Stronger pack warnings predict quitting more than weaker ones: finding from the ITC Malaysia and Thailand surveys
More details
Hide details
Clearing House for Tobacco Control, the National Poison Center, Universiti Sains Malaysia, Minden, Malaysia
Department of Pharmacy Practice, College of Pharmacy, Qassim University, Buraidah, Saudi Arabia
VicHealth Centre for Tobacco Control, Cancer Council Victoria, Carlton, Australia
Institute for Population and Social Research, Mahidol University, Salaya, Thailand
Department of Psychology, University of Waterloo, Waterloo, Canada
Department of Health studies & Gerontology, University of Waterloo, Waterloo, Canada
Ahmed I Fathelrahman   

Clearing House for Tobacco Control, the National Poison Center, Universiti Sains Malaysia, Minden, Pulau Pinang 11800, Malaysia
Submission date: 2013-06-24
Acceptance date: 2013-09-15
Publication date: 2013-09-18
Tobacco Induced Diseases 2013;11(September):20
We examined the impact of cigarette pack warning labels on interest in quitting and subsequent quit attempts among adult smokers in Malaysia and Thailand.

Two overlapping cohorts of adults who reported smoking factory- made cigarettes from Malaysia and Thailand were interviewed face-to-face (3189 were surveyed at baseline and 1781 re-contacted at Wave 2; 2361 current smokers were surveyed at Wave 2 and 1586 re-contacted at Wave 3). In Thailand at baseline, large text only warnings were assessed, while at Wave 2 new large graphic warnings were assessed. In Malaysia, during both waves small text only warnings were in effect. Reactions were used to predict interest in quitting, and to predict making quit attempts over the following inter-wave interval.

Multivariate predictors of “interest in quitting” were comparable across countries, but predictors of quit attempts varied. In both countries, cognitive reactions to warnings (adjusted ORs; 1.57 & 1.69 for Malaysia at wave 1 and wave 2 respectively and 1.29 & 1.19 for Thailand at wave 1 and wave 2 respectively), forgoing a cigarette (except Wave 2 in Malaysia) (adjusted ORs; 1.77 for Malaysia at wave 1 and 1.54 & 2.32 for Thailand at wave 1 and wave 2 respectively), and baseline knowledge (except wave 2 in both countries) (adjusted ORs; 1.71 & 1.51 for Malaysia and Thailand respectively) were positively associated with interest in quitting at that wave. In Thailand only, “cognitive reactions to warnings” (adjusted ORs; 1.12 & 1.23 at wave 1 and wave 2 respectively), “forgoing a cigarette” (adjusted OR = 1.55 at wave 2 only) and “an interest in quitting” (adjusted ORs; 1.61 & 2.85 at wave 1 and wave 2 respectively) were positively associated with quit attempts over the following inter-wave interval. Salience was negatively associated with subsequent quit attempts in both Malaysia and Thailand, but at Wave 2 only (adjusted ORs; 0.89 & 0.88 for Malaysia and Thailand respectively).

Warnings appear to have common mechanisms for influencing quitting regardless of warning strength. The larger and more informative Thai warnings were associated with higher levels of reactions predictive of quitting and stronger associations with subsequent quitting, demonstrating their greater potency.

