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(1)Running head: EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. International Master‟s Program in International Communication Studies College of Communication National Chengchi University. 碩士論文 Master‟s Thesis. 論文題目 Evaluation of Graphical Warnings on Cigarette Packs in Russia. Student: Anna Tamurova, 安恩雅 Advisor: Wen-Ying Liu, 劉文英. 中華民國 104 年 1 月 January 2015.

(2) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. Table of contents. Introduction ................................................................................................................................ 2 Literature Review....................................................................................................................... 6 Smoking and its effects on health ...................................................................................... 6 Smoking in Russia ............................................................................................................. 8 Health-Communication Campaigns ................................................................................. 11 World experience of warning labels on cigarette packs ................................................... 12 Warning labels on cigarette packs in Russia .................................................................... 20 Fear Appeals and EPPM .................................................................................................. 24 Research Question ................................................................................................................... 38 Method ..................................................................................................................................... 40 Participants ....................................................................................................................... 40 Procedure ......................................................................................................................... 41 Measures .......................................................................................................................... 43 Results ...................................................................................................................................... 46 Discussion ................................................................................................................................ 57 Conclusion ............................................................................................................................... 66 References ................................................................................................................................ 69 Appendix 1. Cigarette packs examples .................................................................................... 79 Appendix 2. Basic information questionnaire ......................................................................... 85 Appendix 3. Graphic warning label evaluation questionnaire ................................................. 88 Appendix 4. Focus group script (edited).................................................................................. 95. II.

(3) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. List of Figures Figure 1. Warning label on the cigarette packs in Canada: “Warning. Cigarettes cause mouth diseases. Cigarette smoke causes oral cancer, gum diseases and tooth loss”. ...................................................... 15 Figure 2. Picture Warnings on Cigarette Packs in Russia. .......................................................................... 22 Figure 3. Protection Motivation Theory (1983). Source: Witte (1992). ....................................................... 31 Figure 4. Extended Parallel Process Model (EPPM). .................................................................................. 33. III.

(4) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. List of Tables Table 1. Focus group participants: general information and smoking behavior ......................................... 41. IV.

(5) Running head: EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. Abstract Nowadays tobacco use leads to one of the most common reasons of preventable deaths. According to the Global Adult Tobacco Survey, in 2012 Russia has moved to the first place as a most smoking country in the world. Since 2013 Russian government has implemented a variety of methods to reduce smoking in the country. There is not much research done to analyze one of these methods, graphic warning labels on cigarette packs, which were implemented in Russia more than one year ago. Therefore current study aims to evaluate how college students in Russia react on these warning labels. Using fear appeal theory and Witte‟s Extended Parallel Process Model (EPPM), this research explains the advantages and disadvantages of graphic warning labels in Russia. Focus group was conducted to evaluate each of 12 graphic warnings. According to the focus group participants, the paradontosis, stillbirth, oncological diseases, and prematurity were the labels that made them feel concerned. The participants felt that these topics were very important, as the pictures were unpleasant, scary, or disgusting. However, topics, such as impotence, suffering, and emphysema were evaluated as indifferent, irrelevant, and not impressive. Also it has been noted that there is lack of knowledge among Russian college students about the harmful consequences of smoking. Topics, such as early aging and impotence were evaluated as they make no sense and irrelevant to smoking. Key words: graphic warning labels, cigarette, smoking, fear appeal.

(6) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. Introduction. According to WHO (2014), smoking is claimed to be harmful for people‟s health. Bad skin, yellow teeth and bad breath could be caused by smoking. These are all visible factors, but there are also effects that we cannot see, such as decreased athletic performance, and overall poor condition of the body. Smoking is an individual choice, that is why it is a habit that can be regarded as a preventable addiction. Most adult smokers began to smoke during their adolescent age. Therefore preventing adolescent smoking is important for reducing the public health burden of smoking-related illnesses over the life course. Adolescence is a very sensitive time for people to start smoking (Kobus, 2003). There are many different reasons for that. Adolescents feel that smoking can help them to fit in society. Some of them even start smoking, because they are afraid to say no when their friends ask them to smoke together (NSDUH, 2012). Adolescents with smoking parents or family members may perceive it as being adult, causing them to want to begin smoking as well. They believe that it will make them look and behave as grown-ups (NSDUH, 2012). Finding ways to discourage adolescents from taking up smoking is important because those who begin smoking at an earlier age are more likely to become addicted and have greater difficulty in quitting (Zawahir, Omar, Awang, Pharm, Yong, Borland, Sirirassamee,. 2.

