Introduction
lung cancer
LUNG CANCER, DISEASE, EMA
Health warning labels (HWLs) first appeared on tobacco packaging in the United States in the 1960s.At their most basic, HWLs consist of a text-only warning on a section of an otherwise traditionally branded tobacco package. Such “text-only” warnings typically describe a particular threat to mortality or health caused by smoking (eg “Smoking cigarettes can cause lung cancer”). More stringent legislation—such as that enacted in Australia—requires these text warnings to be accompanied by images depicting the suffering and disease caused by tobacco.The purpose of including warnings on tobacco packaging is firstly to prevent smoking uptake and secondly to catalyze smoking cessation; they are proposed to do this by increasing the readers’ perceptions of the health risks caused by smoking and inducing negative emotional arousal.Despite the widespread adoption of HWLs in their current forms, theories of health behavior change suggest the effectiveness of health risk communication could be further increased by targeting smokers’ beliefs about their abilities to quit.The Extended Parallel Process Model proposes that defensive processes leading to maladaptive behavior are likely when people are confronted with information about a health threat that they do not feel they can adequately protect against, resulting in attempts to reduce negative emotion rather than risk (so-called “fear control”).Incorporating efficacy information into HWLs was recently explored in a mixed-methods study involving roll-your-own tobacco smokers in New Zealand. Participants were shown mockup tobacco pouches with efficacy content provided on the internal flap. The authors concluded that integrating efficacy content into the packaging design of tobacco pouches may lead to emotional reactions, beliefs, and behavioral intentions associated with quitting.To determine whether exposure to efficacy content on tobacco HWLs is associated with danger control efforts (increases in quitting intentions), and whether this relationship is mediated by self-efficacy beliefs or perceptions of risk, we designed a two-arm RCT study with daily measurements using Ecological Momentary Assessment (EMA) methods. We specifically tested whether exposure to efficacy content on HWLs is associated with increases in quitting intentions, and, secondly, whether this relationship is mediated by self-efficacy beliefs or perceptions of risk.