Gajalakshmi CK, Jha P, Ranson K, Nguyen S: Global patterns of smoking and smoking-attributable mortality. Tobacco control in developing countries. Edited by: Jha P, Chaloupka F. 2000, New York: Oxford University Press for the World Bank and WHO, 12-39.
Kenkel D, Chen L: Consumer information and tobacco use. Tobacco control in developing countries. Edited by: Jha P, Chaloupka F. 2000, New York: Oxford University Press for the World Bank and WHO, 177-214.
Mackay J, Eriksen M, Shafey O: The tobacco atlas. 2006, Atlanta, Georgia, USA: American Cancer Society, 2.
WHO: WHO framework convention on tobacco control. 2005, Geneva, Switzerland: World Health Organization.
WHO: WHO report on the global tobacco epidemic, 2008: the MPOWER package. 2008, Geneva: World Health Organization.
Borland R, Hill D: Initial impact of the new Australian tobacco health warnings on knowledge. Tob Control. 1997, 6: 317-325. 10.1136/tc.6.4.317.
Thrasher JF, Hammond D, Fong GT, Arillo-Santillan E: Smokers’ reactions to cigarette package warnings with graphic imagery and with only text: a comparison between Mexico and Canada. Salud Publica Mex. 2007, 49 (Suppl 2): S233-240.
Hammond D, Fong GT, McNeill A, Borland R, Cummings KM, McNeill , suppl II: Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey. Tob Control. 2006, 15 (suppl III): iii19-iii25.
Borland R, Yong H, Wilson N, et al: How reactions to cigarette packet health warnings influence quitting: findings from the ITC Four-Country survey. Addiction. 2009, 104 (4): 669-675. 10.1111/j.1360-0443.2009.02508.x.
Borland R, Wilson N, Fong GT, et al: Impact of graphic and text warnings on cigarette packs: findings from four countries over five years. Tob Control. 2009, 18 (5): 358-364. 10.1136/tc.2008.028043.
Hammond D, Fong GT, McDonald PW, Brown KS, Cameron R: Graphic Canadian cigarette warning labels and adverse outcomes: evidence from Canadian smokers. Am J Public Health. 2004, 94 (8): 1442-1445. 10.2105/AJPH.94.8.1442.
Yong HH, Fong GT, Driezen P, Borland R, Quah ACK, Sirirassamee B, Hamman S, Omar M: Adult smokers’ reactions to pictorial health warnings labels on cigarette packs in Thailand and moderating effects of type of cigarette smoked: findings from the International Tobacco Control Southeast Asia (ITC-SEA) Survey. Nicotine Tob Res. advance access January 4, 2013.
Fathelrahman AI, Maizurah O, Rahmat A, et al: Smokers’ responses toward cigarette pack warning labels in predicting quit intention, stage of change, and self-efficacy. Nicotine Tob Res. 2009, 11 (3): 248-253. 10.1093/ntr/ntn029.
International Tobacco Control (ITC) Policy Evaluation Project: Wave1 ITC SEA technical report. 2005, (accessed 28 September 2012).
International Tobacco Control (ITC) Policy Evaluation Project: Wave2 ITC SEA technical report. 2010, (accessed 28 September 2012).
Thompson ME, Fong GT, Hammond D, Boudreau C, Driezen P, Hyland A, et al: Methods of the International Tobacco Control (ITC) four country survey. Tob Control. 2006, 15 (Suppl. 3): iii12-iii18.
International Tobacco Control (ITC) Policy Evaluation Project: ITC Malaysia national report. 2012, (accessed 28 September 2012).
Kennedy R, Lee WB, Omar M, et al: Understanding the influence of the Malaysia-wide media campaign “TAK NAK” on intentions to quit and perceived risk of smoking: findings from the International Tobacco Control Policy Evaluation Project. Proceedings of the society for research on nicotine and tobacco. 2007, Austin, Texas, USA: 13th Annual Meeting, 115.
Borland R, Balmford J: Understanding how mass media campaigns impact on smokers. Tob Control. 2003, 12 (Supp II): ii45-ii52. doi:10.1136/tc.12.suppl_2.ii45.
Wakefield MA, Spittal MJ, Yong HH, Durkin SJ, Borland R: Effects of mass media campaign exposure intensity and durability on quit attempts in a population-based cohort study. Health Educ Res. 2011, 26 (6): 988-97. 10.1093/her/cyr054. doi:10.1093/her/cyr054.
Wegner DM: Ironic processes of mental control. Psychol Rev. 1994, 101 (1): 34-52.
Does Reactance against Cigarette Warning Labels Matter? Warning Label Responses and Downstream Smoking Cessation amongst Adult Smokers in Australia, Canada, Mexico and the United States
Yoo Cho, James Thrasher, Kamala Swayampakala, Hua-Hie Yong, Robert McKeever, David Hammond, Dien Anshari, K. Cummings, Ron Borland, Olga Gorlova
Waterpipe tobacco smoking: what is the evidence that it supports nicotine/tobacco dependence?
Eiman Aboaziza, Thomas Eissenberg
Tobacco Control
Knowledge of the health risks of smoking and impact of cigarette warning labels among tobacco users in six European countries: Findings from the EUREST-PLUS ITC Europe Surveys
Antigona Trofor, Sophia Papadakis, Lucia Lotrean, Cornel Radu-Loghin, Marius Eremia, Florin Mihaltan, Pete Driezen, Christina Kyriakos, Ute Mons, Tibor Demjén, Sarah Nogueira, Esteve Fernández, Yannis Tountas, Krzysztof Przewoźniak, Ann McNeill, Geoffrey Fong, Constantine Vardavas, on consortium*
Tobacco Induced Diseases
Prioritizing the causes and correctors of smoking towards the solution of tobacco free future using enhanced analytic hierarchy process
