Identifying principles for effective messages about chemicals in cigarette smoke☆
Introduction
Tobacco use is responsible for nearly six million deaths each year (World Health Organization, 2013), making it the leading cause of preventable death in the world. Approximately 20% of all deaths in the US are directly attributable to tobacco use (Mokdad et al., 2004). These deaths are the consequence of the myriad negative health effects of smoking such as cardiovascular disease, cancer, respiratory disease, and reproductive complications. Smoking also exacerbates communicable diseases, including tuberculosis and respiratory tract infections (World Health Organization, 2012, U.S. Department of Health and Human Services, 2014a). The direct (i.e., healthcare expenses) and indirect (i.e., productivity losses) costs of smoking are substantial, with estimates as high as $193 billion per year in the US (US National Cancer Institute and World Health Organization, 2016).
Cigarette smoke contains more than 7000 constituents, many of which are toxic to human health and at least 69 of which are carcinogenic (Rodgman and Perfetti, 2008, Talhout et al., 2011, U.S. Food and Drug Administration, 2012a). Some constituents occur naturally in tobacco (e.g., nicotine), some are added during the manufacturing process (e.g., ammonia), and most are generated through burning the tobacco and paper (e.g., acrolein) (Hecht, 2012, International Agency for Research on Cancer, 2004, U.S. Department of Health and Human Services, 2014b). Carcinogenic constituents present in cigarettes include benzene, 1,3-butadiene, and formaldehyde, as well as tobacco-specific nitrosamines (nicotine-derived nitrosamine ketone or NNK, and N-Nitrosonornicotine or NNN) (Hecht, 2012, International Agency for Research on Cancer, 2004, Fowles and Dybing, 2003, Biener et al., 2013). Different constituents have been linked to specific negative health consequences. For example, acrolein and acetaldehyde are two of the most harmful constituents to respiratory health, and arsenic and hydrogen cyanide pose great risk to cardiovascular health (Fowles & Dybing, 2003). In addition to direct health effects, some constituents (e.g., nicotine, ammonia) may cause indirect harm to consumers by increasing cigarette addictiveness, leading to higher intensity or frequency of tobacco use as well as hindering tobacco cessation success (U.S. Food and Drug Administration, 2011).
The 2009 Family Smoking Prevention and Tobacco Control Act granted the US Food and Drug Administration (FDA) broad authority to regulate tobacco products, including educating the public about the harms of tobacco constituents (Public Law 111-31, H.R. 1256, n.d.). To that end, in 2012, FDA published draft guidance on 93 harmful and potentially harmful constituents in tobacco products and tobacco smoke (Food & Administration, 2012b) and later released an abbreviated list of 18 cigarette smoke constituents prioritized for industry reporting. Cigarette manufacturers are required to submit information on the quantities of those 18 constituents to the FDA by cigarette brand and sub-brand (U.S. Food and Drug Administration, 2012a, Public Law 111-31, H.R. 1256, n.d). The FDA is required to eventually release this information to the public in a way that is both “understandable” and “not misleading” (U.S. Food and Drug Administration, 2011). In addition to enforcing industry reporting of constituents, FDA has the authority to communicate with the public about tobacco constituents in various ways (e.g., requiring constituent disclosure labels on packs) if the information benefits public health (Public Law 111-31, H.R. 1256, n.d.).
Several studies have examined knowledge, risk perceptions, and attitudes about tobacco constituents, both qualitatively (Environics Research Group, 2003, Swayampakala et al., 2014, Moracco et al., 2016) and quantitatively (Environics Research Group, 2003, Brewer et al., 2016, Cummings et al., 2004, Hammond et al., 2006). These studies have indicated that the public has little knowledge about tobacco constituents beyond nicotine and tar, and that the public generally assumes that most harmful chemicals are added during the manufacturing process. As a consequence, many people erroneously perceive cigarettes without additives to be less harmful than those with additives (Pearson et al., 2016). Studies have found that people want more readily accessible information about constituents and that well-designed constituent information increases knowledge and has potential to change behavior (Swayampakala et al., 2014, Morgan et al., 2017).
