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The effects of tobacco-related health-warning images on intention to quit smoking among urban Chinese smokers

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Objective The purpose of this study was to explore the effects of different tobacco health-warning images on intention to quit smoking among urban Chinese smokers. The different tobacco health-warning images utilised in this study addressed the five variables of age, gender, cultural-appropriateness, abstractness and explicitness. Design Participants were administered a questionnaire that contained 10 graphic anti-smoking images. Of the 10 images, two each represented the independent variables of age, gender, cultural-appropriateness, abstractness and explicitness. The dependent variable in this study was intention to quit smoking. Setting A cross-sectional survey was conducted using face-to-face interviews with 699 residents of Hangzhou, China. The study focused on 202 of those residents who self-reported as smokers. Method Data were collected using a multi-stage sampling design. A Likert-type scale was used to measure quitting intentions after viewing graphic health-warning images. Data analysis was conducted using SAS version 9.3, and paired Chi-square tests were performed to analyse the effect of different graphic tobacco health-warning images on intention to quit smoking among current smokers. Results More than 50% of smokers studied reported they were interested in quitting smoking after viewing the graphic images. Images featuring children and women, real pictures of damaged lungs and pictures that were more explicit produced higher intentions to quit smoking than abstract, male-dominated or less explicit images. Conclusion When designing tobacco-related health-warning images for mass media campaigns, utilising more explicit photos and photographs involving women and children is potentially most effective. These findings provide evidence that the Chinese government should consider when initiating future anti-smoking campaigns utilising such images. Furthermore, these images should appear on all cigarette packages replacing the current text-only warnings.
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Health Education Journal
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DOI: 10.1177/0017896914535377
published online 8 June 2014Health Education Journal
Dan Wu, Tingzhong Yang, Randall R Cottrell, Huan Zhou, Xiaozhao Y. Yang and Yanqin Zhang
among urban Chinese smokers
The effects of tobacco-related health-warning images on intention to quit smoking
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DOI: 10.1177/0017896914535377
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The effects of tobacco-related
health-warning images on intention
to quit smoking among urban
Chinese smokers
Dan Wua, Tingzhong Yanga, Randall R Cottrellb, Huan
Zhoua, Xiaozhao Y. Yangc and Yanqin Zhanga
a Center for Tobacco Control Research/Department of Social medicine, Zhejiang University School of Medicine,
Hangzhou, China
bDeparment of Community Health Education, University of North Carolina Wilmington, Wilmington, NC, USA
cDepartment of Sociology, Purdue University, West Lafayette, IN, USA
Abstract
Objective: The purpose of this study was to explore the effects of different tobacco health-warning images on
intention to quit smoking among urban Chinese smokers. The different tobacco health-warning images utilised
in this study addressed the five variables of age, gender, cultural-appropriateness, abstractness and explicitness.
Design: Participants were administered a questionnaire that contained 10 graphic anti-smoking images. Of
the 10 images, two each represented the independent variables of age, gender, cultural-appropriateness,
abstractness and explicitness. The dependent variable in this study was intention to quit smoking.
Setting: A cross-sectional survey was conducted using face-to-face interviews with 699 residents of
Hangzhou, China. The study focused on 202 of those residents who self-reported as smokers.
Method: Data were collected using a multi-stage sampling design. A Likert-type scale was used to measure
quitting intentions after viewing graphic health-warning images. Data analysis was conducted using SAS
version 9.3, and paired Chi-square tests were performed to analyse the effect of different graphic tobacco
health-warning images on intention to quit smoking among current smokers.
Results: More than 50% of smokers studied reported they were interested in quitting smoking after viewing
the graphic images. Images featuring children and women, real pictures of damaged lungs and pictures that were
more explicit produced higher intentions to quit smoking than abstract, male-dominated or less explicit images.
Conclusion: When designing tobacco-related health-warning images for mass media campaigns, utilising
more explicit photos and photographs involving women and children is potentially most effective. These
findings provide evidence that the Chinese government should consider when initiating future anti-smoking
campaigns utilising such images. Furthermore, these images should appear on all cigarette packages replacing
the current text-only warnings.
Keywords
Effects, intention, quit smoking, tobacco-warning images, urban Chinese smokers
Corresponding author:
Tingzhong Yang, Center for Tobacco Control Research/Department of Social medicine, Zhejiang University School of
Medicine, Hangzhou 310058, Zhejiang, China.