(7) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. Fong, & Hammond, 2012). Considering its effects on people‟s health, cigarette smoking has been claimed one of major causes of preventable death. According to statistics provided by WHO, tobacco kills nearly 6 million people each year. More than 5 million of those deaths are the result of direct tobacco use. Unfortunately, smoking affects not only those who chose this habit by themselves, but also all people around smokers. WHO reports that more than 600 000 deaths are the result of non-smokers being exposed to second-hand smoke. Therefore smoking becomes an issue that affects society in total: unnecessary deaths, decreased quality of life, increase in public health costs and significant losses in productivity are not the only outcomes of smoking (Andrews, Felton, Wewers, Waller, & Tingen, 2007). According to WHO reports an urgent action should be taken, otherwise the annual death toll could rise to more than 8 million by 2030. Also, according to ASH (Action on Smoking & Health), the number of tobacco-related death will reach 1 Billion in 21st century, comparing with 100 Million in 20th century. Under the influence of this statistics and predictions, there were a lot of efforts taken to prevent the public from consuming tobacco products. Especially, the most vulnerable groups, such as the adolescents, have repeatedly been cautioned against smoking (Smith & Stutts 2003). The WHO Framework Convention on Tobacco Control (FCTC) has a comprehensive plan that aims to help and guide countries in developing effective tools for tobacco control 3.

(8) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. policies: high tobacco tax levels, smoke-free places, prevention campaigns, effective health warnings, etc. In addition to WHO, many countries try to develop their own plans to prevent their citizens from smoking. As a result, some of the countries managed to design effective anti-smoking campaigns and achieve declines in smoking and tobacco-related diseases, while other countries, where anti-smoking campaigns were not successful, experienced increasing in smoking prevalence. Anti-smoking campaigns have improved over time, countries tried to learn from each other‟s experience. As a result, nowadays many different approaches are used in anti-smoking campaigns. However many researchers still try to investigate more on this problem. (Wilson, Tang, Chander, Hutton, Odelola, Elf, Heckman-Stoddard, Bass, Little, Haberl, & Apelberg, 2012; Pechmann, Guangzhi, Goldberg, & Reibling, 2003) Up to now all the variety of methods used in different countries include ban of smoking in public places, ban of cigarette advertising, anti-smoking advertising, healthy lifestyle advertising, advertising of institutes that will help to cure tobacco addiction, etc. Starting from June 2013 along with other tobacco bans and restrictions Russia adopted one type of anti-smoking campaigns widely used in other countries: warning pictures on cigarette packs showing the outcomes of smoking. As long as this type of advertising has been used in other countries for many years, Russian government had a chance to learn on their experiences. There are contradicting reviews and findings about this new way to change smokers‟ 4.

(9) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. habits in Russia. Therefore, in this research I would like to find out if this anti-smoking campaign is working well in Russia, to see what emotions and feedbacks do the images on cigarette packs have on young smokers, and to see advantages and disadvantages of Russian version of the campaign. Using this information I can provide useful information for future studies and can help to find the ways to improve existing campaign.. 5.

(10) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. Literature Review. Smoking and its effects on health. Nowadays tobacco use leads to one of the most common reasons of preventable death in the world (Ogranov, 2002). Tobacco use kills more people than tuberculosis, HIV/AIDS and malaria altogether (WHO). WHO reports proved bad impact of tobacco use on human health. Particularly, there were more than 70 thousand academic papers on dangerous consequences of tobacco use published since 1950s. That is why there are no more doubts about importance of this topic. Due to many reasons (stress, addiction, etc.) many people still keep smoking and may be affected by harmful influence of tobacco leading to horrible results. High toxicity of tobacco smoke, strong addiction developed by nicotine consumption, and influence on non-smokers‟ health – all these factors cause great damage to population‟s health (Ogranov, 2002). Tobacco is the only legally available product that even in small dozes has negative impact on health and that kills half of those using it. Nicotine is one of the most powerful drugs that cause very strong addiction (Gerasimenko, Fridze, & Sakharova, 2007). According to the research provided by Imperial Tobacco in 1989, “in 6 months 43% of smokers tried to quit smoking, however only 1.8% of them succeeded. Also, 72% of pregnant women started smoking again right after they gave birth. In 50% of cases, people with lung cancer started 6.

(11) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. smoking right after they had surgery. Same situation happened to 40% of smokers that had larynx cancer”. This statistics shows scary results comparable with attempts to quit using heroin. (Cutter, Samaraweera, Price, Haskell, & Schaeffer, 1977; Lewis, 1999) The worst part of the problem is that the nicotine addiction develops in young age. Some smokers say (and believe) that now that they are adults, the choice to smoke is their own. However, this is proving to be a myth. Statistics shows that more than 80% of smokers started smoking before the age of 18, and almost one fourth of them started smoking before the age of 10 (WHO Tobacco Free Initiative, 2008). Nicotine is not the only component of tobacco products. They also include a lot of other harmful ingredients. Carbon monoxide, arsenic, hydrogen cyanide and benzene are all present in cigarette smoke, along with hundreds of other ingredients (Zaridze, 1991; Martin, 2014). Smoking causes a great variety of diseases: . Cancer. Smoking is a reason of 90% of the cases of lung cancer. Also, 30% of other types of cancer are also results of smoking (laryngeal cancer, intraoral cancer, bladder cancer, uterine cancer, etc.) (Ogranov, 2002; Vartanyan, 2002).. . Respiratory diseases. In many cases smoking is a reason of Chronic Obstructive Lung Disease (COPD), including emphysema and chronic bronchitis. Risk of death from these diseases is 10% higher within smokers (Ogranov, 2002; U.S. Department of Health and Human Services, 2004). 7.