Research has demonstrated that consumers are likely to better understand non-numerical, descriptive information about tobacco constituents compared to numerical information about constituent levels (Environics Research Group, 2003, Hammond and White, 2012). Some evidence suggests that providing numerical information about quantities or amounts of constituents may mislead consumers by creating the impression that cigarettes with lower quantities of constituents cause less harm than those with higher quantities (Hammond & White, 2012). This pattern of findings holds some parallels to the now disallowed marketing of some cigarette types as “light,” which consumers interpreted as presenting a lower health risk (due to low tar) compared to other cigarettes (Gilpin et al., 2002). To date, few studies have experimentally tested descriptive, non-numerical cigarette pack constituent disclosures to understand which descriptive disclosure messages have the greatest potential for increasing knowledge of constituent content and their associated harms. One set of “proof of concept” experiments found that adding health effect or toxic product information to a cigarette smoke constituent disclosure discouraged smoking more than disclosing just the constituent (Baig et al., 2016). Although informative, this experiment examined a limited range of constituents, toxic products, and health effects.
In order to develop evidence-based constituent disclosures appropriate for national dissemination via cigarette packs and other media, systematic research is needed to develop scientifically-supported messages and to identify principles of effective constituent disclosures. The current study builds upon a series of studies by our research team that began with a systematic review (Morgan et al., 2017) and focus groups examining smokers' and non-smokers' thoughts about cigarette smoke constituents (Moracco et al., 2016). Then, we conducted nationally representative surveys assessing the public's awareness and perceptions of constituents (Brewer et al., 2017). Finally, we conducted a study to examine effective elements to use in disclosure messages (Kelley et al., 2017). In the current message-testing study, we sought to examine: 1) whether perceived message effectiveness varied by constituent; 2) whether the presence of more than one constituent in a disclosure increased perceived message effectiveness; and 3) whether the presence of contextualizing information in disclosures – toxic products that also contain tobacco constituents and constituent-associated health effects – increased perceived message effectiveness.
Section snippets
Participants and procedures
In April 2015, we recruited 1148 US cigarette smokers ages 18 or older to participate in an online experiment of messages about chemicals in cigarette smoke. Recruitment took place through Amazon Mechanical Turk (MTurk), a web-based platform commonly used for social science and experimental research (Berinsky et al., 2012, Buhrmester et al., 2011, Paolacci et al., 2010, Rand, 2012). Although MTurk uses nonprobability-based methods, MTurk samples are typically more representative of the US
Results
Smokers' average age was 35.7 (SD = 11.2; range 18–73 years). The majority were white (85%), had at least some college education (83%) and made less than $50,000 per year (60%). Participants reported smoking an average of 14.6 cigarettes per day (SD = 8.5). Fifty-six percent of smokers reported having used a tobacco product other than cigarettes at least once within the last 30 days (Table 2).
Discussion
Our study identified several principles that explain why some constituent messages may outperform others (Table 5), and these findings corroborate and extend our previous work (Baig et al., 2016, Brewer et al., 2017, Hall et al., 2014). The first principle is that messages with constituents that are familiar and have negative associations elicit higher perceived effectiveness. In a nationally representative survey, only 11% of adult smokers were aware that nitrosamines are in cigarette smoke,
Conclusion
Since 2009, the FDA has had broad authority to regulate tobacco products, including educating the public about the harms of tobacco constituents. Evidence-based constituent messages – on cigarette packs and potentially in public education campaigns – could be an effective way to communicate this information to the public and have an impact. Our findings suggest that to be most effective, constituent messages should follow the principles identified in this study. That is, they should prioritize
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Research reported in this publication was supported by P50CA180907 from the National Cancer Institute and the FDA Center for Tobacco Products (CTP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration.