Tobacco products are required to carry health warnings because tobacco is a highly addictive product that kills about half of its long-term users (Doll, Peto, Boreham, & Sutherland, 2004
). The high reach at the population level and the high frequency of exposure at the individual level make health warnings a very cost-effective tool for communicating the health risks of smoking to consumers. The World Health Organization Framework Convention on Tobacco Control requires ratifying countries to mandate health warnings on cigarette products and recommends the use of pictorial warnings. The guidelines for Article 11 state that warnings should cover at least 50% of the top of the front and back of the pack and may include pictorial images. These guidelines were shaped by evidence from studies conducted over the past decade demonstrating that pictorial health warnings are more effective than text-only warnings (see recent review by Hammond, 2011
Much of the evidence on the effectiveness of pictorial health warning labels on cigarette packages is based on findings from studies conducted in Western well-educated populations (Borland, Wilson, et al., 2009
; Hammond, 2011
). Past research has established that warning labels will have an impact if they can generate emotionally charged responses—either cognitive and/or behavioral (Borland, Yong, et al., 2009
; Hammond, 2011
). Mere awareness in frequency of noticing and/or reading warnings is not associated with subsequent quitting activity unless it first leads to such reactions (Borland, Yong, et al., 2009
). Because pack warnings have the capacity to be seen many times per day, they only need to be attended to on a minority of occasions to have effects. Indeed, research studies have consistently found that reported frequency of avoiding warnings is positively associated with cognitive and behavioral responses that predict subsequent quitting activity (Borland, Yong, et al., 2009
; Hammond, 2011
The limited evidence that has been published suggests that the effects of health warnings are similar in developing countries. For instance, an experimental study found that showing smokers pictorial warnings covering 40% of the front and 60% of the back of pack (proposed for use in Malaysia) had greater positive impact than the text-only warnings that appeared only on the side of packs used at the time (Fathelrahman et al., 2010
). Similarly, an experimental study in China found that adult smokers were more likely to rate pictorial warnings to be more effective than text-only warnings in motivating smoking cessation and in preventing smoking among youth (Fong et al., 2010
). This is complemented by two cross-sectional population studies. The first study, which made use of some of the Malaysian data used here, found cognitive and behavioral reactions to text-only warnings were related to interest in quitting (Fathelrahman et al., 2009
). The second study conducted in Brazil, Uruguay, and Mexico found that health warnings with pictorial images had greater cognitive impacts than text-only warnings, particularly among smokers with low education attainment (Thrasher et al., 2010
). Stronger inferences are possible from longitudinal quasiexperimental studies, that is, those that employ cohort designs, comparing one country before and after a change in policy with another country during that same time period where there has been no change in that policy (IARC, 2008
). To date, no such studies have been published on the effects of pictorial warnings in low- and middle-income countries (LMICs).
This article reports on the first quasiexperimental study of the impact of pictorial warnings in LMICs. We analyzed the longitudinal data collected between 2005 and 2008 from the International Tobacco Control Southeast Asia (ITC-SEA) Project conducted in Thailand and Malaysia to evaluate the introduction of pictorial warnings on cigarette packaging in Thailand. From March 25, 2005, just after the collection of the first wave of data, Thailand introduced larger pictorial warnings (50% on the front and back top panel of cigarette packs) to replace the smaller text-only warnings (33% on the front and back of the pack) introduced in 1997.
Thailand was the second country in the region, after Singapore, to adopt pictorial health warnings on tobacco packaging. In an attempt to evaluate the new warnings in Thailand, Silpasuwan et al. (2008)
in March 2005 conducted a cohort study in five regions of Thailand, including Bangkok, where they collected baseline data from 1,637 Thai workers working in 22 workplaces, but this data were collected partway through rollout, a time that warnings can have had much of their initial impact (Borland & Hill, 1997
). They followed the cohort up a year later, only 37% were successfully recontacted. They found a significant increase in positive attitudes toward quitting related to reported exposure to the new pictorial warnings. However, there was no significant gain in knowledge about the health risks of smoking. In addition, they found an unexpected decline in intention to quit smoking following reported exposure, but the reason for this was unclear. Given the above-mentioned methodological problems and a lack of capacity to control for possible confounding factors, no firm conclusions can be drawn from this study. The dataset we have allows us to overcome some of the main limitations of that study. Further, it provides us with the opportunity to explore the effects on smokers of hand-rolled or roll-your-own (RYO) cigarettes. It is unclear whether the new warnings would have different impacts on smokers who smoke RYO cigarettes versus factory-made (FM) cigarettes in Thailand. Previous research in Thailand using data collected in early 2005 found 58% of smokers used RYO sometimes, with 33% using it exclusively (Young et al., 2008
). RYO tobacco is mostly a product of informal economy (i.e., not FM), bought from roadside vendors rather than commercially manufactured products (Young et al., 2008
). That study found that exclusive RYO smokers were less aware of health warnings but there was no knowledge deficit, suggesting that health risk information was getting through to them as well (Young et al., 2008
). Until July 2007 no warning was required, but since then one out of two designated pictorial health warning labels in black and white is also required on manufactured RYO products (Sangthong, Wichaidit, & Ketchoo, 2011; Termsirikulchai, Benjakul, Kengganpanich, Theskayan, & Nakju, 2008
). Given that few Thai RYO smokers use manufactured RYO tobacco (Dalvey Group, 2004
), exposure to these warnings is likely to be limited.
In Malaysia, the health warning labels were text-only printed on the side of cigarette packs, first introduced in 1979. The warning carried a single text-only message: “Warning by the Malaysian government; smoking is hazardous to health.” The warning labels remained unchanged over the study period, thus, allowing Malaysia to serve as a control. Malaysian smokers predominantly smoke FM cigarettes, estimated at 83% (Young et al., 2008
This study aimed to (a) examine the impact on adult smokers’ reported awareness of warnings and their cognitive and behavioral reactions following the change from text-only to pictorial warnings that appear on cigarette packages in Thailand and (b) explore whether the impact of the new Thai warnings was moderated by the type of cigarette smoked (RYO vs. FM).