Impact of health warning messages on smokeless tobacco products
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Tobacco remains the leading preventable cause of death in the world, and 5 million people worldwide continue to smoke. Further adding to the problem is the fact that smoking cessation rates are very low, and there are some smokers for whom quitting smoking is extremely difficult. Many smokers find nicotine replacement therapy (NRT) products unappealing, and even when used as directed NRTs only achieve modest cessation rates. Smokeless tobacco (ST) may be more appealing than NRT and deliver nicotine in a more palatable way to cigarette smokers. ST is also far less harmful than smoking. It is for these reasons that many scientists and health professionals have suggested the use of ST as a substitute for smoking to reduce tobacco-related harm. Although the health risk posed by ST appears to be much less than conventional cigarettes, the extent to which ST may serve as a harm reduction product is highly contentious. Furthermore, although ST products are legal and widely available, it remains unclear whether conventional cigarette smokers in Canada will use ST products as a substitute for cigarettes or as a cessation aid, if at all. And despite the strong evidence for the effectiveness of cigarette warning labels, there is little research on ST health warning labels. The current study investigated perceptions of ST products with and without HWLs and relative health risk messages among 611 young adult Canadian smokers aged 18-30. The study sought to examine the impact of ST health warning labels (HWLs) on appeal, willingness to use, and perceived health risk and addictiveness. Participants completed a survey during which they were asked to view and provide their opinions on a series of ST packages that were digitally altered according to each of six experimental conditions: (1) "standard" packages of leading ST brands, (2) "standard" packages + a relative risk message about the harm of cigarettes compared to ST added, (3) "Standard" packages + text HWL, (4) "Standard" packages + text HWL and relative risk message, (5) "Standard" packages + picture HWL, and (6) "Standard" packages + picture HWL and relative risk message. The findings indicate that many smokers are unaware that ST is less harmful to health compared to smoking. Despite this, approximately half of young adult Canadian smokers indicated that iv they were willing to try ST as a substitute for smoking and to help quit smoking. Picture warnings increased misperceptions about the health risk of ST and decreased smokers‘ willingness to try ST, whereas text warnings did not. Similarly, adding a relative health risk message to the warning label that communicates the lower risk of ST compared to cigarettes increased willingness to try ST when added to text warnings, and decreased willingness to try ST even further when added to picture warnings. This study is among the first to examine ST warning labels, and is the first to examine the impact of picture warning labels on ST. Overall, the findings suggest picture warnings may make it more difficult to communicate the differences in risk between ST and cigarettes.