Discussion
fatigue
SEPARATION, SAID, EMA
This small pilot study set out to evaluate the effectiveness of using modified HWLs to increase self-efficacy beliefs as a way of influencing quitting intentions. We used EMA to examine relationships between constructs theorized to influence quitting (risk-perception and self-efficacy) and intentions to quit at both the within- and between-participant levels. Statistically speaking, we did not find any direct effect of exposure to warnings with efficacy content on intentions to quit smoking (research question 1), nor was there an effect of the intervention on self-efficacy beliefs or risk perceptions; variables predicted to mediate the relationship between threat communication and quitting intentions (research question 2). Further, at the between person-level, no associations between self-efficacy or risk perception and intention to quit were observed, indicating that people who report higher levels of these cognitions are not more likely to have higher quitting intentions than those who feel less efficacious or perceive less risk. Having said this, it is worth noting that the relationships between treatment group self-efficacy, risk perception, and intention to quit were consistent and in the predicted direction, though the parameter estimates were small and not statistically significant. Treatment group also predicted intention to quit indirectly through self-efficacy; again, however, the parameter estimates were nonsignificant.We did observe the expected relationships between risk perception and self-efficacy as predictors of intention to quit at the within-person level. On days when participants reported having greater confidence in their ability to quit or felt themselves to be at a greater risk of harm (relative to their own personal means), they were more likely to also have higher intentions to quit. This observation was consistent with predictions made by the EPPM,Exposing smokers to efficacy content via tobacco packaging has been shown to increase behavioral intentions linked to quittingOne possible explanation is that the specific messages we used were not able to bolster efficacy beliefs. When developing the efficacy messages used in this study, there was minimal literature to provide empirical or theoretical guidance around what might constitute an effective efficacy message. Messaging was further constrained by the space and format of existing Australian tobacco labeling and the need to draw a thematic link between efficacy content and the graphic images featured on labels. Development was informed by literature recommending the use of gain-framed messaging and interrogative questioning,The amount of time or the level of exposure to efficacy content required to shift cognitions was another factor which was difficult to predict. The three-week period of the study used here with two-weeks’ exposure was in line with other studies looking at the effects of tobacco packaging/warningsAlthough the current study did not induce any significant changes to self-efficacy beliefs or risk perception, the study observed both theoretically and practically relevant relationships between self-efficacy, risk perception, and intention to quit on the within-person level: On days on which smokers felt more confident in their ability to quit, and on days when they perceived higher risk to their health compared to their usual levels, they also experienced higher intentions to quit. These findings provide support for the idea that these cognitions fluctuate over time and might be successfully manipulated in a different context and supports the theoretical rationale for investigating these variables further as potential targets to catalyze cessation; it is possible, for example, that for efficacy messages might be most impactful when they overlap with a smoker’s natural fluctuations (as opposed to by gradually changing these cognitions directly over time).These findings also underscore the necessity of research methods which can capture shifts in the relationships between health cognitions over time and allow for the separation of between- and within-persons effects. More research is required in this field to identify what constitutes a successful efficacy message, how efficacy content can best be deployed in a public health context, and which populations would be most likely to benefit. Future studies should consider more pretesting of message content but should bear in mind that the effects may vary depending on the duration of exposure. When designing such studies, it would be prudent to consider the potential impact of intensive sampling on participant fatigue; daily monitoring may be a reasonable compromise that allows for monitoring of changes over time while reducing participant burden. Subsequent research exploring the impact of on-pack efficacy content should seek to determine the minimum level or timeframe of exposure to efficacy content and consider using HWLs with a novel format to reduce possible attentional effects of prior exposure to warning HWLs.