Emily Brennan

Background: Pictorial health warnings on tobacco packs stimulate short-term cognitive and emotional responses that can lead to quit attempts. We tested novel product attribute health warnings (PAHWs) that corrected misperceptions about product harmfulness. PAHWs uniquely influenced outcomes assessing knowledge of industry manipulation of cigarettes, industry-centric negative emotional responses and product-specific smoking dissonance. We aimed to examine if these unique short-term responses predicted subsequent quitting-related behaviours. Method: We analysed follow-up data from a between-subjects online experiment during which participants were randomised to view PAHWs alone (PAHW condition) or with a complementary video (PAHW+Video) during a baseline session and daily for 7 days. In the present study, covariate-adjusted logistic regression models examined associations between short-term responses to the PAHWs measured at 8-day follow-up (predictors) and subsequent quitting-related behaviours measured at 4-week follow-up (outcomes). Results: Participants with valid data for the 8-day and 4-week follow-up surveys were analysed (N=301). Two short-term responses to the PAHWs—knowledge of industry manipulation of cigarettes and product-specific smoking dissonance—significantly and positively predicted all three quitting-related outcomes: smoke-limiting microbehaviours (eg, foregoing cigarettes), quit attempts and 7-day sustained abstinence. Industry-centric negative emotional responses positively predicted smoke-limiting microbehaviours and 7-day sustained abstinence but not quit attempts. Conclusion: Short-term responses elicited by PAHWs featuring corrective information about the tobacco industry’s manipulation of tobacco products predicted subsequent engagement in smoke-limiting microbehaviours, quit attempts and sustained quit attempts. PAHWs can complement other health warnings featuring the health risks of smoking and may help motivate people who smoke to quit and stay quit.

Objective Regulating tobacco product features can reduce the appeal and addictiveness of smoking and promote quitting, but may be undermined by misperceptions about the reasons for the ban and the relative harmfulness of the remaining products. We tested how messages about slated (menthol/flavoured crushballs) or hypothetical (filter ventilation, regular nicotine content) tobacco product bans in Australia affected quit intentions, product harmfulness perceptions and knowledge about the ban’s rationale. Methods Australian adults who currently smoked (n=1514) completed one arm of an online study (menthol, filter ventilation or regular nicotine content, allocated based on the products they usually smoke). Within arms, participants were randomly allocated to one of three message conditions: condition A introduced the ban and rationale and encouraged quitting; B and C additionally highlighted the harmfulness of remaining products; and C additionally described other negative attributes of remaining products. Results Message condition did not affect perceived product harmfulness or quit intentions for any ban. Awareness of one (of three) accurate statements about the menthol ban rationale was significantly higher in condition C than A. Regardless of condition, awareness of the rationale (menthol arm: one of three statements, other arms: all statements) predicted quit intentions in response to each ban. Conclusions Boosting awareness of the rationale for tobacco product bans may maximise quitting in response. This may be achieved for a menthol ban using messages describing the rationale, emphasising the remaining products’ harmfulness and negative attributes and explicitly encouraging quitting (relative to merely describing the ban and rationale and encouraging quitting).

Background Regulating features of tobacco products can reduce the appeal and addictiveness of smoking. We examined predicted behavioural responses to bans on i) filter ventilation (FV), ii) regular nicotine content (RNC), and iii) menthol and flavour crushballs (MFC), as well as perceived rationales for these bans. Methods Australian adults who smoked at least weekly were recruited from an online research panel to participate in a cross-sectional survey and were allocated to either the FV (n=301), RNC (n=335), or MFC (n=298) study arm, depending on current product use. Respondents viewed a basic description of each ban before completing measures of predicted behavioural responses and perceived rationale. Results The proportion of respondents who reported being likely to try to quit smoking in response to the product regulations was 25.9% in the FV arm, 18.5% in the RNC arm, and 13.4% in the MFC arm. However, in each study arm, respondents more commonly predicted that they would switch to tobacco products that would remain available after the ban (FV: 33.6%; RNC: 37.0%; MFC: 51.3%), and some reported being likely to switch to e-cigarettes (FV: 14.6%; RNC: 11.6%; MFC: 23.2%). The majority of respondents reported either misperceptions or uncertainty about the rationale for the bans (FV: 69.8%; RNC: 81.5%; MFC: 62.4%). Conclusion A higher proportion of people who smoke anticipate that they would respond to tobacco product bans by switching to a different product, rather than using the ban as an opportunity to quit. Future studies should experimentally investigate whether public health messaging about these product regulation measures can be used to encourage greater rates of quitting by minimising switching to available products, including e-cigarettes, and to minimise misperceptions by increasing awareness of the rationale for each product regulation measure.