(12) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. . Heart diseases and heart attack. Smoking is the main factor that causes cardiovascular diseases. Both, active and passive smoking can be associated with accelerated development of atherosclerosis (Ogranov, 2002).. . Other diseases: impotence, rheumatoid arthritis, hearing loss, problems with vision, cataract, etc.. Smoking in Russia. According to the WHO statistics, in 2012 Russia moved to the first place as a most smoking country in the world. Also Russia is on the second place (after China) for physical volume of tobacco market. According to research that was held within the GATS (Global Adult Tobacco Survey) framework in Russia in 2010, there are 44 million adult smokers in Russia. Moreover, there are hundreds thousands of people dying because of the diseases caused by smoking, which costs Russian government more 1.5 trillion rubles every year (Stub of Freedom, 2013). According to the Ministry of Health, in total, Russians spend more than 600 billion rubles a year for cigarettes and other tobacco products (2011). The WHO Framework Convention on Tobacco Control (WHO FCTC) was established in 2003 due to the growing threat of tobacco use all over the world. It provides new dimensions for different countries to join forces against smoking. Since that time WHO FCTC became one of the most rapidly and widely embraced treaties in United Nations 8.

(13) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. history. According to the information provided by WHO (2013), the Russian Federation accepted it in June 2008 and it entered into the force in September 2008. It is very difficult to find anti-smoking advertising in Russia. Most actions of the government are aimed to make smoking illegal and to stop selling tobacco products. However, recently there are lots of advertisements of clinics and medicine that will help people stop smoking. Even with taking in account these actions, there are some weaknesses in Russian anti-smoking policy. The Ministry of Public Health failed to make corrections to the Internal Revenue Code to raise excise taxes on tobacco. Nowadays the cigarette cost in Russia is one of the lowest in Europe (Krasovsky, 2011). Few actions were taken against smoking in Russia until 2013. In 2012 Russian government started preparing anti-smoking campaign. It was the first tough bill (draft law) that totally restricts smoking in public places and also puts a lot of restrictions on tobacco products‟ sales (Stub of Freedom, 2013). Further, on February 23, 2013, the anti-smoking law № 15-ФЗ “For protection of citizens‟ health from influence of surrounding tobacco smoke and from the consequences of tobacco use” was passed and signed by President of the Russian Federation, Vladimir Putin. According to the document, the law will be integrated in 4 steps. The first step took force on June 1, 2013. Since that day it is prohibited to smoke at schools, universities, hospitals, public service and governmental buildings, elevators, airplanes, city transport, inside and within 15 9.

(14) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. meters from the entrance to airports and train stations. Also, advertising of tobacco products is banned. The second step took force on January 1, 2014. Price and tax policy changes directed to reduce tobacco products consumption were implemented. Since June 1, 2014, when the third step took force, smoking is banned on selected territories and closed places; promotion of tobacco products‟ sales and sponsorship is also banned; there are restrictions on tobacco products sales. The last step will take force on January 1, 2017. It will be focused on prevention of illegal sales of tobacco products. Following this plan, the anti-smoking law will fully take its force in the beginning of 2017. The first three steps were implemented with varying success. Up to now it was prohibited to sell tobacco products in kiosks. Also, supermarkets have to hide the cigarette packs from the public, making only price-list without any pictures visible for the customers‟ reference (Anti-smoking Law № 15-ФЗ, 2013). With every new step, anti-tobacco law becomes tougher for current smokers. The list of places where smoking is prohibited gets considerably expanded (Anti-tobacco law in Russia-2014: places where you cannot smoke and where you can, 2014). This list includes: cafes, bars, restaurants, dormitories, hotels, markets, railway platforms, long distance trains, etc. All movies that include smoking scenes have to be followed by a public service announcement. There are fines for breaking this law (Anti-smoking Law № 15-ФЗ, 2013; Anti-tobacco law in Russia-2014: places where you cannot smoke and where you can, 2014). 10.

(15) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. Russian Ministry of Health states about good impact of a new anti-smoking law in Russia, which results in decline of tobacco products consumption by 16-17%. It will help save 150-200 thousand of lives every year (Anti-tobacco law in Russia-2014: places where you cannot smoke and where you can, 2014). This statistics appears to be very promising, however, specialists are a little worried, pointing that these numbers are too optimistic. In fact, different sources provide different information. According to Federal Service of State Statistic declares that since the anti-smoking law took its force number of smokers declined for 12%, at the same time, tobacco companies state that tobacco products‟ sales declined only for 6-8%. Nevertheless, the fact is – new anti-smoking law provides positive results (Anti-tobacco law in Russia-2014: places where you cannot smoke and where you can, 2014).. Health-Communication Campaigns. According to Rice and Atkin (2013), “public communication campaigns can be defined as purposive attempts to inform or influence behaviors in large audiences with a specified time period using an organized set of communication activities and featuring an array of mediated messages in multiple channels generally to produce noncommercial benefits to individuals and society” (p.3). Over the past decades, public communication campaigns have been more and more focused on various health behaviors, mainly concentrating on disease prevention, such as 11.