Tisya Halim, Hasimah Sapiri, Norhaslinda Abidin
Why smokers avoid cigarette pack risk messages: Two randomized clinical trials in the United States
Marissa Hall, Jennifer Mendel, Seth Noar, Noel Brewer
Social Science & Medicine
Path analysis of warning label effects on negative emotions and quit attempts: A longitudinal study of smokers in Australia, Canada, Mexico, and the US
Yoo Cho, James Thrasher, Hua-Hie Yong, André Szklo, Richard O'Connor, Maansi Bansal-Travers, David Hammond, Geoffrey Fong, James Hardin, Ron Borland
Social Science & Medicine
Reactions to FDA-Proposed Graphic Warning Labels Affixed to U.S. Smokers’ Cigarette Packs
Amy McQueen, Matthew Kreuter, Sonia Boyum, Vetta Thompson, Charlene Caburnay, Erika Waters, Kimberly Kaphingst, Suchitra Rath, Qiang Fu
Nicotine & Tobacco Research
Smokers’ reactions to the new larger health warning labels on plain cigarette packs in Australia: findings from the ITC Australia project
Hua-Hie Yong, Ron Borland, David Hammond, James Thrasher, K Cummings, Geoffrey Fong
Tobacco Control
Impact of Canadian tobacco packaging policy on quitline reach and reach equity
N. Baskerville, Lynda Hayward, K. Brown, David Hammond, Ryan Kennedy, H. Campbell
Preventive Medicine
Longer term impact of cigarette package warnings in Australia compared with the United Kingdom and Canada
L. Li, R. Borland, H. Yong, K. Cummings, J. Thrasher, S. Hitchman, G. Fong, D. Hammond, M. Bansal-Travers
Health Education Research
Smoking-related thoughts and microbehaviours, and their predictive power for quitting
Lin Li, Ron Borland, Geoffrey Fong, Yuan Jiang, Yan Yang, Lili Wang, Timea Partos, James Thrasher
Tobacco Control
Speaking out about physical harms from tobacco use: response to graphic warning labels among American Indian/Alaska Native communities
Silver Patterson, Molly Tovar, Kellie Thompson, Jamie Ishcomer, Matthew Kreuter, Charlene Caburnay, Sonia Boyum
BMJ Open
The impact of the 2009/2010 enhancement of cigarette health warning labels in Uruguay: longitudinal findings from the International Tobacco Control (ITC) Uruguay Survey
Shannon Gravely, Geoffrey Fong, Pete Driezen, Mary McNally, James Thrasher, Mary Thompson, Marcelo Boado, Eduardo Bianco, Ron Borland, David Hammond
Tobacco Control
How should sugar-sweetened beverage health warnings be designed? A randomized experiment
Anna Grummon, Marissa Hall, Lindsey Taillie, Noel Brewer
Preventive Medicine
Effects of Strengthening Cigarette Pack Warnings on Attention and Message Processing: A Systematic Review
Seth Noar, Diane Francis, Christy Bridges, Jennah Sontag, Noel Brewer, Kurt Ribisl
Journalism & Mass Communication Quarterly
Health Warnings, Smoking Rules, and Smoking Status: A Cross-National Comparison of Turkey and the United States
Jenna Wintemberg, Mansoo Yu, Ozge Caman
Substance Use & Misuse
Are the Same Health Warnings Effective Across Different Countries? An Experimental Study in Seven Countries
David Hammond, Jessica Reid, Pete Driezen, James Thrasher, Prakash Gupta, Nigar Nargis, Qiang Li, Jiang Yuan, Christian Boudreau, Geoffrey Fong, K Cummings, Ron Borland
Nicotine & Tobacco Research
The impact of strengthening cigarette pack warnings: Systematic review of longitudinal observational studies
Seth Noar, Diane Francis, Christy Bridges, Jennah Sontag, Kurt Ribisl, Noel Brewer
Social Science & Medicine
Do more graphic and aversive cigarette health warning labels affect Brazilian smokers' likelihood of quitting?
André Szklo, Eliane Volchan, James Thrasher, Cristina Perez, Moysés Szklo, Almeida de
Addictive Behaviors
Changes in Vietnamese Male Smokers' Reactions Towards New Pictorial Cigarette Pack Warnings Over Time
Thu Tran, Vu Le, Thi Nguyen, Ngoc Nguyen
Asian Pacific Journal of Cancer Prevention
Impact of Point-of-Sale Tobacco Display Bans in Thailand: Findings from the International Tobacco Control (ITC) Southeast Asia Survey
Lin Li, Ron Borland, Hua-Hie Yong, Buppha Sirirassamee, Stephen Hamann, Maizurah Omar, Anne Quah
International Journal of Environmental Research and Public Health
Impact of Graphic Pack Warnings on Adult Smokers’ Quitting Activities: Findings from the ITC Southeast Asia Survey (2005–2014)
Lin Li, Ahmed Fathelrahman, Ron Borland, Maizurah Omar, Geoffrey Fong, Anne Quah, Buppha Sirirassamee, Hua-Hie Yong
Journal of Smoking Cessation
Evaluating the influence of message framing and graphic imagery on perceptions of food product health warnings
Daniel Rosenblatt, Helen Dixon, Melanie Wakefield, Stefan Bode
Food Quality and Preference
Impact of the WHO FCTC over the first decade: a global evidence review prepared for the Impact Assessment Expert Group
Janet Chung-Hall, Lorraine Craig, Shannon Gravely, Natalie Sansone, Geoffrey Fong
Tobacco Control
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
Mourik van, Gera Nagelhout, Marc Willemsen, den van, Vries de
BMC Public Health
Tobacco use patterns and predictors among college students in Mangalore, South India: Findings from the Global Adult Tobacco Survey
Praveen Jodalli, Ganesh Panchmal
Tobacco Prevention & Cessation