Avoidance of cigarette pack health warnings among regular cigarette smokers

ContentslistsavailableatScienceDirect

Drug

and

Alcohol

Dependence

jo u r n al h om ep age :w w w . el s e v i e r . c o m / l o c a t e / d r u g al c d e p

Avoidance

of

cigarette

pack

health

warnings

among

regular

cigarette

smokers

Olivia

M.

Maynard

_,

_Angela

_Attwood

_,

_Laura

_O’Brien

_,

_Sabrina

_Brooks

_,

Craig

Hedge

_,

_Ute

_Leonards

_,

_Marcus

_R.

_Munafò

a_{MRCIntegrativeEpidemiologyUnit,UniversityofBristol,UnitedKingdom} b_{UKCentreforTobaccoandAlcoholStudies,UnitedKingdom}

c_{SchoolofExperimentalPsychology,UniversityofBristol,UnitedKingdom}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received14October2013 Receivedinrevisedform 10December2013 Accepted2January2014 Availableonline15January2014 Keywords: Healthwarnings Plainpackaging Smoking Adultsmokers Eye-tracking

a

b

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Background:Previousresearchwithadultsandadolescentsindicatesthatplaincigarettepacksincrease visualattentiontohealthwarningsamongnon-smokersandnon-regularsmokers,butnotamongregular smokers.Thismaybebecauseregularsmokers:(1)arefamiliarwiththehealthwarnings,(2) preferen-tiallyattendtobranding,or(3)activelyavoidhealthwarnings.Wesoughttodistinguishbetweenthese explanationsusingeye-trackingtechnology.

Method:Aconveniencesampleof30adultdependentsmokersparticipatedinaneye-trackingstudy. Participantsviewedbranded,plainandblankpacksofcigaretteswithfamiliarandunfamiliarhealth warnings.Thenumberoffixationstohealthwarningsandbrandingonthedifferentpacktypeswere recorded.

Results:Analysisofvarianceindicatedthatregularsmokerswerebiasedtowardsfixatingthebranding ratherthanthehealthwarningonallthreepacktypes.Thisbiaswassmaller,butstillevident,forblank packs,wheresmokerspreferentiallyattendedtheblankregionoverthehealthwarnings.Time-course analysisshowedthatforbrandedandplainpacks,attentionwaspreferentiallydirectedtothebranding locationfortheentire10softhestimuluspresentation,whileforblankpacksthisoccurredforthelast 8softhestimuluspresentation.Familiaritywithhealthwarningshadnoeffectoneyegazelocation. Conclusion:Smokersactivelyavoidcigarettepackhealthwarnings,andthisremainsthecaseevenin theabsenceofsalientbrandinginformation.Smokersmayhavelearnedtodiverttheirattentionaway fromcigarettepackhealthwarnings.Thesefindingshaveimplicationsforcigarettepackagingandhealth warningpolicy.

©2014TheAuthors.PublishedbyElsevierIrelandLtd.

1. Introduction

Anumberof countriesare nowconsidering,orhave already implemented,plainpackagingofcigarettes.We havepreviously showninaseriesofeye-trackingexperimentsthatplainpackaging canincreasevisualattentiontohealthwarningsinadult(Munafò etal.,2011)andadolescent(Maynardetal.,2013)non-smokers and non-regular smokers. This is what would be predicted by modelsofnaturalimageviewing(Parkhurstetal.,2002);through

∗ Correspondingauthorat:SchoolofExperimentalPsychology,Universityof Bris-tol,12aPrioryRoad,BristolBS81TU,UnitedKingdom.Tel.:+441173310493; fax:+441179288588.

E-mailaddresses:[email protected],[email protected]

(O.M.Maynard).

sensory-driven bottom-up processes, attentionis automatically drawntowardsthemostsalientpartofanimage(Vincentetal., 2009).However,increasedattentiontohealthwarningsonplain packswasnot observedamongeitheradultoradolescent regu-larsmokers.Thismaybearesultofattentionbeingbiasedaway fromthevisuallysalientbottom-up(physical)featuresofthehealth warningsviatop-down,volitionalcontrol.Thereareanumberof possibleexplanationsforthesevoluntaryshiftsofattention,such as:(1)familiarityand,therefore,habituation tothehealth war-nings,(2)apreferenceforbranding,evenintheabsenceofcolours andlogos,and/or(3)activeavoidanceofthehealthwarnings.

