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The use of graphic health warnings (GHWs) on tobacco packaging is one of the most widely used public health strategies worldwide, but there is little evidence of the emotional impact of its content and craving they generate. The objective of the present study was to evaluate the emotional and craving responses to GHW content. The study included 300 men and women of different ages (adolescents, young adults, and adults), both smokers and non-smokers. We evaluated the participants' emotional and craving responses to 16 GHWs with different content (i.e., cancer, cardiovascular disease, abortion, and childhood illness). We analyzed the effects of sex, smoking status, and age. GHWs exhibited the capacity to elicit aversive emotional states, with low levels of arousal and high levels of dominance and did not produce craving. GHWs that showed images of cancer and abortion had the greatest emotional impact. Non-smoking adolescent females experienced the greatest emotional impact of GHWs. The results suggest that GHWs effectively reduce the attractiveness of cigarette packages and discourage consumption, and increasing the size of GHWs may favor avoidance of the package. GHWs that depicted explicit threats had a greater emotional impact, especially in women.

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AIMS: To measure how cigarette packaging (standardised packaging and branded packaging) and health warning size affect visual attention and pack preferences among Colombian smokers and non-smokers. DESIGN: To explore visual attention, we used an eye-tracking experiment where non-smokers, weekly smokers and daily smokers were shown cigarette packs varying in warning size (30%-pictorial on top of the text, 30%-pictorial and text side-by-side, 50%, 70%) and packaging (standardised packaging, branded packaging). We used a discrete choice experiment (DCE) to examine the impact of warning size, packaging and brand name on preferences to try, taste perceptions and perceptions of harm. SETTING: Eye-tracking laboratory, Universidad Nacional de Colombia, Bogotá, Colombia. PARTICIPANTS: Participants (n = 175) were 18 to 40 years old. MEASUREMENTS: For the eye-tracking experiment, our primary outcome measure was the number of fixations toward the health warning compared with the branding. For the DCE, outcome measures were preferences to try, taste perceptions and harm perceptions. FINDINGS: We observed greater visual attention to warning labels on standardised versus branded packages (F[3,167] = 22.87, P < 0.001) and when warnings were larger (F[9,161] = 147.17, P < 0.001); as warning size increased, the difference in visual attention to warnings between standardised and branded packaging decreased (F[9,161] = 4.44, P < 0.001). Non-smokers visually attended toward the warnings more than smokers, but as warning size increased these differences decreased (F[6,334] = 2.92, P = 0.009). For the DCE, conditional trials showed that increasing the warning size from 30% to 70% reduced preferences to try (odds ratio [OR] = 0.48, 95% CI = [0.42,0.54], P < 0.001), taste perceptions (OR = 0.61, 95% CI = [0.54,0.68], P < 0.001); and increased harm perceptions (OR = 0.78, 95% CI = [0.76,0.80], P < 0.001). Compared with branded packaging, standardised packaging reduced our DCE outcome measures with ORs ranging from OR = 0.25 (95% CI = [0.17,0.38], P < 0.001) to OR = 0.79 (95% CI = [0.67,0.93], P < 0.001) across two brands. These effects were more pronounced among non-smokers, males and younger participants. Unconditional trials showed similar results. CONCLUSIONS: Standardised cigarette packaging and larger health warnings appear to decrease positive pack perceptions and have the potential to reduce the demand for cigarette products in Colombia.

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BACKGROUND: Uruguay, a South American country of 3.4 million inhabitants that has already banned tobacco advertising, prohibited such terms as light, mild and low-tar and required graphic warnings covering 80% of cigarette packs, is considering the imposition of plain, standardised packaging. METHODS: We conducted an experimental choice-based conjoint analysis of the impact of alternative cigarette package designs on the risk perceptions of 180 adult current Uruguayan smokers. We compared plain packaging, with a standardised brand description and the dark brown background colour required on Australian cigarette packages, to two controls: the current package design with distinctive brand elements and colours; and a modified package design, with distinctive brand elements and the dark brown background colour. Graphic warnings were also varied. RESULTS: Plain packaging significantly reduced the probability of perceiving the stimulus cigarettes as less harmful in comparison to the current package design (OR 0.398, 95% CI 0.333 to 0.476, p<0.001) and the modified package design (OR 0.729, 95% CI 0.626 to 0.849, p<0.001). CONCLUSIONS: Plain packaging enhanced the perceived risk of cigarette products even in a highly regulated setting such as Uruguay. Both the elimination of distinctive brand elements and the use of Australia's dark brown background colour contributed to the observed effect.

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Between 2008 and 2013, Brazil experienced a large decline in smoking prevalence, with an innovative round of aversive pictorial health warnings implemented on cigarette packs and at points of sale in 2009. The objective of this study was to examine changes over time in the distribution of quitting attempts and self-reported thoughts about quitting due to health warnings among current smokers. We conducted a pre-post study to evaluate data from two nationally-representative surveys conducted in 2008 and 2013. Responses to questions on smokers' quitting attempts in the last year (yes vs. no) and whether health warnings led them to think about quitting in the last month (yes vs. no) were combined into four categories, for which the distribution of the Brazilian smoking population by year was estimated. A multinomial model was used to obtain proportions for each category, adjusted by socio-demographic variables and nicotine dependence. The proportion of smokers who reported making a quitting attempt in the last year and stated that health warnings led them think about quitting smoking statistically increased over time (from 30.0% to 33.1%; p-value=0.010). The percentage of those who answered "no" to these two questions also increased over time (from 23.5% to 32.9%; p-value≤0.001). These findings suggest that innovative warnings introduced in Brazil likely served as a "reminder" for continuing to think about cessation among those who attempted to quit in the last year. These warnings may have also triggered more avoidance of thinking about their contents than the previous warnings, which some studies have found to promote subsequent quitting activity.