Email: ytingzhongyang@yahoo.com
535377HEJ0010.1177/0017896914535377Health Education JournalWu et al.
research-article2014
Article
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2 Health Education Journal
Introduction
Globally, tobacco continues to kill nearly six million people each year, including more than
600,000 non-smokers who die from exposure to tobacco smoke (World Health Organization
[WHO], 2011). Smoking causes hundreds of billions of dollars of economic damage worldwide.
In China, 28.1% of the adult population smokes, including 52.9% of men and 2.4% of women
(Chinese Center for Disease Control and Prevention, 2010). To address global tobacco use issue,
the WHO established the Framework Convention on Tobacco Control (FCTC) in 2003. Article
11.1(b) (v) of the WHO FCTC recommends the use of pictures or pictograms to emphasise health
warnings on cigarette packaging that informs consumers of the harmful effects of tobacco use
(WHO, 2003). Studies show that graphic warnings on cigarette packages attract the attention of
smokers, increase knowledge and awareness of the health hazards of smoking (Thrasher et al.,
2007) and raise beliefs about risks associated with smoking (Hammond et al., 2003; O’Hegarty et
al., 2007). Graphic warning labels have been shown to cause reactions that are prospectively pre-
dictive of cessation activity (Borland et al., 2009; Thrasher et al., 2007), and also prevent young
people from smoking initiation and dependency (Vardavas et al., 2009). Furthermore, the mes-
sage expressed by graphic warnings can reach large numbers of people who cannot read written
messages or who have low health literacy (Thrasher et al., 2012; WHO, 2011). Studies indicate
that pictorial health-warning labels may be one of the few tobacco control policies that have the
potential to reduce communication inequalities across different socioeconomic classes and differ-
ent ethnicities (Cantrell et al., 2013).
A total of 30 countries with over one billion people have incorporated graphic health-warning
labels on cigarette packs (WHO, 2013). Unfortunately, graphic pictures depicting the harmful
effects of smoking have not been used in China. To date, Chinese cigarette packages have con-
tained only text-based warning labels. Somewhat paradoxically, in China cigarette packages have
traditionally been highly adorned with beautiful pictures depicting nature, Chinese history or cul-
ture. The more expensive the cigarettes, the more decorative the packages are. The gifting of ciga-
rettes is highly engrained in Chinese culture. Cigarettes in beautiful packages are highly valued and
often given to family and friends for holidays, weddings and special events. Most anti-tobacco
advocacy campaigns conducted in China do not use graphic health warnings and any graphic
image warnings that have been used are usually copied from other countries and do not appear on
cigarette packages as well.
While the WHO FCTC was signed by the Chinese government in 2003, ratified by the National
People’s Congress on 27 August 2005 and activated on 9 January 2006, it has not been imple-
mented well. In compliance with FCTC Article 11, the Chinese government enacted the Provision
on Cigarette Packaging and Labelling Selling to replace warnings on cigarette packing in 2008 (Lv
et al., 2011). The new health warning placed on Chinese cigarette packages, however, consists of
only two very general text-only messages (‘smoking is harmful to your health’ and ‘quit smoking
reduces health risk’). Those warning labels exclude pictorial images showing the specific health
effects and neglect the impact of exposure to tobacco smoke as well. Despite these health warnings
occupying the minimum 30% of the front and back of packages as required, they are printed
entirely in English on the back, which seems strange for a non-English-language-speaking country.
In addition to the poor choice of language, there are grammatical errors as well (Fong et al., 2010;
Lv et al., 2011). Also the warning appears at the bottom of the package rather than at the top and it
is in the same background colour which causes it to blend in with the rest of the package (Fong
et al., 2010; Lv et al., 2011).
Due to the actions of State Tobacco Monopoly Administration (STMA), a government admin-
istrative body that shares the same leadership, staff and functions as the National Tobacco Industry,
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Wu et al. 3
the Chinese government has been reluctant to change cigarette packaging. They use the rationale
that Chinese culture and national sentiment would not accept explicit warning images on cigarette
packages (Fong et al., 2010). For instance, replacing images of beautiful mountains and rivers with
pictures of decaying lungs might insult and offend the general public and would not be appropriate
in the context of Confucianist culture. The unspoken concern of the government, however, is that
changing the packaging may decrease tobacco sales (Zhou and Cheng, 2006). In response to the
considerable gap between current Chinese health warnings on tobacco packages and the FCTC
requirements, a ‘Dirty Ashtray Award’ was given to China for making a mockery of Article 11
guidelines. The award was made during the third session of the Conference of the Parties to the
WHO FCTC (Cop 3) in 2008 (Framework Convention Alliance, 2008; Lv et al., 2011). To date,
China has failed to adopt an evidence-based policy, preferring beautiful cigarette packaging over
the health of its citizens.
Graphic tobacco health-warning images have not only been used on tobacco product packag-
ing in other countries but have also been widely utilised as part of anti-tobacco mass media
campaigns or tobacco-control advocacy activities. Graphic images have been incorporated into
many different formats such as posters, billboards, brochures and websites. Evaluating the effi-
cacy of health-warning images and identifying what characteristics graphic tobacco-warning
images should possess to both raise awareness and change behaviours are of vital importance to
anti-smoking initiatives. Assessing the impact of different types of tobacco-related health-warn-
ing images is critical to evaluating anti-tobacco mass media campaigns (Bazzo et al., 2012).
While significant research on health-warning images has been done worldwide, little has been
done in China. Given the history and cultural significance of gifting cigarettes, concerns about
offending Chinese culture with graphic images, and lack of studies on acceptance and impact of
graphic health-warning images, research is needed to determine how Chinese citizens will react
to graphic tobacco health-warning images and the potential impact of such images on tobacco
use behaviours.
Studies have found that actual pictures of the harmful effects of cigarette use are comprehended
better than more abstract pictures (Davies et al., 1998). Social marketing and public health studies
examining anti-smoking campaigns focusing on children have been completed (Reardon et al.,
2006). Several studies have indicated that anti-tobacco advertisements targeting teenagers and
women can decrease smoking initiation and smoking prevalence (Andrews et al., 2004; Friend and
Levy, 2002; Gallopel-Morvan et al., 2011; Pechmann and Knight, 2002). Fear arousal has been
shown to sometimes be an effective method for the design of tailored health messages (Sweet
et al., 2003). Specifically, results indicated that smokers who reported more fear when exposed to
the images were more likely, after 3 months, to quit smoking, to try to give up smoking or to reduce
the amount they smoked (Crespo et al., 2008; Hammond et al., 2003).
Previous work suggests that cultural differences exist in relation to the meaning of visual images
in anti-tobacco media campaigns (Laroche et al., 2001). This would seem to imply that graphic
images should be specific to the culture in which they will be used. In the light of this, and after
reviewing the literature related to graphic anti-smoking images, five variables (age, gender, cultur-
ally appropriate, abstractness and explicitness) were chosen for incorporation into the designed
warning images for this study.
In the warning label literature, common measures include cognitive and affective aspects (atten-
tion, personal relevance, credibility, emotional response and perceived effectiveness) and behav-
ioural outcomes (e.g. cessation behaviour or smoking initiation) (Fathelrahman et al., 2009;
Hammond, 2011). This study aims to explore and test the impact of different tobacco health-
warning images on intention to quit smoking among Chinese urban smokers. The results of this
study may provide important information that could help encourage the Chinese government to
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design, develop and evaluate a series of graphic tobacco health-warning images, so as to update the
current text-only statements on cigarette packages, and promote the more comprehensive imple-
mentation of the FCTC policies.
Methods
Study design
Five groups of graphic tobacco health-warning images were developed for use in this study. Each
group contained two pictures that compared different variables considered to impact on a smoker’s
intention to quit smoking. All the targeted images were selected from the Internet, post-processed
using Photoshop software and then printed out onto questionnaires to be presented to the
participants.
Group 1 was designed to compare an actual picture with an abstract picture on intent to quit.
Both images focused on the concept that smoking causes lung disease. Graphic Image 1 took the
form of an outline of a lung made by using cigarette butts. Graphic Image 2 was a picture of a real
human, tar-filled, diseased lung, clearly indicating that smoking causes fatal lung diseases such as
cancer.
Group 2 was designed to examine the impact of an adult versus a child experiencing the nega-
tive effects of tobacco on intent to quit. Graphic Image 3 depicted a scene in which an adult man is
smoking beside a boy and the lit cigarette is changed to the shape of a gun pointing to the child’s
head using a shadow effect. This picture used the metaphor of a gun to depict the effect of second-
hand smoke on a child’s health. Graphic Image 4 is similar to Graphic Image 3, but the victim of
the secondhand smoke is another adult man instead of a boy.