Inourpreviousstudies,healthwarningsweretakenfromthose currentlyusedintheUK,and,therefore, werefamiliarto regu-larsmokers.Thisfamiliarityperhapsledtoreducedattentionto healthwarnings duetodiminishedimpactoverrepeated expo-sure.EvidencefromCanada(EnvironicsResearchGroup,2007)and theUK(Hammondetal.,2007)suggeststhatnewhealthwarnings aremoreeffectivethanoldwarnings,whichexperiencewear-out

0376-8716©2014TheAuthors.PublishedbyElsevierIrelandLtd.

http://dx.doi.org/10.1016/j.drugalcdep.2014.01.001

Open access under CC BY license.

overtime.Alternatively,smokers’lackofvisualattentiontohealth warningsmaybebecausetheirattentionisinsteaddrawntothe branding.Inourpreviousstudies,theplainpacksstilldisplayed thebrandnamesofthecigarettes.Smokersmaycontinuetoattend tothis area iftheyare interested in thebranding information, reducing thetimespentattending healthwarnings. Finally,the lackofvisualattentiontohealthwarningsmaybetheresultof activeavoidance.InterviewswithCanadianregularsmokersfound that36%reportedmakingsomeattemptatavoidingthewarnings (Hammondetal.,2004).Healthwarningavoidancehasalsobeen showntobegreaterforpictorialhealthwarningsthantext-only warnings(Borlandetal.,2013).

Thepresentstudyaimedtoestablishwhichofthesethree expla-nationsaccountsforwhyregularsmokersdonotattendcigarette packhealth warnings.To establishwhetherfamiliaritywasthe most accurateexplanation, smokers were presented with both familiar and unfamiliar health warnings. If familiarity wasthe cause,wepredictedrelativelygreaterattentiontotheunfamiliaras comparedwiththefamiliarhealthwarnings.Toestablishwhether regularsmokerspreferentiallyattendtobrandingoractivelyavoid health warnings, we includeda ‘blank’packin addition tothe brandedandplainpacks.Theblankpackhadallbrandingremoved, and only the health warning present. If smokers preferentially attend tobranding, theyshouldallocate more attentiontothe healthwarningsthantheblankregionontheblankpacks,asno brandingispresent.However,ifsmokersactivelyavoidhealth war-nings,theyshouldallocatemoreattentiontotheblankregionon blankpacksratherthanthehealthwarnings.

2. Methods

2.1. Designandoverview

Thisstudyusedarepeatedmeasuresdesignwitheyegazelocation(health warning,branding),packtype(branded,plain,blank)andhealthwarning famil-iarity(familiar,unfamiliar)aswithin-subjectsfactors.Eye-trackingequipmentwas usedtomeasurethenumberofsaccadesmadetohealthwarningsandbrandingon thedifferentpacktypes.TestingtookplaceattheUniversityofBristol,andethics approvalwasgrantedbytheFacultyofScienceResearchEthicsCommittee.

2.2. Participants

Thirty-twoparticipantswererecruitedfromthestaffandstudentpopulationat theUniversityofBristol,andthegeneralpopulation.Participantswererequiredto smokefiveormorecigarettesadayandsmokewithin1hofwaking.Allparticipants wererequiredtobeagedbetween18and40,tohavelivedintheUKsince2008 (whenpictorialwarningswereintroducedintheUK)andtoprimarilypurchasetheir cigarettesfromwithintheUK(morethan90%ofthetime,minimisingexposureto non-UKhealthwarnings).