(16) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. HIV/AIDs (Bertrand, 2004) and tuberculosis (Thuy, Huong, Tawfik, & Church-Balin, 2004), tobacco use (National Cancer Institute, 2008; U.S. Department of Health and Human Services, 2012), alcohol and drug use (Elder, Shults, Sleet, Nichols, Thompson, & Rajab, 2004), and others. These campaigns are distributed through various channels to find their target audience. Most frequently it is possible to find these messages on television, radio, outdoor media (such as billboards and posters), and print media (such as magazines and newspapers). However, comparing to commercial advertisings, it is harder for health campaigns to get a big budget to place enough advertisings in all types of media. That is why health campaign messages have to be attractive, involving, proactive and engaging to catch attention of the audience (Rice & Atkin, 2003). Unfortunately, even now public remains passive to most of these campaigns. World experience of warning labels on cigarette packs The most common motivation for a smoker to quit smoking is his concern about health risks; and health warnings on cigarette packs have emerged as an important medium for communicating the health risks of tobacco use to consumers (Hammond, 2011; Mutti, Hammond, Reid & Thrasher, 2013). Cigarette health warnings were established by WHO Framework Convention on Tobacco Control (FCTC), which was developed in response to the tobacco epidemic (Volchan, 12.

(17) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. David, Tavares, Nascimento, Oliveira, Gleiser, Szklo, Perez, Cavalcante, Pereira, & Oliveira, 2013). In “Elaboration of guidelines for implementation of Article 11 of the Convention” (FCTC, 2008) it is stated that “every person should be informed of the health consequences, addictive nature and mortal threat posed by tobacco consumption and exposure of tobacco smoke.” Article 11 also specifies that warning labels and messages on tobacco products must be large, clear, visible, and legible (2003). Two major purposes of warning labels were formulated by the Institute for Global Tobacco Control (2013). First, they provide important information about the full range of harmful consequences of tobacco products‟ use for human health. Second, they aim to reduce the use of tobacco products, encourage quitting smoking, and prevent non-smokers and formal smokers from using tobacco products. Tobacco packages provide high reach and frequency of exposure-pack-a-day smokers are potentially exposed to the warnings over 7000 times per year as well as an opportunity to communicate with smokers during the act of smoking (Slade, 1997). Tobacco packs also serve as portable advertisements with high levels of exposure among non-smokers: unlike many other consumer products, cigarette packs are displayed each time the product is used and are often left in public view between uses (Hammond, 2011). Cigarette packages are unique in that, while other products‟ packages are discarded upon opening, these packs are kept on the smoker‟s person or nearby until the cigarettes are gone. Furthermore, with each 13.

(18) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. new cigarette, the smoker takes out the pack and may leave it on public display during use, creating a portable advertisement (Wakefield, Morley, Horan, & Cummings, 2002). In their research in 2002, Strahan, White, Fong, Fabrigar, Zanna, and Cameron, pointed out that tobacco package warning labels can be a potentially effective method to influence attitudes and behaviors. Also, research by Volchan et al. (2013) concludes that health warning labels are considered one of the key components of the integrated approach to control the global tobacco epidemic. Starting from the text-only, warning labels were improved into graphic warnings, showing harmful physical and psychological consequences of tobacco products‟ use for human health (The Institute for Global Tobacco Control, 2013). According to WHO FCTC requirements, graphic warnings on cigarette packs should cover at least 30% of the pack area (not including the border area); warning messages should be accepted by the national health organization and should be changed once in a while. Pictures can be placed on any side of the pack according to the country‟s law requirements. Up to now, there are more than 170 countries that have ratified the cigarette health warnings (Hammond, 2011; Hammond & Reid, 2012); however, the position of the warnings, their size, strength, and the way information is presented varies in different regions (Aftab, Kolben, & Lurie, 1999; Hammond, Fong, McNeil, Borland, & Cummings, 2006; Fong, Hammond, & Hitchman, 2009). In his review, Hammond (2011) states that size, design and position of the messages are 14.