Group 3 compared the effect of gender on the intention to quit smoking. Graphic Image 5
depicted an adult woman suffering from secondhand smoke, while the main character of Graphic
Image 6 was an adult man.
Group 4 examined the importance of using pictures that are culturally appropriate. Graphic
Image 7 was a picture of a sleeping foreign baby and a skull, surrounded by heavy smoke from a
lighted cigarette. Graphic Image 8 is exactly the same as Graphic Image 7 except that the sleeping
baby is Chinese.
Group 5 examined how pictures with different degrees of explicitness, intensity or unpleasant-
ness might influence intention to quit. Both images in this group depicted individuals with mouth
cancer caused by smoking. Graphic Image 9 was less explicit, or as Chinese students involved in a
pre-test said, ‘less terrifying’. Graphic Image 10 was more frightening.
Pilot test
In order to assess the adequacy of the study design and procedures, a pilot test was conducted to
evaluate the sequence effect in each image group. Pilot tests were conducted with 26 smokers,
including 13 medical students and 13 service personnel from Zhejiang University. Each partici-
pant was randomly assigned to complete an instrument, with each pair of images appearing in a
specific order on first administration. One month later, each participant again completed the
instrument, but with the images appearing in the opposite order in each pair as they had on the
first administration. The results from this pilot test demonstrated that there was no significant dif-
ference in intention to quit based on the order in which the images were presented in each group.
As part of this pilot test, confirmation was also obtained as to which image was more explicit or
frightening in Group 5.
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Wu et al. 5
Study sample
Data were collected using a multi-stage sampling design. In Stage 1, Hangzhou was selected by
convenience as the study setting. Situated in the southeast of China, Hangzhou is the capital of
Zhejiang province with a population of 6.72 million and features light industry and tourism (Yang
et al., 2012b). In Stage 2, two residential districts (Gongshu and Jianggan) were randomly selected
from within Hangzhou city. Both of these districts have high population densities. In Stage 3, four
communities were randomly selected within each district. In Stage 4, the Community Committee
Office randomly sampled households in each community. Individuals aged 15 years and older,
who had resided in that community for at least a year, were identified within each household.
Finally, in Stage 5, one qualified resident from each selected household was identified to com-
plete the interview based on his or her birth date being closest to the date of the interview (Yang
et al., 2012a).
Study procedure
Individual face-to-face meetings were scheduled with each selected study participant. The meet-
ings were schedul arranged through a well-recognised community organisation and were resched-
uled as necessary to accommodate the participant’s needs. Research assistants, who were 2nd-year
graduate students or 4th-year medical students, collected data at each individual meeting. Each
research assistant received 1-day training on the study protocol and survey procedures prior to col-
lecting data. Upon receiving instructions from the research assistants, participants were asked to
complete a questionnaire of approximately 30-minute duration. Questionnaires were administered
privately to participants in their home or in a quiet place, such as a backyard or local park. Each
participant was afforded an opportunity to ask questions or seek clarification regarding the purpose
of the study or any individual questionnaire items. Participants were given adequate time to com-
plete the questionnaire. The graphic images were printed directly onto the questionnaire and a
question regarding intent to quit smoking was included after each of the 10 graphic images. The
study was approved by the Ethics Committee of the Zhejiang University Medical Center. Informed
written consent was obtained directly from all study respondents prior to interviews. Upon comple-
tion of the questionnaire, each participant was given two tubes of toothpaste (about ¥ 10 RMB) as
a small token of appreciation.
Measures
Demographic characteristics. Demographic information collected in this study included date of
birth, gender, race, educational attainment, marital status, occupation and per capita annual family
income.
Smoking status. To assess smoking status, participants reported whether they had smoked in the
past 6 months. Current smokers included both daily smokers and occasional smokers. Daily smok-
ers were defined as those who smoked every day, and occasional smokers were defined as those
who smoked on 1 or more days within the past 6 months but not every day (Yang et al., 2007).
Quitting intention. Current smokers were asked whether they would consider quitting smoking in
the next 6 months after viewing each experimental tobacco health-warning image. ‘No’, ‘probably
not’, ‘probably yes’ and ‘yes’ were the available responses. Responses were recoded dichoto-
mously with 1 = no/probably not and 2 = probably yes/yes during data analysis.
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Data analysis
EpiData 3.1 was used for data entry, and data analysis was conducted using SAS version 9.3.
