September 8th, 2014:
The impacts of cigarette packaging pictorial warning labels on smokers in the city of tehran
Cigarette smoking is considered the first preventable cause of death in the world. Social, familial, and personal factors play an important role in prevention or cessation of smoking. Educating the public in order to enhance their knowledge, change their attitude and improve their habits is also effective in this respect. In 2007, the executive protocol of the Comprehensive Law on Smoking Control was compiled in the Ministry of Health and according to the Article 5 of this law pictorial health warning labels had to be applied on cigarette packaging. This study was designed and conducted in 2 phases of before and 9 months after the implementation of this law and evaluated the effect of it on smokers' knowledge, attitude and pattern of smoking.
This was a cross-sectional descriptive study conducted to evaluate the effect of cigarette packs' pictorial health warning labels on the knowledge, attitude and smoking pattern of smokers residing in Tehran. After calculating the size of understudy population and estimation of the exclusions, 1731 subjects were randomly selected using the multiphase cluster method from the 22 districts of Tehran. Data were collected using a questionnaire designed according to the standard questionnaire of the World Health Organization (WHO) and International Union Against Tuberculosis and Lung Disease (IUATLD). Qualitative and quantitative value and reliability of the variables including cigarette consumption, knowledge about the law, and pattern of smoking were evaluated in 2 phases and the quality of pictures and their effects on the mentioned variables were assessed in the 2(nd) phase.
Before adopting the pictorial warning labels in the first phase of the study, 1731 respondents were evaluated out of which 71.8% were males and 28.2% were females. These cases had an average of 17.6±12.3 years history of smoking. A total of 38% (675 subjects) used Iranian cigarette brands and 39.5% were aware of the implementation of pictorial health warning labels on cigarette packs. In terms of smokers' attitude towards the implementation of this law, they mostly had no opinion about it. A total of 33.3% stated that they may cut down on smoking as the result of this law. Men had a higher percentage of smoking a cigarette first thing in the morning before breakfast and women had a higher rate of consuming foreign cigarette brands (P < 0.001). In the second phase of the study, 1590 cases of the phase 1 subjects participated. Subjects had a significantly higher knowledge about the implementation of pictorial health warning labels on cigarette packs (P < 0.001). Attitude towards this law did not change significantly compared to the first phase although the mean score improved by 0.07%. Enforcement of this law resulted in decreased consumption in 7.6% of the participants. However, the Wilcoxon test did not show any significant difference. In terms of the quality of pictures, 61.6% had no opinion, and 28.7% expressed that the pictures had poor quality. No significant difference was observed between the Iranian or foreign brands in terms of smoking rate after applying the pictorial warning labels.
We believed that the smoking rate would decrease after applying the pictorial health warning labels on cigarette packs. However, it did not happen. Also, adopting these labels did not have a significant effect on smokers changing their favorite brand from Iranian to foreign brands or vice versa. Type and quality of pictures require major revision and corrections.
The association between smokers' perceived importance of the appearance of cigarettes/cigarette packs and smoking sensory experience: a structural equation model
We assessed the reliability of a measure of the latent construct "smoking sensory experience." We further measured the relationship between "smoking sensory experience" and smokers' rating of the importance of the appearance of cigarettes/cigarette packs in brand choice and smoking dependence.
Analyses involved a national sample of smokers (n = 633) who participated in the 2010 South African Social Attitudes Survey (N = 3,112). Smokers ranked on a scale of 1-5, the importance of the following attributes in choosing their cigarette brand: health concerns, cost, packaging, taste, satisfaction, and flavor/strength. Using structural equation modeling, an a priori model was specified based on the hypothesis that taste, satisfaction, and flavor/strength are measures of a construct of "smoking sensory experience" and that cigarette packaging would be positively related to "smoking sensory experience." Furthermore, "smoking sensory experience" would be positively related to cigarettes smoked per day.
The latent construct–"smoking sensory experience" was considered reliable (Cronbach's α = 0.75). The structural equation model confirmed that the specified model fitted the data well (goodness of fit index = 0.993; normed fit index = 0.978; root mean square error of approximation = 0.031). Higher "smoking sensory experience" was positively associated with increasing cigarettes smoked per day (β = 0.12). Higher rating of the cigarette package in brand choice positively covaried with both "smoking sensory experience" (β = 0.29), and higher rating of health considerations (β = 0.42).
These findings support the regulation of the appearance of cigarettes/cigarette packs to reduce cigarettes' appeal and abuse liability in line with Article 11 of WHO's Framework Convention on Tobacco Control.