain-Packaged Tobacco Products and Avoidant Responses in Current Smokers: a Qualitative Study

Background

The introduction of tobacco plain packaging legislation in Australia meant that all tobacco products were to be sold in plain dark-brown packaging with 75 % front-of-pack graphic health warnings and standardised font type and size for brand name and product variant. The change in the size and prominence of the warnings has been proposed as a reason for behaviour change in smokers in terms of increased intentions to quit and quit attempts.

Purpose

The current research examined attitudes and beliefs of cigarette smokers toward the increased size and prominence of the warnings and effects on their behaviour.

Method

Participants (N?=?160) completed open-ended responses to questions on beliefs, attitudes and responses to plain packaging. Responses were subjected to inductive thematic content analysis for key themes.

Results

Four themes emerged from the analysis: emotional response to packaging, scepticism of health warnings, warnings and cessation behaviour, and avoidant coping behaviours. Participants reported increased negative emotional responses to the packaging and made specific reference to the graphic health warnings. Some participants attempted to discredit the messages. Others reported increased intentions to quit or quitting attempts. There were pervasive reports of avoidant responses including covering or hiding the warnings.

Conclusion

Consistent with theories of illness perceptions and coping, current findings indicate that the larger, prominent graphic health warnings on plain-packaged tobacco products had pervasive effects on threat perceptions and subsequent behavioural responses. While some of the reported responses were adaptive (e.g. attempts to quit), others were maladaptive (e.g. avoiding the warnings).

     

The "black box" warning and allergy drugs

In the past years, several drugs commonly used by allergy specialists have received a "black box" warning added to their package insert at the direction of the Food and Drug Administration (FDA). A "black box" warning is the highest level of 5 possible warning categories found in the package insert. The FDA has never articulated the basis for "black box" warnings. They generally appear to be based on clinical data, but occasionally can be based on serious animal toxicity. In the last several years, several drugs commonly used by allergists have received recommendations for "black box" warnings. Long-acting beta-agonists (salmeterol and formoterol) received "black box" warnings because of reports of the occurrences of severe asthma exacerbations in some patients with asthma, with some associated death. Topical calcineurin inhibitors (tacrolimus and pimecrolimus) received a recommendation for application of a "black box" warnings because of a possible increase of cancer developing in patients taking these drugs. Although the addition of a "black box" warning was recommended by the FDA Pediatric Advisory Committee for these 2 topical agents, the FDA has not yet implemented this warning. Informed consent principles require that a patient be adequately informed of the risks (among other components) of any recommended treatment. The risks, as described, of the long-acting beta-agonists and topical immunosuppressants should be presented to the patients to aid them in deciding whether they are willing to take these drugs when recommended by their physician.     

Why Is Such a Smart Person Like You Smoking? Using Self‐Affirmation to Reduce Defensiveness to Cigarette Warning Labels1

When researchers communicate the negative health risks of smoking, smokers are likely to minimize such effects. This experiment addressed a way to reduce this defensiveness: allowing smokers to affirm aspects of the self. Smokers (n= 100) and nonsmokers (n= 30) viewed eight health‐warning messages about smoking. Smokers were randomly assigned to view (a) warnings without a self‐affirmation manipulation, (b) warnings after a self‐affirmation manipulation, or (c) warnings that had a positive self‐statement attached to it. Analyses indicated that compared to nonsmokers, no‐affirmation smokers rated the warning messages as: (a) communicating less serious consequences, (b) less accurate, and (c) less likely to influence smokers. However, compared to no‐affirmation smokers, smokers who affirmed the self were no more likely to rate the messages as serious, accurate, or effective. These data suggest that affirming the self before, or using a self‐affirmation within a warning message may not encourage smokers to be more accepting of risk information.     

