Cigarette pack health warning labels can elicit negative emotions among smokers, yet little is known about how these negative emotions influence behavior change. Guided by psychological theories emphasizing the role of emotions on risk concern and behavior change, we investigated whether smokers who reported stronger negative emotional responses when viewing warnings reported stronger responses to warnings in daily life and were more likely to try to quit at follow-up. We analyzed data from 5439 adult smokers from Australia, Canada, Mexico, and the US, who were surveyed every four months from September 2012 to September 2014. Participants were shown warnings already implemented on packs in their country and reported negative emotional responses (i.e., fear, disgust, worry), which were averaged (range = 1 to 9). Country-stratified logistic and linear generalized estimating equations were used to analyze the effect of negative emotional responses on self-reported responses to warnings in daily life (i.e., attention, risk concern, avoidance of warnings, forgoing planned cigarettes) and quit attempts at follow-up. Models were adjusted for socio-demographic and smoking-related characteristics, survey wave, and the number of prior surveys answered. Smokers who reported stronger negative emotions were more likely to make quit attempts at follow-up (Adjusted ORs ranged from 1.09 [95% CI 1.04 to 1.14] to 1.17 [95% CI 1.12 to 1.23]; p < .001) than those who reported lower negative emotions. This relationship was mediated through attention to warnings and behavioral responses to warnings. There was no significant interaction of negative emotions with self-efficacy or nicotine dependence. Negative emotions elicited by warnings encourage behavior change, promoting attention to warnings and behavioral responses that positively predict quit attempts.

Some researchers have raised concerns that pictorial health warning labels (HWLs) on cigarette packages may lead to message rejection and reduced effectiveness of HWL messages. This study aimed to determine how state reactance (i.e., negative affect due to perceived manipulation) in response to both pictorial and text-only HWLs is associated with other types of HWL responses and with subsequent cessation attempts. Survey data were collected every 4 months between September 2013 and 2014 from online panels of adult smokers in Australia, Canada, Mexico, and the US were analyzed. Participants with at least one wave of follow-up were included in the analysis (n = 4,072 smokers; 7,459 observations). Surveys assessed psychological and behavioral responses to HWLs (i.e., attention to HWLs, cognitive elaboration of risks due to HWLs, avoiding HWLs, and forgoing cigarettes because of HWLs) and cessation attempts. Participants then viewed specific HWLs from their countries and were queried about affective state reactance. Logistic and linear Generalized Estimating Equation (GEE) models regressed each of the psychological and behavioral HWL responses on reactance, while controlling for socio-demographic and smoking-related variables. Logistic GEE models also regressed having attempted to quit by the subsequent survey on reactance, each of the psychological and behavioral HWL responses (analyzed separately), adjustment variables. Data from all countries were initially pooled, with interactions between country and reactance assessed; when interactions were statistically significant, country-stratified models were estimated. Interactions between country and reactance were found in all models that regressed psychological and behavioral HWL responses on study variables. In the US, stronger reactance was associated with more frequent reading of HWLs and thinking about health risks. Smokers from all four countries with stronger reactance reported greater likelihood of avoiding warnings and forgoing cigarettes due to warnings, although the association appeared stronger in the US. Both stronger HWLs responses and reactance were positively associated with subsequent cessation attempts, with no significant interaction between country and reactance. Reactance towards HWLs does not appear to interfere with quitting, which is consistent with its being an indicator of concern, not a systematic effort to avoid HWL message engagement.

Cigarettes with flavour-changing capsules in the filter, a continuing success story for tobacco companies, have grown exponentially since being introduced in 2007. The global capsule market is estimated to be 150 billion sticks in 2017.1 We provide an update on the capsule market since 2014.2 From this time, capsule cigarettes have been introduced in new markets in Europe (Croatia, Spain), Africa (Tunisia), Latin America (Bolivia, Ecuador, Uruguay) and Asia (China, India, Philippines, Thailand, Vietnam).3 They are the fastest growing segment of the combustible market,4 with market share increasing between 2014 and 2017 in 52 of the 67 countries where they are sold and monitored by tobacco analyst Euromonitor.3 These products now have market share greater than 10% in four European countries (UK, Hungary, Ireland, Poland), and have increased 12% in the Middle East and Africa.1 The five most popular capsule markets remain in Latin America (see figure 1), with market share increasing by at least 40% …

Introduction: Cigarette packaging is a primary channel for tobacco advertising, particularly in countries where traditional channels are restricted. The current study evaluated the independent and interactive effects of cigarette packaging and health warning label (HWL) characteristics on perceived appeal of cigarette brands for early adolescents in Mexico.Methods: A discrete choice experiment (DCE) was conducted with early adolescents, aged 12–14 years (n=4251). The DCE involved a 3×2⁵design with six attributes: brand (Marlboro, Pall Mall, Camel), tobacco flavour (regular, menthol), flavour capsule (none, 1 or 2 capsules), presence of descriptive terms, branding (vs plain packaging), HWL size (30%, 75%) and HWL content (emphysema vs mouth cancer). Participants viewed eight sets of three cigarette packs and selected a pack in each set that: (1) is most/least attractive, (2) they are most/least interested in trying or (3) is most/least harmful, with a no difference option.Results: Participants perceived packs as less attractive, less interesting to try and more harmful if they had plain packaging or had larger HWLs, with the effect being most pronounced when plain packaging is combined with larger HWLs. For attractiveness, plain packaging had the biggest influence on choice (43%), followed by HWL size (19%). Interest in trying was most influenced by brand name (34%), followed by plain packaging (29%). Perceived harm was most influenced by brand name (30%), followed by HWL size (29%).Conclusion: Increasing the size of HWLs and implementing plain packaging appear to reduce the appeal of cigarettes to early adolescents. Countries should adopt these policies to minimise the impact of tobacco marketing.

Heated tobacco products (HTPs), or ‘heat-not-burn tobacco products’, are battery-powered devices that deliver nicotine to the user by heating a tobacco stick, instead of combusting tobacco like conventional cigarettes or heating liquids like electronic cigarettes.1 2 Philip Morris International (PMI) launched its HTP, I Quit Ordinary Smoking (IQOS), in Japan in November 2014. Since then, PMI has rapidly expanded the IQOS market. PMI’s CEO has publicly expressed a belief in HTPs’ commercial success in upcoming years.3 As of July 2018, IQOS is sold in 37 countries,4 with evidence of rapidly increasing sales.5–9 To help ensure that potentially reduced harm products like HTPs benefit public health, the tobacco control community must monitor industry behaviour around HTPs. In November 2017, KT&G, the largest Korean tobacco company, introduced the product innovation of tobacco sticks with flavour capsules for HTPs (hereafter capsule heat-sticks) into the Korean market. The filters for capsule heat-sticks include a small case that contains flavouring agents, and consumers are to crush the capsule at any time during a smoking session to …