(19) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. very important in terms of the impact that health warnings will have on people. Hammond (2011) states that both, adolescents and adults remember larger warnings, rate them as having greater impact, and correlate the size of the warning with magnitude of the risk. One of the first countries to use graphic warnings on cigarette packs was Canada (in 2000). In 2001 these pictures were improved and covered 50% of pack area. Colorful pictures, numerous warning signs, and „how to quit smoking‟ advices were added to strengthen the effect of the advertising (Senior, 2000; Strahan et al., 2002). The example of a graphic warning label in Canada is presented on Figure 1. Canadian research in 2004 shows that 20% of smokers reported that they started smoking less as a result of the warning labels on cigarette packs (Hammond, Fong, McDonald, Brown, & Cameron, 2004).. Figure 1. Warning label on the cigarette packs in Canada: “Warning. Cigarettes cause mouth diseases. Cigarette smoke causes oral cancer, gum diseases and tooth loss”.. Following the Canada example, some countries in Europe also started using graphical warnings on cigarette packs, putting photos of human organs affected by different diseases caused by smoking, and of some other smoking consequences (Hammond, 2011; Fong et al., 2009; Huang, Chaloupka, & Fong, 2014). According to the information provided by the Institute for Global Tobacco Control (2013), “as of March 2013, 64 countries/jurisdictions 15.

(20) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. required or were finalizing implementation of picture-based warning labels on cigarette packs” (p. 2). Graphic warning labels on cigarette packs received a lot of critique as “they will cause unnecessary or excessive emotional distress; smokers will simply avoid the warnings; graphic labels will undermine the credibility of the message; and graphic labels will cause reactance, or increases in consumption” (Hammond et al., 2004, p.1442). Hammond et al. (2006) stated that there are still some gaps remained in smokers‟ understanding of risks caused by smoking: many of them do not associate some health-related diseases with smoking, and very often smokers underestimate the harmful effect of smoking. In his review, Weinstein (1998) found that although most smokers acknowledge the risk of smoking, they tend to „„minimize that risk and show a clear tendency to believe that the risk applies more to other smokers than to themselves‟‟ (p.139). A growing body of research showed that smokers are still not fully informed about the risks of smoking (Hammond et al., 2006; Hammond, 2011). Even in Canada, which serves a good example of warning labels implementation (Hammond, 2011), a significant proportion of smokers continue to underestimate the most serious risks of smoking, including heart disease, stroke, and respiratory diseases, as well as the risks of environmental tobacco smoke (Hammond et al., 2006). However, research also demonstrates that health warnings on cigarette packages are among the most common means of communicating the health risks of 16.

(21) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. smoking that can have an impact on both smokers and non-smokers and that causes such outcomes as health knowledge, risk perceptions, intentions to quit, quit attempts, use of smoking quit lines, cigarette consumption and smoking relapse (Hammond et al., 2006; Environics Research Group, 2007; Shanahan & Elliott, 2009; Huang et al., 2014). Health warning labels on tobacco products are considered the most cost-effective tool for educating both smokers and non-smokers of all gender, age and social status about the harmful consequences for health caused by tobacco use (Strahan et al., 2002; O‟Hegarty, Pederson, Nelson, Mowery, Gable, & Wortley, 2006; Fong et al., 2009; Hammond, Thrasher, Reid, Driezen, Boudreau, & Arillo-Santillan, 2012). In many countries, more smokers report on getting information about the health risks of smoking from warning labels than from any other source (except television). For example, in Thailand, Australia and Uruguay, countries that use large pictorial warnings on cigarette packs, more than 85% of smokers cited packages as a source of health information (Hammond, 2011; FTCT, 2009). Additionally, non-smokers, including children, also report high awareness of warning labels. Research by Fong et al. (2009) shows that smokers would like to see even more health-related information on the cigarette packs. In their research, Fong et al. (2009) found that some of the former smokers mention graphical warnings as an important factor in their attempt to quit. The increase in the use of free telephone helplines is also considered as one of the warning labels‟ positive outcomes 17.

(22) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. (Fong et al., 2009). These findings were supported by the other research by Cameron, Pepper, and Brewer (2014), where it was proved that graphic warnings on cigarette packs can discourage smoking when viewers understand the messages they are conveying, and when the warnings arouse fear and worry about consequences. Research shows the evidence that comprehensive warning labels that elicit strong emotional reactions are effective among smoking youth and also may help to prevent smoking initiation, especially if they are paired with information about how to avoid the fearful consequences (Hammond, 2009; Fong et al., 2009; Hammond, 2011; Hammond, Reid, Driezen, & Boudreau, 2012). Approximately 6 years after their introduction, more than 90% of Canadian youth agreed that picture warnings on Canadian packages had provided them with important information about the health effects of smoking cigarettes, and made smoking seem less attractive (Hammond, 2011). Also, in 2008, almost 80% of youth smokers in the UK agreed that the warnings had „put me off smoking‟ (Moodie, Mackintosh, & Hammond, 2010; Hammond, 2011). Another example was provided by research in Brazil, where 78% of smokers accepted the appearance of such warnings, 67% of smokers wanted to quit smoking, and 50% of smokers changed their mind about smoking effects on their health (Nascimento, Oliveira, Vieira, Joffily, Gleiser, Pereira, Cavalcante, & Volchan, 2008). The effect of warning labels can be worn-out over time, that is why they have to be renewed once in a while. However, the effects of graphical warnings are stronger and can 18.

