Graphic health warnings on Australian cigarette packets: evaluation of a social marketing intervention.

Tobacco-related illness remains the single greatest preventable burden of morbidity and mortality in Australia. Reducing tobacco use is a major public health imperative. This thesis investigates the impact of a public policy intervention designed to inform smokers of the harms associated with smoking and to reduce tobacco use; namely graphic consumer warnings labels on cigarette packets, introduced in Australia in March 2006. The specific aim of this thesis is to examine the impact of these warnings. Social psychology provided a theoretical framework, with models predicting that behaviour can be influenced by new information. This thesis poses questions focussed on the relationship between such information, smokers’ beliefs and attitudes, their behavioural intentions and their actual behaviour. The first question examined is practical: What occurred during the introduction and implementation of graphic consumer warnings labels on Australian cigarette packets? This was asked with a view to (i) offering lessons for interested policy-makers in other countries; and (ii) documenting the intervention under study. The second question is: Did the warnings attract the attention of smokers and communicate information about smoking to change smokers’ beliefs? Thirdly: Were there attitude changes or other changes predictive of quitting? and fourthly Did behaviour change occur? Firstly, studies monitored press coverage about the new warnings and the pace of the rollout into shops. Results (presented in Chapter 2) document tobacco industry lobbying and its apparent influence in delaying the introduction of the warnings in Australia. The nature of the Australian legislation created further opportunities for delay. The second question is addressed in Chapters 2 and 3. Chapter 2 reports on a smoker intercept study; conducted once new warnings were prevalent. Chapter 3 presents smokers’ awareness of new warnings and their beliefs about a range of smoking-related health effects, from a series of cross-sectional population surveys spanning 4 years. Chapters 4 and 5 look in detail at the third and fourth research questions i.e. the impact of on smokers’ attitudes, intentions to quit and quitting behaviour. Chapter 4 presents the short-term marker of success - calls to the Quitline. Chapter 5 applies Fishbein & Ajzen’s[1] Reasoned Action Approach with a cohort of smokers; using the model to investigate the influence of graphic warnings on smokers’ quitting behaviour and its precursors. Taken as a whole, this thesis provides a case study of the roll-out of Australian graphic cigarette packet warning labels and evidence of their impact on smokers. Australia was the 8th country to introduce such warnings. A further 31 countries have since adopted them with many more planning to. Very little is published about the process of implementation and this information from the Australian roll-out offers insight for other policy-makers. This thesis also contributes very strong evidence that Australia’s graphic warnings labels were successful in attracting smokers’ attention and in communicating information that influenced their beliefs about the consequences of smoking. There is also good evidence of translation into interest in quitting and some evidence of quitting behaviour, the ultimate aim of the public policy intervention.Thesis (Ph.D.) -- University of Adelaide, School of Population Health and Clinical Practice, 201