The tobacco industry manipulates cigarettes to provide sensory cues that mislead people who smoke. We assessed the effectiveness of health warnings (HWs) focussed on the impact of misleading product attributes, including filter ventilation, menthol, and roll-your-own tobacco, which were called Product Attribute HWs. Australian adults who smoke (n = 2544) were randomly assigned to view: control medication warnings; new Standard HWs with smoking harm images; Product Attribute HWs; or Product Attribute HWs plus a video. At baseline, participants were exposed to seven condition-specific warnings (+ video for those in the Product Attribute HWs + Video condition), then they were potentially re-exposed to one warning daily for 7 days (+ up to six video viewings). Participants (n = 1414) were followed-up at 8 days. Compared to controls, exposure to Product Attribute HWs elicited: greater increases in concern when inhaling smoke with misleading favourable (e.g. smooth) and unfavourable (e.g. harsh) sensory cues; greater knowledge of industry manipulation; greater self-centric and industry-centric negative emotions; higher product-specific smoking dissonance; and a higher likelihood of past-week rumination about HWs. Compared to Standard HWs, Product Attribute HWs elicited greater knowledge of product manipulation and industry-centric negative emotions, but similar self-centric negative emotions and past-week rumination about warnings. Only the Product Attribute HWs + Video condition resulted in greater discussion and online information-seeking about warnings. Product Attribute HWs that challenge long-standing myths fostered by tobacco companies yield many similar outcomes to Standard HWs but also provide unique beneficial outcomes. Nations should consider including Product Attribute HWs in their suites of tobacco HWs.

Objective: To assess adolescents baseline knowledge of smoking health harms scheduled to be covered in future graphic health warnings (GHWs) and inform the content of future tobacco control public communication campaigns. Methods: Cross-sectional survey of 8631 secondary school students (mean age=14.5 years) in Australia in 2022/2023 (weighted n=8655). Students were asked (a) for their agreement/disagreement that smoking causes each of nine harms (eg, lung cancer, stomach cancer and asthma), (b) to indicate where most of smokings harmful chemicals come from and (c) for their agreement/disagreement concerning the relative harmfulness of different tobacco product attributes (eg, menthol and roll-your-own). Multivariable logistic regression analyses examined associations between students knowledge and perceptions and their smoking status, controlling for demographics and school-level clustering. Results: Students had greater awareness of harms previously publicised in Australia. Among students who had never smoked, those open to future smoking had lower awareness of six smoking harms than those with a firm future intention not to smoke. Only 17.8% of all students were aware that most harmful chemicals came from burning the tobacco, with 37.8% not knowing and 34.6% attributing the source to additives. Three-quarters held misperceptions that roll-your-own cigarettes are less harmful than factory-made cigarettes or that cigarette smoke which feels light or smooth is less harmful than smoke that feels harsh. Only 25.9% of students were aware that menthol cigarettes are more addictive than non-menthol cigarettes. Discussion: New GHWs and public communication campaigns could improve student knowledge of previously unpublicised smoking harms and counter pervasive misperceptions about tobacco products.