(23) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. sustain longer, comparing with text-only warning labels. (Li & Grigg, 2009; Hammond, Fong, Borland, Cummings, McNeill, & Driezen, 2007) Graphic warnings on cigarette packs are proved to be effective because they catch and hold the viewer‟s attention, result in greater information processing and improve memory for the health message (Hammond, 2011; The Institute for Global Tobacco Control, 2013). It is very important to choose the image for the warning label carefully; because the picture is generally the first thing people look at and relate to (Hammond, 2009; Hammond, 2011). According to the results of 40 focus groups conducted in Canada approximately 5 years after the introduction of pictorial warnings, picture determined the strength of the warning‟s emotional impact and noticeability. Also, for many participants, the picture played the key role in understanding the message, and tended to explain the meaning conveyed by the words in the headline (Les Etudes de Marche Createc, 2006; Hammond, 2011). Previous research on effectiveness of graphic warning labels on cigarette packs (Hammond et al., 2012) shows that warnings were perceived as more effective if they were: full color (vs. black and white), featured real people (vs. comic book style), contained graphic images (vs. nongraphic), and included a telephone “quitline” number or personal information. Taken as a whole, the research on graphic warnings show that they are: more likely to be noticed than text-only warning labels, more effective for educating smokers about the health risks of smoking and for increasing smokers‟ thoughts about the health risks, and associated 19.

(24) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. with increased motivation to quit smoking (Fong, Hammond, & Hitchman, 2009).. Warning labels on cigarette packs in Russia. Health warning messages on cigarette packs were proved to be an effective and cost-effective way of communicating with smokers in many different countries (Environics Research Group, 2007; Fong et al., 2009; Li & Grigg, 2009; Shanahan & Elliott, 2009; Hammond, 2011). One of the advantages of health warnings on cigarette packs is that they provide considerable flexibility and a number of options. Cigarette packs can carry a number of rotating messages and should be revised over time (FCTC). For example, there are 16 different messages used in Canada. This allows regulators to communicate a wide range of messages on different themes: for example, different health effects, messages to support cessation, and messages that seek to “denormalize” smoking (Hammond, 2011). Tobacco warning labels on cigarette packs have been shown to reduce cigarette consumption in other countries (Fong et al., 2009). Following this example, recently written and visual warnings also started appearing on tobacco products in Russia (Ministry of Public Health of the Russian Federation; News web-portal KM.ru, 2013). Before the implementation on graphic warning labels in Russia, Research by Wade, Merrill, and Lindsay (2010) have done a research to study the Russian population‟s acceptance and preference of graphic tobacco warning labels. This research showed that Russian population would strongly support government policy to place graphic warning 20.

(25) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. labels on cigarette packs in the Russian Federation. Approximately 87% of the respondents agreed that Russian authorities should make cigarette producers place graphic warning labels on cigarette packs. Research by Wade et al. (2010) showed the results that are consistent with the recommendations stated in the Article 11 of the WHO Framework Convention on Tobacco Control: “the more graphic the warning label is, the more effective its impact” (p. 3). This is also consistent with previous research that has measured the impact of graphic warning labels (O‟Hegarty, Pederson, Yenokyan, Nelson, & Wortley, 2007). As a conclusion to their research Wade et al. (2010) state that in order to best deter Russian population from smoking, it is important for future cigarette warning labels in Russia to be as graphic as possible. It is not clear, whether the Russian government adopted the recommendations from the scholars mentioned above. The Russian State Duma (lower legislative house) and the Federal Council of Russia (upper legislative house) both passed and approved “Technical Regulations on Tobacco Products” in December 2008, which requires warning labels to cover 30% of the front surface and 50% of the back and allows for pictures to be included. (Russian Federation. Federal Law: Technical Regulations on Tobacco Products. Official legislation (N 268-F3). 2008) In June 12, 2013 a new law passed in Russia. According to this law, graphic warning 21.

(26) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. labels are required to be placed on all cigarette packs in Russia. There are 12 different graphic warning labels used in Russia. The pictorial label covers 50% of the back of the package, while 30% of the front of the display has in bold text “Tobacco Kills”. Figure 2 shows all 12 pictures that are currently used in Russia. The warning topics include (from left to write, from top to bottom): amputation, suffering, periodontitis, stillbirth, impotence, oncological diseases, early aging, danger, self-destruction, addiction, prematurity, and emphysema. More shots of cigarette packs currently used in Russia are displayed in Appendix 1.. Figure 2. Picture Warnings on Cigarette Packs in Russia. 22.