Reconsidering the duty to warn genetically at-risk relatives

The duty to warn genetically at-risk relatives of patients is one of the most misunderstood legal and ethical issues affecting clinical genetics. The legal doctrines are often associated with three state appellate court cases beginning in the mid-1990s. Since the HIPAA Privacy Rule went into effect in 2003, the duty to warn must be accomplished by warning the patient of the genetic nature of a diagnosed disorder or genetic risk and the necessity of warning at-risk relatives. Health-care providers are neither required nor permitted to warn at-risk relatives without the consent of their patients. Having warnings issued by the patient most closely aligns with traditional ethical principles and the interests of the parties. Physicians and other health-care providers can assist their patients by preparing jargon-free explanations of the genetic risk and offering consultation or referral services. In the future, the need for warnings is less likely to be triggered by diagnoses and more likely to be based on predictive information derived from genome sequencing and other technologies and data sources.     

Malingering on the RAVLT: Part II. Detection strategies.

In this study two potential indices of malingering derived from the Rey Auditory Verbal Learning Test (RAVLT) were evaluated as a means of detecting malingering. These were indices based on discrepancies between recognition-recall scores and differences in the serial position effect (SPE). Sixty undergraduate students were randomly assigned to one of four conditions: malingerers, malingerers-with-warning, warning-only, and control. Incentives were offered to participants in all conditions to encourage faking in a believable manner (malingering conditions), or to encourage optimal performance (nonmalingering conditions). Two predictions were made. First, it was predicted that the serial position curve for subjects in malingering conditions would show suppression of primacy effects relative to nonmalingerers. Second, it was predicted that recall would be better than recognition for subjects in malingering conditions compared to nonmalingering conditions. The utility of these indices was also explored in the context of providing subjects' with warnings regarding use of methods to detect malingering. Results indicated that both indices failed to reliably differentiate between malingerers and nonmalingerers, and warnings failed to modify participants' behaviour.     

Fatal necrotizing angiitis after sulfadimethoxine therapy presenting as anaphylactoid purpura

Summary A fatal case of diffuse systemic necrotizing angiitis is described in a 14 year old boy presenting with Schönlein-Henoch purpura and developing renal failure. It is proposed that a long-acting sulfonamide (sulfamidethoxine) caused the disease, thus serving to reinforce previously published warnings against the indiscriminate use of long-acting sulfonamides.     

Emergency Decision Making: A Theoretical Analysis of Responses to Disaster Warnings

Abstract

This article presents a theoretical model of emergency decision making that focuses on the decision maker's answers to basic questions evoked by warnings or signs of danger. Effective emergency decisions are most likely to be made, according to the theory, when a vigilant coping pattern is dominant, which requires that the following four mediating conditions are met: 1) awareness of serious risks if no protective action is taken; 2) awareness of serious risks if any of the salient protective actions is taken; 3) moderate or high degree of hope that a search for information and advice will lead to a better (i.e., less risky) solution; and 4) belief that there is sufficient time to search and deliberate before any serious threat will materialize. When one or another of these conditions is not met, a defective coping pattern, such as defensive avoidance or hypervigilance, will be dominant, which generally leads to maladaptive actions. In addition to suggesting new interventions for facilitating adaptive behavior in emergencies, the theoretical model provides a basis for integrating disparate findings from psychological research on the effects of warnings and confrontations with danger.     

Evaluating performance of early warning indices to predict physiological instabilities

Patient monitoring algorithms that analyze multiple features from physiological signals can produce an index that serves as a predictive or prognostic measure for a specific critical health event or physiological instability. Classical detection metrics such as sensitivity and positive predictive value are often used to evaluate new patient monitoring indices for such purposes, but since these metrics do not take into account the continuous nature of monitoring, the assessment of a warning system to notify a user of a critical health event remains incomplete. In this article, we present challenges of assessing the performance of new warning indices and propose a framework that provides a more complete characterization of warning index performance predicting a critical event that includes the timeliness of the warning. The framework considers 1) an assessment of the sensitivity to provide a notification within a meaningful time window, 2) the cumulative sensitivity leading up to an event, 3) characteristics on if the warning stays on until the event occurs once a warning has been activated, and 4) the distribution of warning times and the burden of additional warnings (e.g., false-alarm rate) throughout monitoring that may or may not be associated with the event of interest. Using an example from an experimental study of hemorrhage, we examine how this characterization can differentiate two warning systems in terms of timeliness of warnings and warning burden.     