Cigarette brand variant names and characteristics such as the taste and feel of the smoke can mislead consumers into believing some products are less harmful. We assessed the characteristics of three common cigarette variants sold in Australia, “gold”, “blue” and “red”, to determine which characteristics differed by color, and which affected tar, nicotine and carbon monoxide (TNCO) yields. TNCO yields, physical parameters, expanded tobacco and filter ventilation were measured in cigarette color variants from eight brands. Filter ventilation and expanded tobacco were common across brands and variants. Compared to blue and red variants, gold variants had slightly shorter tobacco rods and greater filter ventilation. Gold variants had lower TNCO when measured using the industry-favored International Organization for Standardization (ISO) protocol. ISO-measured TNCO yields were associated with filter ventilation and tobacco rod length, but not use of expanded tobacco. When measured using the Health Canada Intensive (HCI) protocol, which better emulates human smoking behavior, TNCO emissions were markedly higher, and the emission differences by extent of filter ventilation were minimized, indicating that ISO measurements are misleading. These findings confirm that cigarette color names, and the filter ventilation levels they signify, remain misleading more than a decade after plain packaging eliminated pack colors in Australia, as higher levels of filter ventilation are not associated with reduced TNCO emissions measured using the HCI protocol. Consumer education and communication campaigns could amplify the impacts of Australia’s newly passed tobacco legislation banning color and other variant names that imply reduced harm.

Reducing the amount smoked per day, or smoking at a low rate, confers limited protection from smoking harms. We aimed to quantify the prevalence of misperceptions about cutting down and low-rate smoking among Australian adults who smoke. Cross-sectional online survey in April/May 2022 (N=2,740). Participants were asked whether they agreed (misperception) or disagreed that “Reducing the number of cigarettes smoked per day is an effective way to reduce the risk of experiencing the health harms of smoking”. They were also asked whether the statement “Smoking 1 cigarette per day is about 1/20^th as dangerous as smoking a pack of 20 cigarettes per day” sounded about right (misperception) or if it was less dangerous (misperception) or more dangerous than that. The misperception that reducing the number of cigarettes smoked is an effective way to reduce risk was held by 72.0% of people who smoke overall, but was more common among those who smoked <5 cigarettes daily (76.3%; Adj PR=1.11 [95% CI 1.01-1.21]) or only occasionally (79.7%; Adj PR=1.14 [1.06-1.23]) compared with those who smoked 5+ cigarettes daily (66.7%). Over two-thirds (67.9%) underestimated the dangers of smoking 1 cigarette per day, and this misperception was also more common among low-rate smokers (77.6%, Adj PR=1.14 [95% CI 1.04-1.26]) compared to those who smoked 5+ cigarettes daily (63.1%). Misperceptions about the value of cutting down and low-rate smoking for reducing the risk of tobacco-caused harm are pervasive, especially among those who currently smoke at a low-rate or only occasionally. Recent epidemiological evidence confirms that the risks of harm associated with low-rate smoking and cutting down are much higher than would be expected if the relationship between consumption and harm was linear. Findings from this study indicate that misperceptions about the benefits conferred by these smoking patterns are pervasive among people who smoke, particularly among those who currently smoke at a low rate. Corrective education that explains the mechanisms for the increased risk posed by these behaviours could be delivered via package health warnings and/or public health campaigns and may provide low-rate and occasional smokers with additional reasons to quit.

Background: Pictorial health warnings on tobacco packs can stimulate short-term cognitive and emotional responses that lead to quit attempts. We tested novel product attribute health warnings (PAHWs) that corrected misperceptions about harm created by the use of filter-venting, menthol and roll-your-own tobacco. PAHWs uniquely influenced outcomes assessing knowledge of industry manipulation of cigarettes, industry-centric negative emotional responses, and product-specific smoking dissonance. In this study, we examined if these unique short-term responses predicted subsequent quitting-related behaviours. Method: We analysed follow-up data from a between-subjects online experiment that assessed effects of new PAHWs. Participants were randomised to view PAHWs alone (PAHW condition) or with a complementary video (PAHW+Video), and exposure occurred during a baseline session and then repeatedly each day for 7 days. Short-term PAHW responses were measured at 8-day follow-up (N=712). Quitting-related behaviours were measured at 4-week follow-up (N=301). Covariate-adjusted logistic regression models examined associations between short-term PAHW responses and subsequent quitting-related behaviours. Results: Two of the short-term responses – knowledge of industry manipulation of cigarettes, and product-specific smoking dissonance – significantly and positively predicted all three quitting-related outcomes: smoke-limiting micro-behaviours (e.g., foregoing cigarettes), quit attempts, and 7-day sustained abstinence. Additionally, industry-centric negative emotional responses significantly and positively predicted smoke-limiting micro-behaviours and 7-day sustained abstinence, but not quit attempts. Conclusion: PAHWs featuring corrective information about the tobacco industry’s manipulation of tobacco products elicited short-term responses that predicted subsequent engagement in smoke-limiting micro-behaviours, quit attempts, and sustained quit attempts. PAHWs can complement other health warnings featuring the health risks of smoking and may help motivate people who smoke to quit and stay quit.