(27) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. It has been more than a year since the pictures on the cigarette packs appeared in Russia (since June 12, 2013). Since then there was not much research done to analyze the effectiveness of these new warning labels. However, there were some news articles providing different points of view on this anti-smoking campaign. One survey research was conducted by Specialists of Research Center of web-portal SuperJob.ru in October 2013. The results of this research was mentioned at the same day by two different news agencies, KM.ru (October 11, 2013) and Russian Newspaper (October 11, 2013). However, the way these findings were introduced differed in these two news articles. The first news article called “Sociologists proved that scary photos on cigarette packs are ineffective” published in news web-portal KM.ru on October 11, 2013 stated that according to 82% of respondents scary pictures on the cigarette packs are ineffective for smokers. Also the research showed that 80% of female and 83% of male respondents would not take any actions to change their smoking habits. Approximately 4% of respondents admitted that after they saw photos with signs "Self-destruction", "Aging", and "Still birth", they started smoking even more. Respondents explain it in a "more stress equals to more cigarettes" way. According to the research, only 9% of smokers started thinking more about the problem and made an attempt to smoke less. The second news article that mentioned the same research by SuperJob.ru with a title "Russians started smoking less because of the pictures on cigarette packs" was also published 23.

(28) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. on October 11, 2013 in "Russian Newspaper". It was stated that 9% of respondents started smoking less after pictures showing the results of smoking appeared on cigarette packs. The goal of this news article was to show that Russia adopted the way to fight smoking that is widely used in many countries all over the world and that this way already shows positive results. However, it is difficult to say if smoking decline has been provoked by the pictures on the cigarette packs or by the other methods that were used at the same time. Research on tobacco control in the Russian Federation by Lunze and Migliorini (2013) showed that 87% of Russians (both smokers and non-smokers), “perceive graphic warning labels on cigarette packages as highly effective and strongly support a government policy mandating these” (p. 8). The research also showed that the graphic warning labels were noticed by the majority of smokers (94%); however, only 32% of them agreed that the text on warning labels made them think about quitting smoking (Lunze & Migliorini, 2013).. Fear Appeals and EPPM. Anti-smoking advertising can use either positive framing, or negative framing. Message with positive framing shows the benefits of avoiding tobacco, while message with negative framing is concentrated on the losses incurred by smokers. Negatively framed anti-smoking campaigns are used more often, aiming to fear the audience with the negative consequences of smoking (Rice & Atkin, 2013). An appeal is the motive to which an ad is directed, and its purpose is to move the 24.

(29) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. audience toward a goal set by the advertiser (Williams, 2012). Fear appeals are defined by Kim Witte (1992) as “persuasive messages designed to scare people by describing the terrible things that will happen to them if they do not do what the message recommends” (p. 329). Fear appeal shows the risks of using or not using a specific product. Fear appeal relies on threatening individual‟s well-being and by this way motivates him towards action (Williams, 2012). Fear appeal messages usually contain "gruesome content" in the form of vivid language or gory pictures. They are defined according to amount of fear experienced by the audience (Witte, 1992). According to O‟Keefe (1990), there are two important definitions of fear appeals, taking in account message content and audience reactions. He states that messages that have gruesome content will not necessarily arouse fear, and at the same time audience can experience fear even without gruesome content. However, the majority of fear appeal studies tried to combine both definitions by using manipulation checks and by describing the high fear appeal condition as the one with the message depicting a large threat and the receiver perceiving a large threat at the same time. Fear appeals have been used in public communication campaigns against smoking, drug use, drinking, driving, and unsafe sex for more than 50 years (Hill, Chapman, & Donovan, 1998; Ruiter, Abraham, & Kok, 2001). However, according to research in different disciplines, the effectiveness of fear appeals has been questioned many times (Ruiter et al., 25.

(30) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. 2001). In her research, Witte (1992) states that overall, the empirical findings about fear appeals are “disappointingly inconsistent, if not contradictory” (p. 329). She points out that there are at least three major reasons for the lack of convergence in fear appeal findings. First, sometimes the terms fear and threat are not well defined. For example, if fear and threat are equated, it may lead to confusing results, because fear and threat produce different outcomes (Sutton, 1982, Witte, 1992) Second, most of the studies were concentrated only on message acceptance, however it is also crucial to study the processes connected to message rejection. To fully understand fear appeals, it is very important to understand when and why fear appeals fail, as well as when and why fear appeals work (Dillard, 1992; Witte, 1992). Third, according to Witte (1992), the role of efficacy has not been fully studied. Studies by Rogers (Kleinot & Rogers, 1982; Rogers & Mewborn, 1976) presented that fear appeals with high level of threat and high level of efficacy will lead to message acceptance. At the same time, high levels of threat and low levels of efficacy should lead to message rejection. However there is still not enough research done to prove why threat and efficacy are causal variables (Witte, 1992). During the fear appeal studies, three key elements were distinguished: fear, perceived threat and perceived efficacy. 26.

