Smoking-related health risk knowledge, and reactions to cigarette warning labels amongst South African adults

Abstract

Background Tobacco control is a public health concern. By 2020, it is estimated that seven out of every 10 people killed by smoking will be from developing countries. Smoking ranked third after unsafe sex/sexually transmitted disease and high blood pressure in a South African study. There are numerous smoking-related conditions. While it is known that knowledge and understanding of health risks by smokers may influence their smoking behaviour, few studies have been conducted in this regard in South Africa.

Most countries communicate health risks to smokers through cigarette warning labels or media campaigns. Limited information is available on the effects of health warnings on smoking behaviour, particularly in South Africa, and on whether pictorial warnings will influence South Africans.

Additionally, to date, no current nationally representative study has been conducted among South Africans to gather information on the acceptability of pictorial warnings, even though current tobacco legislation recommends that such warnings be implemented on tobacco packs.

Aims and Objectives Aim: This thesis aimed to assess the knowledge of tobacco health risks among a population of South Africans and to determine the effectiveness of text-based health warning messages and pictorial warnings with brand design elements (branded) and pictorials without brand design elements (plain) on smoking behaviour.

Objectives: The objectives of this study were: 1. To select pictorial health warning labels with brand design elements (branded) and without brand design elements (plain) on cigarette packs to prioritise for testing among South Africans.

2. To determine the reactions of a select sample of South Africans (non-smokers and smokers) towards text-only and pictorial (on branded and plain packs) cigarette health warning labels under a quasi-experimental condition. 3. To assess the factors associated with change in motivation and plan to quit smoking following experimental exposure to test cigarette packages with text-only and pictorial (branded and plain) warning labels among smokers. 4. To determine the knowledge of smoking-related health risks among a nationally representative sample of South Africans and potential reactions to the selected pictorial warnings on branded pictorial warning packs at population level.

Methods The thesis consists of three interrelated parts as discussed below:  Part One: In Part One, secondary data analysis using data from the 2010 South African Social Attitudes Survey (SASAS) (n ~3000) was used, together with other published sources to select the prioritised health warning themes and messages for use in Part Two of the thesis.  Part Two: Part Two of the thesis was conducted in South Africa, in the Gauteng and Western Cape provinces respectively, so as to have greater representation of the South African population. Part Two used a quasi-experimental crossover design and mixed methods, including focus group discussions, to establish the effectiveness of text and pictorial health warnings with (branded) and without (plain) brand design elements on the change in motivation and plans of a smoker to quit, which are proximal determinants of actual change in behaviour i.e. quitting. Using a crossover design, participants were requested individually to assess each of the health warnings – text and pictorial (branded or plain package). After that, they completed a post-evaluation questionnaire after being exposed to all the health warnings.

The post-evaluation questionnaire concluded the individual assessment of the health warnings. The same participants then proceeded to the next part of the evaluation,

which was the focus groups. Focus group discussions were conducted – among the same participants who had previously completed the individual assessment of the health warnings – to establish and examine the prevailing attitudes, perceptions, understanding and behaviours among the target groups of non-smokers and smokers towards the tobacco health warning labels. Participants were allocated to one of 12 categories of focus groups of 10 each (n=960) according to their race, gender, age, and smoking status. Focus groups were conducted until saturation of the focus groups, where no more new information was obtained.

Participants rated their responses (on a scale of 1 to 5) using previously validated measures of effectiveness, grounded in the constructs of persuasive communication theory, namely “attention,” “communication,” “identification” and “effect.” After the participants’ responses to the health warning labels had been analysed, the labels were revised. Focus groups were then held among a smaller select sample of participants only in Gauteng who were requested to assess the revised pictorial health warning messages: with brand design elements (branded) and those without brand design elements (plain). A structural equation model (SEM) was also constructed to understand the pathway from reaction to health warnings to changes in planning to quit.  Part Three: Part Three included secondary data analysis, using data from the 2016/17 South African Social Attitudes Survey (SASAS), which is a nationally representative household survey to assess the state of knowledge of tobacco health risks among South Africans in 2016/17 (n ~3000). Using a self-administered questionnaire, the data obtained included socio-demographics; tobacco use; and participants’ reaction about whether “plain” packs, as shown on a “show card” to each participant, could make smokers think about quitting. Another structural equation model (SEM) was constructed this time to understand the pathway from response to exposure to health warnings and quit attempt at population level. Results This thesis showed that although South Africans have some knowledge of smoking-

related health risks, this knowledge differs by the type of smoking-related health risk. South Africans have particularly limited knowledge of the vascular (hypertension, impotence, and stroke) smoking-related health consequences, compared to their knowledge about the risks related to cancer and/or respiratory diseases. Furthermore, although the participants were not the same individuals, there was no increase in the overall knowledge of smoking-related health risks among South Africans who participated in the 2010 SASAS and those who participated in the 2016/17. These results on knowledge indicate an urgent need to implement interventions that will increase South Africans’ knowledge of tobacco-related health risks, such as pictorial warnings.