2.3. Materials

Visualstimuliofbrandedandplainpacksofcigaretteswereidenticaltothose usedinourpreviouseye-trackingstudies(Maynardetal.,2013;Munafòetal.,2011). Blankpackswerecreatedbyremovingalltextfromtheplainpacks,leavingonly thehealthwarning.ExamplesofthethreepacktypesareshowninFig.1a.The11 pictorialhealthwarningscurrentlyusedintheUKcomefromalargersetof42 EuropeanUnionhealthwarnings.Theeffectivenessofthesehealthwarningswas assessedinpre-studypiloting,duringwhichparticipantsratedeachhealthwarning individuallyonfourmeasuresofeffectiveness.Theoverallscoresforeachhealth warningwasusedtoselect20warningsforuseinthepresentstudy:10fromthose currentlyusedintheUK(familiarhealthwarnings),and10fromthosenotusedinthe UK(unfamiliarhealthwarnings),matchedforeffectiveness.The20healthwarnings werepairedwitheachofthe10brandedandplainpackstimuli,tocreateatotalof 400stimuli(200branded,200plain).Eachwarningwasalsopairedwiththeblank pack.Eachparticipantwasshownall20blankpacksandapseudo-randomselection of20brandedand20plainpacks(whereeachhealthwarningwaspresentedonce andeachbrandwaspresentedtwice,pairedwithbothafamiliarandanunfamiliar healthwarning).

2.4. Procedure

Followinginformedconsent,participantsweresat57cmfrom anLCDcomputerscreenandfittedwithanEyelinkIIeyetracker(SR ResearchLtd,ON,Canada)tomeasureeyemovementsfromtheir dominanteye.Theeye-trackingprocedurewasthesameasforour previouseye-trackingstudies(Maynardetal.,2013;Munafòetal., 2011).Participantsviewedfiveblocksof12imagesandeachblock includedtwoimagesfromeachofthesixdifferentstimulitypes (branded,plainandblankpacks,eachwithfamiliarandunfamiliar healthwarnings).Stimuliwerepresentedfor 10sand were fol-lowedbyafixationcross,whichactedtocorrectfordriftdueto headmovementsandensuredafixedstartingposition.Asinour previousstudies,arecallphasefollowedeachblocktoensurethat participantsactivelyattendedtheimagesinthetestphase. Partici-pantsthencompletedtheFagerströmTestforNicotineDependence (Heathertonetal.,1991)andthequittingsmokingContemplation Ladder (Bienerand Abrams,1991).Participants werethen fully debriefedandreimbursed

£

2.5. Dataanalysis

Eye-positiondatawereanalysedinthesamewayasinour pre-viousstudies(Maynardetal.,2013;Munafòetal.,2011).A2(eye gazelocation:healthwarning,branding)×3(packtype:branded, plain,blank)×2(healthwarningfamiliarity:familiar,unfamiliar) analysis of variance (ANOVA)was usedto analyse thedata on thenumberofsaccades.Interactioneffectswereexploredby fur-therstratifiedanalysescorrectedformultiplecomparisons,using theBonferronimethod.IncaseswhereMauchly’sTestof Spheric-ityindicatedthattheassumptionofsphericityhadbeenviolated, GreenhouseGeissercorrectedvalueswereused.Effectsizeswere calculatedusingCohen’sdfort-testsandeta-squaredforANOVA. Forconsistency,weusetheterm‘branding’torefertothetop sec-tionofthecigarettepackstimuli,evenfortheblankpacks,where nobrandingispresent.

Apoweranalysisindicatedthatasamplesizeofn=28would berequiredtodetectadifferenceofthreeeyemovements(SD8.5) towardsthebrandingascomparedtothehealthwarning,with80% poweratanalphalevelof5%.Thiseffectsize(dz=0.56)was esti-matedbasedondatafromourpreviousstudies(Maynard etal., 2013; Munafòetal., 2011),and assumesa correlationbetween conditionsofr=0.8.

3. Results

3.1. Characteristicsofparticipants

Twoparticipantswereexcludedfromfurtheranalysisduetoan inabilitytotracktheireyemovements.Participantswere, there-fore,30 regularsmokers (63%male)withanaverageageof21 years(SD=3).Onaverage,participantssmoked11cigarettesaday (SD=5),smokedtheirfirstcigarettewithin45minutesofwaking (SD=15)andstartedsmokingbyage15(SD=2).Noneofthe par-ticipantswereattemptingtoquitsmokingatthetimeofthestudy, basedonscoresofsixorlessonthequittingsmoking Contempla-tionLadder.