Smoking and quitting intention prevalence were calculated, and paired Chi-square tests were per-
formed to analyse the impact of different tobacco health-warning images on quitting intention
among current smokers living in Hangzhou, China.
Results
A total of 699 residents were approached to participate in the study. Of those, 669 individuals
agreed to be interviewed, yielding a response rate of 95.7%. There were no incomplete question-
naires due to an immediate review of the questionnaires by study administrators and immediate
follow-up with those submitting incomplete questionnaires.
Of the 669 respondents, 467 (69.8%) were classified as non-smokers, and 202 (30.2%) were
classified as current smokers, with 23.6% smoking daily and 6.6% being more occasional smokers.
There were 387 (57.8%) men and 282 (42.2%) women. A total of 193 men (49.9%) were current
smokers and 9 (3.2%) women were current smokers.
Socio-demographic characteristics of the 202 current smokers can be seen in Table 1: 95% of
current smokers were men and the vast majority were Han Chinese (97%), married (70.8%), with
an educational level higher than junior high school (87.1%). City residents who engaged in com-
mercial or service occupations and had an annual personal income of 20,000–29,999 RMB made
up the largest percentage of smokers.
Table 2 shows the effects of different groups of warning pictures on quitting intention among
smokers. Real pictures of diseased lungs impacted intention to quit smoking more than abstract
pictures (χ2 = 5.00, p = .025). Images focusing on the harmful effects of smoking to women and
children had a greater impact on intention to quit smoking than images focusing on the harmful
effects of smoking to male smokers (χ2 = 4.57, p = .033; χ2 = 9.78, p = .002). Explicit images
depicting the harmful effects of tobacco use impacted intention to quit smoking more than less
explicit images (χ2 = 16.03, p = .001). Whether the figures in the images were Chinese or some
other ethnicity had no significant impact on quitting intention.
It is worth noting that more than 50% of respondents reported they had an interest in quitting
smoking when each tobacco health-warning picture was shown to them. Graphic image 4, depict-
ing children exposed to secondhand smoke, was especially effective, with 85.7% of viewers report-
ing an intent to quit smoking after viewing that image.
Discussion
The results of this study indicate that graphic health-warning images increased smokers’ inten-
tions to quit smoking. The findings from the International Tobacco Control (ITC) survey of adult
Chinese smokers with no graphic images found that between 15% and 31% expressed the inten-
tion to quit smoking in the next 6 months (Feng et al., 2010). The Global Adult Tobacco Survey
(GATS) 2010 China Report found that 36.4% of current smokers 15 years old who noticed the
text-only health warnings on cigarette packages considered quitting because of the warning
labels (Chinese Center for Disease Control and Prevention, 2010). Comparing to these data, it
has been found that the level of interest in quitting smoking from the current study with graphic
images is far higher, as over 50% expressed an intent to quit smoking after viewing any of the
graphic images.
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Wu et al. 7
In 2008, WHO developed the MPOWER technical assistance package to assist countries to
meet their commitments under FCTC. According to MPOWER, one of the six most important and
effective tobacco control policies is to ‘Warn about the dangers of tobacco’ (WHO, 2008). Many
countries implemented the FCTC policies/MPOWER measures, and graphic warnings were dem-
onstrated to be an evidence-based and cost-effective approach to control tobacco use. In real-world
use, quitting intention is significantly higher among smokers where graphic warnings on cigarette
Table 1. Socio-demographic characteristics of the study sample.
Variable N%
Age (years)
< 25 18 8.9
25–34 52 28.7
35–44 45 22.3
45–54 43 21.3
55 44 21.8
Gender
Male 193 95.5
Female 9 4.5
Ethnicity
Han 196 97.0
Other 6 3.0
Educational attainment
Elementary or lower 26 12.9
Junior high school 70 34.7
High school 55 27.2
College and above 51 25.2
Marital status
Never been married 54 26.7
Married 143 70.8
Divorced/widowed 5 2.5
Occupation
Managers and clerks 21 10.4
Professionals 4 2.0
Commerce and service 45 22.3
Technical worker 23 11.4
Students or army 19 8.6
Operations work 30 14.9
Retired 29 14.4
Other 31 14.1
Income (RMB)/person in family
<10,000 23 11.4
10,000–19,999 31 15.3
20,000–29,999 53 26.2
30,000–39,999 28 13.9
40,000–49,999 27 13.4
50,000 40 19.8
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packages have been employed. For example, the implementation of graphic warning labels in
Taiwan increased the number of persons thinking about quitting by one-third (from 30.2% to
42.5%) (Chang et al., 2011). UK smokers were also more likely to report that new graphic warn-
ings caused them to think more about quitting (Hammond et al., 2007). Other studies have also
found the use of graphic warnings was associated with smokers thinking more about quitting
(Borland et al., 2009; Fathelrahman et al., 2009; WHO, 2009). In sum, the results of this study
complement and strengthen findings from previous research which indicates graphic tobacco
health warnings have an impact on motivating thoughts about quitting smoking. This was the first
study, however, to confirm the impact of graphic images on a Chinese population.
