SOCIAL INTERACTIONS ABOUT PICTORIAL CIGARETTE PACK WARNINGS

Introduction. Social interactions are a key mechanism through which health communication efforts, including pictorial cigarette pack warnings, may exert their effects. We sought to better understand social interactions elicited by pictorial cigarette pack warnings. Methods. US adult smokers (n=2,149) participated in a controlled trial that randomly assigned them to have their cigarette packs labeled with pictorial or text-only warnings for four weeks. Surveys assessed the number of conversations, theoretical mechanisms, and conversational content during the baseline visit and each of the subsequent four weekly visits. Results. Smokers with pictorial warnings had more conversations throughout the trial compared to those with text-only warnings (8.2 conversations vs. 5.0, p<.01). Smokers with pictorial warnings were more likely than those with text-only warnings to discuss the health effects of smoking and whether the warnings would make them want to quit (both p<.05). The number of conversations about the warnings mediated the relationship between exposure to pictorial warnings and quit attempts (p<.001). In serial mediation analysis examining possible theoretical mechanisms, the number of conversations increased cognitive elaboration, which in turn increased quit attempts (p<.001). Conversations during the first week were more common among smokers who were younger, white, low-income, had greater perceived message effectiveness, and had stronger negative emotional reactions to the warnings (all p <.05). Conversations declined during the second week, but these declines were more gradual for minority and older smokers, leading to more conversations throughout the study. Conclusions. Pictorial warnings sparked more conversations about the warnings, the health effects of smoking, and quitting smoking than text-only warnings. These social interactions may extend the reach of pictorial warnings beyond the targeted smoker. These results indicate that cognitive elaboration is a possible theoretical mechanism that explains why conversations about pictorial warnings influence quit attempts. Conversations about cigarette pack warnings decreased over time. Greater perceived message effectiveness of the warnings and stronger negative emotional reactions to the warnings were associated with more conversations during the first week of smoking from packs with pictorial warnings. These results support designing warnings to increase conversations about the warnings.Doctor of Public Healt