3.2. Mainanalyses

Aswithourpreviouseye-trackingstudies(Maynardetal.,2013; Munafò et al., 2011), only the results for the number of sac-cades are reported, as the resultsfor the duration of fixations showedthesamepattern,andthetwovariablesarehighly inter-dependent. ANOVAindicated a pack type×location interaction

Fig.1.(a)Examplesofbranded,plainandblankpackstimuli,respectively.

(b)Numberofsaccadestobranding(greybars)andhealthwarnings(blackbars)onthethreepacktypes.Errorbarsrepresentadjustedstandarderrorscorrectedfor within-subjectscomparisons.

(c)Time-courseanalysisacrosstheentirestimuluspresentationof10,000mstoshowthepercentageoftrials(20trialsperpacktype)inwhichparticipantswerefixating thebranding(greylines)asopposedtohealthwarnings(blacklines)forbranded,plainandblankpacksofcigarettes.

(F(2,43)=75.37,p<0.001,p2=0.72),displayedin Fig.1b.

Impor-tantly,forallthreepacktypes,moresaccadesweremadetothe brandingthan to health warnings (branded packs: t(29)=13.12,

p<0.001, d=2.44; plain packs: t(29)=10.59, p<0.001, d=2.05;

blankpacks:(t(29)=3.40,p=0.002,d=0.69).However,more

sac-cadesweremadetobrandingonbrandedpacksthanplainpacks (t(28)=5.47,p<0.001,d=0.35),andonbrandedpacks(t(28)=12.56,

p<0.001,d=1.06)andplainpacks(t₍₂₈₎=8.97,p<0.001,d=0.76) thanblankpacks.Conversely,anequalnumberofsaccadeswere madetohealthwarningsonbrandedandplainpacks(t(28)<0.001,

p=1.00,d=0.08),butmoresaccadesweremadetohealthwarnings onblankpacksthaneitherbranded(t(28)=3.85,p<0.001,d=0.53)

orplainpacks(t(28)=4.00,p<0.001,d=0.44).Therewasnomain

effectoffamiliarityandnointeractionsincludingthisfactor,even whenthenumberofcigarettesparticipantsreportedsmokingper day(aproxy forfamiliarity)wasincludedasa covariateinthe ANOVA.

3.3. Exploratoryanalyses

Todescribethefocusofparticipants’attention,atime-course analysiswasconductedforeachofthethreepacktypes(seeFig.1c). Foreachparticipant,each10000mstrialwasdividedinto10ms time bins for branding and health warnings. A valueof 1 was assignedtoabin ifasaccade fellontherespectiveareawithin thatinterval.Anaverageperparticipantwastakenforeachpack type.Timebinswhereparticipantswerefixatingtheareaoutside ofthecigarettepack,wheretheyweremakingtheactualsaccadic eyemovement,orblinked,wereexcluded.

Broadlythesamepatternofresultswasseenforbrandedand plainpacks:throughoutstimuluspresentation,participantswere morelikelytofixatethebrandingthanthehealthwarning(see

Fig.1c).Participantsalwaysstartedtrialsbyfixatingthe brand-ing,asthisreplacedthefixationcross,althoughimmediatelyafter stimulusonset,thepercentageoffixationsonbrandingreduced. After3000ms,however,fixationsonbrandingincreasedand par-ticipantsfixatedthebrandingareaforapproximately70%oftrials. Incontrast,fortheblankpackstherewasasharperdeclinein fix-ationsonthe‘branding’(i.e.,theblankregion)atthebeginningof stimulusonset.After2000ms,however,thepatternreversed,with participantsmorelikelytofixatethebrandingandafter4000ms, thepatternwascomparabletothatforbrandedandplainpacks. 4. Discussion