One key finding from this study is that actual pictures depicting the devastating effects of smok-
ing have a stronger effect on intention to quit than abstract ones for Chinese smokers. In traditional
Chinese Confucianist culture, there is an emphasis on indirect and euphemistic forms of expression
(Yang, 2010). It is thought that more abstract, euphemistic messages will give people more space
to think about and discuss issues in depth. Based on this line of thinking, abstract pictures depicting
the harmful effects of smoking should be more effective than actual pictures. The results from this
study, however, suggest it is more effective to use actual pictures than abstract pictures to demon-
strate the health hazards of smoking. Actual graphic pictures may cause people a shock reaction,
which may produce a longer and more sustained impact on memory. Generally, graphic warnings
with higher recall rates are more likely to motivate behavioural change. Second, graphic images
directly or closely relate to the health hazards of smoking, while abstract images have a more dis-
tant relationship to the concept (Dreyfuss, 1984). Given graphic warning images must be under-
standable by the entire public including adults with lower literacy, and children or adolescents with
less life and social experience, actual graphic pictures are easier to understand than abstract images
and can relate to all ages, education level and social groups. Moreover, the abstract graphic warn-
ings take more time and energy to devise and pilot-test than actual pictures. Graphic images send
strong messages to the public within a short period of time. Actual graphic picture warnings have
a stronger impact and should be included in China’s future tobacco control advocacy campaigns.
Table 2. Effects of different groups of graphic warnings on quitting intention among smokers.
Graphic warning Quitting intention
N X %χ2p
Abstract–real
Abstract 202 107 53.0 5.00 .025
Real 202 117 57.9
Adult–child
Adult (male) 202 118 58.4 9.78 .002
Child (boy) 202 133 85.7
Male–female
Male 202 118 58.4 4.57 .033
Female 202 126 62.4
Foreign–domestic
Foreign 202 132 65.4 0.00 1.00
Domestic 202 132 65.4
Graphic
Less graphic 202 117 57.9 16.03 .001
More graphic 202 142 70.3
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Wu et al. 9
Results from this study also confirmed that depicting the hazards of secondhand smoke expo-
sure on children or women increases smokers’ intentions to quit smoking. Both children and
women are considered special groups in China. The perception is they are relatively vulnerable and
need others’ protection. Men, who are often smokers, are those who are supposed to provide this
support. A qualitative group discussion (Shanahan and Elliott, 2009) found that the graphic image
titled ‘Don’t let children breathe your smoke’ reminded many participants of the dangers of sec-
ondhand smoke and reinforced the need to refrain from smoking near children. Other findings
revealed that the pictures of innocent children affected by passive smoking caused guilty feelings
among smokers. Compared with Western culture, Chinese culture places an increased emphasis on
the value of collectivism. Children are the centre of the family and are responsible for carrying on
the family line. With the ‘one-child policy’ in China, the status of a child in the family is especially
important. The research (Strahan et al., 2002) suggests that warning labels might be more effective
if they conveyed credible messages indicating that children were strongly in support of cessation.
There is evidence that it is socially valued to protect children from secondhand smoke and to be a
good parent (Gallopel-Morvan et al., 2011). Considering the responsibility for children’s health
and pressure from family, smokers might be more likely to think about quitting.
Since China’s reform, the status of women has significantly improved. However, gender equal-
ity is still out of reach for most women. There still exist many differences between men and women.
In traditional Chinese thought, women are the weaker sex and need to be protected. Men accept the
role of protector and, as such, may experience cognitive dissonance when confronted with pictures
that show their secondhand smoke is harming the women they are supposed to protect. This will
strengthen the intent to quit smoking in men. Moreover, smoking rates are quite low among Chinese
women, and Chinese men are the ones exposing women to secondhand smoke and need to be held
accountable for effects of their behaviours on women’s health.