Background Cigarette pack inserts are small cards that highlight the benefits of quitting and promote use of smoking cessation support. With evidence from Canada that they increase self-efficacy to quit, quit attempts and sustained cessation, inserts are set to be introduced into tobacco packs sold in Australia. Some people have expressed concern that the introduction of inserts may create more litter if incorrectly disposed of on pack-opening. Methods We used a cross-sectional survey to assess self-reported pack-opening location and waste disposal behaviours of people who smoke to determine the potential for littering to occur when tobacco packs are first opened. We also visited a sample of supermarkets, convenience stores and tobacconists located throughout Melbourne, Australia, to discreetly collect observational data regarding pack-opening and waste disposal behaviours at the point of purchase. Results Among participants in the cross-sectional study (N=369), the majority reported that they opened their most recent tobacco pack at home (70.9%) where there is little potential for littering, and this proportion was higher among those who smoke daily (78.6%) and men (74.3%). Self-reported behaviours that could result in littering were rare; 1.0% reported that they left tobacco packaging where they believed it would be collected for disposal. Of the 128 individuals observed at the point of purchase across 46 stores, 96.9% did not open the tobacco product immediately after purchase. One incident of littering was observed (0.8%). Conclusion The introduction of cigarette pack inserts in Australia is unlikely to create a substantial amount of additional litter.

Aims: To test whether showing spectators counter‐advertisements exposing alcohol harms alone, or exposing alcohol harms and alcohol sponsorship, before watching an alcohol‐sponsored sporting event promotes less favourable post‐event attitudes and intentions towards alcohol sponsor brands and alcohol in general.Design: On‐line between‐subjects experiment.Setting: Australia.Participants: A sample of Australian adults aged 18–49 years who planned to watch an alcohol‐sponsored National Rugby League (NRL) State of Origin series game was recruited through an online panel.Interventions: Participants were randomly assigned to one of three counter‐advertising conditions: control (neutral advertisement); counter‐advertisement exposing alcohol harms; and counter‐advertisement exposing alcohol sponsorship and harms, to view at least four times during the week before watching the alcohol‐sponsored sporting event.Measurements: Participants (n = 1932) completed a pre‐test questionnaire a week before the sporting event. Within 4 days of watching the sporting event, participants completed post‐test measures assessing sponsor brand awareness, attitudes and preferences towards the brand, as well as knowledge, attitudes and intentions for alcohol in general (n = 1075).Findings: Compared with the control advertisement, the counter‐advertisement exposing alcohol sponsorship and harms promoted higher (6–13%) awareness of sponsor brands, less favourable attitudes towards sponsor brands and drinking beer, lower purchase intentions for sponsor brands (Cohen's d = 0.15, 0.31, 0.27, respectively) and perceived less image‐based similarity and fit between the sporting event and sponsor brands (Cohen's d = 0.20 and 0.56). Both counter‐advertisements promoted lower perceptions of the appropriateness of consuming alcohol while watching sport (Cohen's d = 0.22 and 0.34), higher awareness of alcohol harms (6–34%) and higher intentions (8–13%) to reduce alcohol consumption than the control advertisement.Conclusions: At alcohol‐sponsored sporting events, counter‐advertisements addressing alcohol harms may promote knowledge of harms and intentions to drink less. Counter‐advertisements that additionally expose and critique alcohol sponsorship may detract from perceptions of sponsor brand image and intentions to purchase the sponsor's products.