Ourresultsshowthathealthwarningfamiliarityisnotthecause ofregular smokers’ lackof visualattentiontohealth warnings, asfamiliaritywasnotrelatedtovisualattentiontothewarnings. Instead,bothapreferenceforbrandingandanactiveavoidanceof warningsexplainsregularsmokers’lackofattentiontohealth war-nings.Time-courseanalysisshowedthatforblankpacksthereisa largeshiftinattentiontowardsthehealthwarningswithinthefirst fewhundredmillisecondsofstimulusonset,whileforbothbranded andplainpacks,attentionremainsprimarilyintheareaofbranding andthereisaslowerandsmallerincreaseinattentiontothehealth warninginthefirst2000ms.Weassumethatfixationsearlyinthe time-courseofviewingarestronglyinfluencedbyvisualsalience (Parkhurstetal.,2002).Thisindicatesthatbrandedandplainpacks containsufficientsalientvisualinformationaboutcigarette brand-ingtocompetewiththehealthwarninginformation.Smokers’lack ofattentiontohealthwarningsonplainpacksmustthereforebe dueinparttoapreferenceforthebrand.However,from approxi-mately2000msafterstimulusonset,smokersmadevoluntaryand sustainedshiftsinattentiontowardsthebranding,andawayfrom thehealthwarnings,onallpacktypes.Weinterprettheseresults

asindicatingthatregularsmokersactivelyavoidhealthwarnings oncigarettepacks,viatop-downvoluntarycontrolofattention.

Thereareanumberoflimitationsofthisstudy,thefirstofwhich istheblankpackdesign.Asintended,the‘blank’packlookedlikea cigarettepackwiththebrandingremoved.However,itispossible thattheattentiontothisareaofthepack,whichwehaveascribedto warningavoidance,maybetheresultofaninterestinaparticularly novelcigarettepack(i.e.,onewithoutanybranding).Whilethisis possibleandmayexplainsomeoftheattentiondirectedtothisarea ofthepack,itisunlikelythatthisexplainswhysmokersattended thisregionofthepackforapproximately8000ms,foreachofthe20 blankpacksshowntothem.Second,tofurtherinvestigatetheeffect ofbrandingonvisualattention,itwouldbeinterestingtoseehow theparticipants’owncigarettebrandinfluencesviewingpatterns. However,asinformationonparticipants’preferredbrandswasnot obtained,thisanalysiscannotbeperformed.

Previous studies have relied on self-reported measures of explicitbehaviouralavoidanceofhealthwarningsandhavefound lowtomoderatelevelsofavoidanceamongsmokers(Borlandetal., 2013;Environics ResearchGroup,2007;Hammondet al.,2004, 2007).Bymeasuringhealthwarningavoidanceatamoreimplicit level,usingeye-trackingtechnology,wehavefoundclearevidence of visualavoidance ofhealth warningsamong regularsmokers, evenafteraccountingforsmokers’interestinbranding.

Futureresearchshoulddeterminewhethervisualavoidanceof healthwarningsisassociatedwithself-reportedlevelsofavoidance andwithoutcomespreviouslylinkedwithavoidance,suchas long-termrecallofwarnings,knowledgeofthehealthrisksofsmoking andfuturesmokingcessation.Ifanegativeassociationisobserved, researchshouldfocusonunderstandingthereasonsforthis avoid-ance,andondesigningcigarettepacksandhealthwarningswhich wouldpreventthis.

Roleoffundingsource

FundingfromtheUKCentreforTobaccoandAlcoholStudies, BritishHeartFoundation,CancerResearchUK,EconomicandSocial ResearchCouncil,MedicalResearchCouncil,andtheNational Insti-tute for HealthResearch, underthe auspicesofthe UKClinical Research Collaboration,isgratefully acknowledged.Thefunders hadnofurtherroleinstudydesign;inthecollection,analysisand interpretationofdata;inthewritingofthereport;orinthedecision tosubmitthepaperforpublication.

Contributors

AuthorsO. M. Maynard, A. Attwood,U. Leonards and M. R. Munafòdesignedthestudy.AuthorsL.O’BrienandS.Brookswere responsibleforrecruitmentandtestingofparticipants.AuthorsO. M.MaynardandC.Hedgeundertookthestatisticalanalysesand authorO.M.Maynardwrotethefirstdraftofthemanuscript.All authorscontributedtoandhaveapprovedthefinalmanuscript. Conflictofinterest

Noconflictdeclared. Acknowledgements

O.M.Maynard,A.AttwoodandM.R.Munafòaremembersofthe UKCentreforTobaccoandAlcoholStudies,aUKCRCPublicHealth ResearchCentreofExcellence.

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