The quasi-experimental study using a crossover design. There were 767 participants, with a response rate of 79.9%. There were about equal numbers of smokers and non- smokers. Before exposure to test health warnings, the majority who smoked indicated they were not planning to quit (64.6%). Overall, out of all the 20 health warnings that were evaluated before the revision of the health warnings, text-only health warnings were ranked lowest. Pictorial warnings, regardless of package design, ranked higher than text-only health warnings. However, participants most often indicated that the pictorial warnings on packages without the brand design elements (plain packages) were more effective than the pictorial warnings on packages with the brand design elements (branded packs).

The pictorial warning that was ranked as the most effective before revision was the abortion picture on plain packaging, with a mean rating score of 3.92 (SD=0.40). After revision of the pictorial warnings, which now also included lung cancer warnings, as suggested by participants, the most effective warning was lung cancer on plain packaging with a mean score of 3.77 (SD=0.68). Smokers felt that the pictorial warning on abortion, regardless of the pack (plain pack mean=3.88, SD=0,49; branded pack mean 3.88, SD=0,45) was most effective in motivating smokers to quit smoking or think about quitting. The top five pictures selected as the most effective among the pictorial warnings after revision were those related to lung cancer (62.9%), gangrene (45.2%),

impotence (44.4%), abortion (34.7%), and oral disease (21.8%).

After controlling for potential confounders, some of the factors that were independently associated with higher odds of having a positive change in planning to quit smoking after exposure to health warnings were self-identifying as Indian/Asian (OR=2.70; 95% CI=1.11-6.58) compared to black African; being employed (OR=3.94; 95% CI=1.98- 7.83) as compared to being unemployed; and indicating spending money on cigarettes rather than food (2.62; 1.41-4.88). The SEM depicting pathways to changes in planning to quit after exposure to cigarette health warnings fit the data well (comparative fit index=0.997; normed fit index=0.975; root mean square error of approximation=0.026). SEM confirmed that current text-only warnings were less likely directly to influence changes in planning to quit (β= -0.29). Greater changes in planning to quit were directly influenced by a higher rating of the branded packaging (β=0.25).

Current smoking in 2017 was 19.3% (n=607), with only 49.6% (n=292) planning to quit and 59.9% (n=345) having attempted to quit in the past 12 months. Of the respondents, 70.8% (n=2071) have never or rarely read the current text-only health warnings, but 85.7%(n=2495) agreed that text-only warnings (as shown) were easy to understand. Of those who agreed that packs with pictures would make smokers think of quitting, 54.4% (n=1030) thought the current displays of cigarette packs inside stores and shops could encourage young people to take up smoking.

Only 42.0% (n=273) of the current smokers indicated that adding pictures to cigarette packs as shown would make them think about quitting, but 61.2% (n=385) agreed that displaying the pictorial warnings would encourage the youth not to smoke. Those with an educational status lower than Grade 12 (44%; n=747) and those with an educational status higher than Grade 12 (46.4%; n=196) agreed that adding pictures would make smokers think about quitting. Although the majority of respondents agreed that the text warnings shown to them were easy to understand, only 15.1% (n=509) felt that these warnings would make a smoker think of quitting, whereas 41.9% (n=1301) felt that the

pictorial warnings would make smokers think of quitting.

After controlling for potential confounders, the factors that were independently associated with higher odds of believing that pictorial warnings on a “plain” pack would stop a smoker who wants a cigarette were an educational status of more than 12 years of schooling (OR=1.71; 95% CI=0.74-3.93) as compared to 12 years or less of education, believing that displaying cigarette packs in shops was a form of advertisement (3.27; 1.91-5.60), exposure to smoking at work (2.29; 1.29-4.07) and having attempted to quit smoking within the last 12 months (1.95; 1.11-3.41).

The SEM on path to attempt to quit fitted the data well (comparative fit index=0.986; normed fit index=0.956; root mean square error of approximation=0.028). Smokers’ perceived health risk directly influenced their quit intention (β= 0.21), which in turn was positively directly associated with having actually attempted to quit (β= 0.43). Conclusion Assessing the effectiveness of cigarette pack health warning labels is a matter of public health importance, given the significant burden of disease associated with tobacco use. This thesis is the first of its kind in South Africa and comes at a time when legislation is being amended to include pictorial warnings and plain packs. The thesis provides evidence that pictorial warnings, particularly on plain packaging, would be effective in South Africa.

The findings reported in this thesis were used to assist in providing information on the implementation of pictorial warnings in South Africa that are evidence-based and tailored to the South African market. These pictorial health warnings could therefore potentially save lives by increasing cigarette smokers’ motivation to quit and eventually quitting tobacco use. These findings suggest that adding pictorial warnings to the current cigarette packs in South Africa is more likely to prompt quitting and deter the youth from taking up smoking than text-only warnings. Most countries communicate health risks to smokers through cigarette warning labels or media campaigns. Limited information is available on the effects of health warnings on smoking behaviour, particularly in South Africa and, whether pictorial warnings will influence South Africans.

Additionally, there is also no current nationally representative study conducted among South Africans to inform on the acceptability of pictorial warnings although, current tobacco legislation recommends that such warnings be implemented on tobacco packs.