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O propósito desta dissertação de mestrado é entender a relação que se estabelece entre a adoção de uma medida reguladora pelo governo, com forte impacto na população, e a reação por ela gerada em grupos de interesse.O embasamento teórico do estudo proposto se fundamenta na teoria de políticas sociais, que estuda a ação de grupos de interesse contra a implantação de medidas reguladoras, neste caso específico, a influência da indústria fumageira e seus aliados, na implementação das advertências sanitárias em produtos de tabaco no Brasil.Esta dissertação é dividida em quatro partes, incluindo introdução, percurso teórico metodológico, resultados e discussão e conclusão e recomendações.A metodologia utilizada envolve o estudo de documentos relacionados à implementação e avaliação das advertências sanitárias nos produtos de tabaco comercializados no Brasil, assim como do arcabouço legislativo que amparou a introdução dessas advertências. Em paralelo, foi realizada uma busca dos documentos internos da indústria do tabaco, liberados em 1999 durante ações de litígio nos Estados Unidos, com o objetivo de identificar as reações do setor, no processo de introdução e adoção das advertências sanitárias no mundo e no Brasil. Este trabalho também apresenta a evolução histórica desta medida no Brasil, com o foco na reação da indústria do tabaco.Os resultados deste estudo sugerem que várias ações do governo foram permeadas pela interferência da indústria do tabaco. Em alguns casos as intervenções eram explícitas e em outros momentos eram indiretas ou obscuras.À luz do marco referencial adotado, concluiu-se que houve a interferência da indústria fumageira como um grupo de interesse, de pressão e de lobby nas políticas de advertências sanitárias adotadas. Esta dissertação trouxe informações inovadoras e originais no cenário nacional que poderão ser úteis aos gestores da saúde pública e tomadores de decisão, na promoção de políticas de controle do tabaco, com foco nas advertências sanitárias. Recomendações para a melhoria da condução estratégica da Política Nacional de Controle do Tabaco foram também desenvolvidas.

The purpose of this monograph is to understand the relationship between the adoption of a regulatory measure by the government, with strong impact over the population, and the reaction of interest groups. The theoretical framework of this study is the theory of social policies, which addresses the influence of interest groups against the adoption of regulatory measures, in this specific case, the interference of the tobacco industry and its allies in the regulatory framework of health warnings used on tobacco products in Brazil. The methodology involves the study of documents related to the implementation and evaluation of health warnings on tobacco products sold in Brazil, as well as on the legislative framework that based the introduction of these warnings in the country. In parallel, we conducted a search on tobacco industry’s internal documents, released in 1999 during a litigation process in the United States, aiming to identify the reactions of this sector in the process of introduction and implementation of health warnings globally and specifically in Brazil. This paper presents the historical evolution of this measure, with focus on tobacco industry’s reaction. The text of this monograph has four parts, comprising the introduction, theoretical and methodological aspects, results and discussion and conclusion and recommendations. The results of this study suggest that several governmental actions were targeted by tobacco industry’s interference. In some cases the influence was explicit and in other situations their presence was indirect and obscure. The study concludes that, following the theoretical referential, there is evidence that the industry has interfered on the health warnings regulatory and implementation framework in Brazil acting as an interest/pressure/lobby group. The results of this monograph shadow a new light on this area with useful and innovative information that might be relevant to decision makers and public health managers when 9 furthering tobacco control policies targeting health warnings measures. Recommendations for improvement in the strategic guidance of the Tobacco Control National Policy were made in this regard.

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A exposição a produtos derivados do tabaco é considerada a mais importante causa de morte evitável no mundo. Ações de controle do tabagismo envolvem uma gama de intervenções para ajudar pessoas a parar de fumar e prevenir que jovens não se tornem dependentes. Advertências sanitárias com imagens mostradas em embalagens de cigarro são uma das formas mais efetivas de informar acerca das consequências do tabagismo. Pesquisas em neurobiologia da emoção demonstram que estímulos visuais afetam atitudes e comportamentos; estímulos agradáveis promovem predisposições para aproximação e os aversivos, afastamento. Os apelos positivos que o marketing da indústria tabagista induz em suas embalagens devem ser neutralizados por advertências que mostrem os riscos de fumar, desconstruindo o apelo prazeroso e induzindo predisposições de afastamento em relação ao produto.

Exposure to tobacco products is considered the leading cause of avoidable death in the world. Tobacco control initiatives encompass a gamut of ways of helping people to quit smoking and keeping young people from ever becoming addicted. Pictorial health warnings on cigarette packaging constitute one of the most effective means of conveying information about the consequences of smoking. Research on the neurobiology of emotions shows that visual stimuli affect attitudes and behavior: pleasant stimuli prompt a tendency to approach while unpleasant stimuli prompt a tendency to avoid. The positive appeals placed on packaging by the tobacco industry's marketing departments should be neutralized by warnings that indicate the risks of smoking, thereby deconstructing any pleasurable appeal and prompting a tendency to avoid the product.

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