The potential interaction between clopidogrel and proton pump inhibitors: a systematic review

Background  

Recently, several publications have investigated a possible drug interaction between clopidogrel and proton pump inhibitors (PPIs), and regulatory agencies have issued warnings despite discordant study results. In an attempt to clarify the situation, we performed a systematic review with a critical analysis of study methodologies to determine whether varying study quality (that is, bias) could explain the discordant results.     

Anabolic steroid available again

Bio-Technology General Corp. announced that it is marketing a synthetic anabolic steroid, oxandrolone (Oxandrin), for the treatment of AIDS-related wasting. It is similar to testosterone, but can be taken orally and does not have the same masculinizing side effects. It is not metabolized solely by the liver, so it also does not have the toxicities associated with other anabolics. Oxandrin will be distributed through Quantum Express. It is a controlled substance and will carry warnings about liver and coronary disease.     

THE FUTURE OF THE TRANSFERENCE-BASED THERAPIES

Much demonology has grown up round the acronym IAPT. This paper considers the current state of its effect on the discipline in which we practise. The paper sets out the current landscape and begins to address the implications for those who are practising models of psychotherapy other than the cognitive–behavioural model. The outlook may not be a disaster but we need to heed the warnings and gather our thoughts so that we can ensure not only the continued existence of our model but its continued availability for those who need us.     

Cardiac state diagnosis using adaptive neuro-fuzzy technique

Analysis of heart rate has become a popular noninvasive tool for assessing the activities of the autonomic nervous system (ANS). These signals may either contain indicators of a current disease or even warnings about impending diseases. However, to manually study and pinpoint heart abnormalities in voluminous data is strenuous and time consuming. Here, an adaptive neuro-fuzzy network is used to classify heart abnormalities in 10 different cardiac states and shown to be effective. The results indicate a high level of efficacy of tools used with an accuracy level of more than 94%.     

Histology of the subauricular and rump glands of the pronghorn (Antilocapra americana ord)

Subauricular and rump glands of pronghorns (Antilocapra americana) collected during every month of the year, were examined histologically. In early spring the apocrine and sebaceous zones of the paired subauricular glands, which are found only in males, proliferate abruptly. These zones continue to enlarge and become highly secretory during the summer; they regress during the fall and are quiescent in December. During the peak of activity large sebaceous storage vesicles are present and copious amounts of secretory material occupy the apocrine lumina. Irregular clumps of cells that are associated with the apocrine tubules are numerous in summer and appear to be associated with apocrine secretory activity. The subauricular glands of castrated bucks are small and inactive compared to normal glands. Annual proliferation and regression of the subauricular glands follows similar activities of the testes. Thus, the cycle of activity in these glands is apparently controlled by gonadal hormones. Odors from the subauricular glands may serve for sex recognition, stimulation, and marking of territories. The paired rump glands consist of lobulated sebaceous units and coiled apocrine tubules that maintain limited secretory activity throughout the year. Contraction of large arrector pili muscles associated with hairs in the glands may cause accelerated secretion. The rump glands of normal males, females, and castrated males, are similar in all respects. Apparently these glands are not sexually influenced. The rump glands may serve for olfactory warnings in conjunction with the visual warnings of the white rump patch.     

Transfusion chez les patients âgés

The frequency of anemia is responsible of a frequent use of transfusion in elderly patients. However, transfusion in elderly patients requires several warnings. First, semiology of elderly patients is characterized with atypical clinical signs, and anemia tolerance is often difficult to appreciate. Second, numerous comorbidities make of elderly patients an heterogeneous population, in which guidelines are poorly applicable. Last, elderly patients are particularly sensitive to iatrogenic events, and the haemodynamic overload related to transfusion has to be carefully managed. All these difficulties raise the need of prospective studies on transfusion in elderly patients to validate clinical practice.