This study demonstrated that differences exist when more explicit graphic images of the devas-
tating effects of smoking are compared with graphic images that are more subtle and less explicit.
More explicit graphic warnings aroused higher intentions to quit smoking among smokers. This
result was consistent with previous studies in other countries. For instance, Sobani et al. (2010)
found that a mild sense of fear used in the health warnings was not as effective as an image that
provoked greater fear. A meta-analysis also suggested that stronger fear appeals resulted in greater
attitude, intention and behaviour changes (Witte and Allen, 2000). A Canadian study found that
smokers who reported greater fear and disgust were more likely to quit, make an attempt to quit or
reduce their smoking at follow-up (Hammond et al., 2004). More explicit graphic warnings evoked
stronger emotional reactions than non-explicit graphic warnings. In turn, this fear was positively
related to smokers’ intentions to quit smoking, and the level of fear mediated intentions to quit for
this sample of smokers (Kees et al., 2010). Fear was considered to be the inner driving factor
behind behaviour change. In order to decrease the sense of fear, people might choose to change the
risky behaviour. In summary, fear created by explicit tobacco graphic health warnings has been
associated with increased intentions to quit.
Depicting either Chinese or foreign figures in graphic images had no significant impact on quit-
ting intention among smokers in this study. Other countries have used pictures specific to their
country to design graphic warnings in order to create a strong connection with the public. Given
the imperfect manipulation of graphic image using Photoshop software in this study, it would be
important to repeat this element of the study using better graphics that more clearly depict Chinese
faces compared to faces from other cultures.
This study has several limitations. First, the research was conducted in only one urban city and
thus may not represent responses that would be obtained in other cities or in rural areas of China.
In addition, smoking intention is not the same as actually changing one’s smoking behaviour and
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10 Health Education Journal
quitting. This study did not measure real cessation behaviours, which may be impacted differently
upon by these graphic images than intention to quit. Future longitudinal studies are needed to
determine whether the intention-to-quit levels reported in this study are a reflection of actual quit-
ting behaviour. Finally, this study only examined current smokers. Further study needs to be con-
ducted to determine the impact of graphic anti-smoking images on non-smokers and whether such
images will help prevent initiation of a smoking habit.
Conclusion
This study provides important evidence that graphic warning images impact intention to quit
smoking among Chinese citizens residing in Hangzhou. These findings provide strong support for
the Chinese government to establish policies meeting the minimum FCTC requirements for tobacco
health warnings. When designing the images for anti-smoking campaigns or warning labels on
cigarette packages, actual explicit pictures should be used along with images and messages about
the impact of smoking on women and children.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit
sectors.
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The 2009 Family Smoking Prevention and Tobacco Control Act requires cigarette packages to contain stronger warnings in the form of color, graphic pictures depicting the negative health consequences of smoking. The authors present results from a between-subjects experiment with more than 500 smokers that test (1) the effectiveness of pictorial warnings that vary in their graphic depiction of the warning and (2) an underlying mechanism proposed to drive potential effects of the manipulation of the graphic depiction. The findings indicate that more graphic pictorial warning depictions strengthen smokers' intentions to quit smoking. Recall of warning message statements is reduced by moderately or highly graphic pictures compared with a no-picture control or less graphic pictures. The results also show that the graphic warnings affect evoked fear, and in turn, fear mediates the effects of the graphic warning depiction on intentions to quit for the sample of smokers. This pattern of results indicates that though highly graphic pictures may reduce specific message recall and limit the direct effect of recall on intentions to quit, highly graphic pictures increase intentions to quit smoking through evoked fear (i.e., fear fully mediates the effect of the graphic depiction level). The authors discuss implications for consumer health and policy decisions.
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This exploratory study investigated the moderating influence of culture on the persuasive power of fear appeal advertisements differing on type of fear. The conceptual framework for the study was based on Rogers' Protection Motivation model and incorporated type of fear, physical and social, as an independent variable and culture as a moderating variable. An experiment was conducted on a sample of 173 Anglo-Canadian and 180 Chinese subjects. The findings revealed that the physical threat ads had a much greater effect on the Anglo subjects than on the Chinese. Most importantly, these ads brought about an attitude change for the Anglos, but not for the Chinese. For the social fear ads, contrary to predictions, only the Anglos reacted to the ads. They tended to score higher than the Chinese on attitude towards smoking as well as on behavioural intentions.