(31) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. Fear has been studied mainly in 1953-1975; and research defines it as negatively-valenced emotion, accompanied by a high level of arousal, and is elicited by a threat that is perceived to be significant and personally relevant (Witte, 1992; Witte & Allen, 2000). Williams (2012) mentioned in her study that “fear evolved as a mechanism to protect humans from life-threatening situations” (p. 2). According to Lang (1984), fear can be expressed in different ways: physiologically (as arousal), through language behavior (verbal self-reports), or through overt acts (facial expressions). Also, Rogers (1975, 1983) and Sutton (1982) connected fear to anxiety, physiological arousal, responses to mood adjectives, and ratings of concern or worry. According to Rogers (1975, 1983) threat is an external stimulus variable, and it exists not depending on whether person knows about it or not. The difference is that if person knows about the threat existence, he or she will perceive the threat. Then, concept of perceived threat includes two dimensions: susceptibility and severity. The first term, perceived susceptibility to the threat, is concentrated on the degree to which person feels to be at risk for experiencing a threat. On the other hand, perceived severity of the threat is defined as a magnitude of harm expected from the threat (Witte, & Allen, 2000). Efficacy can be defined as a message cue that is focused on the effectiveness of the recommended response and on the person‟s ability to perform the recommended response (Rogers, 1975, 1983). Depending on the perceptions of the efficacy it can lead to perceived 27.

(32) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. efficacy. Perceived efficacy also includes two dimensions: response efficacy and self-efficacy. Perceived response efficacy is described by "one's beliefs about whether the recommended response works to overcome the threat" (Witte, & Allen, 2000, p. 592). Perceived self-efficacy is described by "one's beliefs about his ability to perform the recommended response" (Witte, & Allen, 2000, p. 592). According to Witte (1992), the most typical outcome of fear appeals is the message acceptance, which is defined by attitude, intention, or behavior change. There could be other outcomes of fear appeals. They are less commonly assessed; however they are very important in the fear appeals research. These outcomes are defensive avoidance and reactance (Witte, 1992). Defensive avoidance can be defined as a motivated resistance to the message, for example, denial of the message or minimization of the threat. The most common way to avoid message is to look away from it (Hovland, Janis, & Kelly, 1953; Janis & Feshbach, 1953; Janis & Mann, 1977). At the same time, reactance can happen when person believes that message tries to reduce his freedom and change his behavior. In this case, person can do even more of prohibited behavior (Witte, 1992). In 50 years of research, many different theories have been developed to explain the inconsistent results with respect to the effects (or lack of effects) of fear appeals. According to Dillard (1992), then can be divided to the three major categories: the drive models (Hovland et al., 1953; Janis, 1967; McGuire, 1968, 1969), the parallel response model 28.

(33) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. (Leventhal, 1970, 1971), and the expectancy value theories (Rogers, 1975. 1983; Sutton. 1982). Drive models try to explain individual‟s reactions to fear appeals. In his fear-as-acquired drive model, Janis (1967) proposed that some fear arousal is needed to bring out a motivational drive state; however, if there is too much fear, it can lead to maladaptive outcomes, such as defensive avoidance. He stated that it does not matter if the response is adaptive or maladaptive, whether individuals will change their behavior or deny the message. The most important for individuals is to reduce their fear. McGuire‟s (1968, 1969) two-factor theory proposed that fear is a drive that motivates people to accept recommendations provided in the message. Fear can be also perceived as a cue that led to message acceptance. McGuire (1968, 1969) concluded that moderate amount of fear arousal would lead to the most attitude change. However, further studies found no support for the hypotheses, that message will be accepted when fear is reduced (Rogers, 1983; Sutton, 1982). Moreover, in their study, Rogers and Deckner (1975) found that “only cognitive appraisal of the threat and whether the response was seen as effective resulted in message acceptance” (Witte, 1992, p. 333) Therefore, both Janis‟ (1967) and McGuire‟s (1968, 1969) theories have been rejected (Rogers, 1983; Sutton, 1982, Witte, 1992). The next model was developed by Leventhal (1970, 1971). His parallel response model 29.

(34) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. (or parallel process model) focused on cognitive process. Leventhal (1970, 1971) argued that “protective adaptive behavior stemmed from attempts to control the danger or threat (cognitions), not from attempts to control the fear (emotions)” (Witte, 1992, p. 333). Leventhal (1970) stated some general conditions that would lead to fear control (focus on the feeling of fear) or danger control (focus on the danger or threat) processes. However, in his research, Leventhal (1970, 1971) failed to provide any specifications about when will these processes occur and what process will dominate. Later, two theories were proposed by Rogers (1975, 1983) and Sutton (1982). In his subjective expected utility (SEU) theory, Sutton (1982) stated that there are three variables that affect the decisions to accept recommendations provided in fear appeal message: “(a) the perceived utility of the threat; (b) the subjective probability that the threat will occur, given no changes in current behaviors; and (c) the subjective probability that the threat will occur if individuals make the recommended changes” (Witte, 1992, p. 334). However, this model was not supported (Sutton & Eiser, 1984). Rogers‟ (1975, 1983) protection motivation theory (PMT) is focused on Leventhal‟s (1970, 1971) parallel process model, specifically on the danger control process. There are four persuasive message factors that will cause cognitive mediating process: probability of occurrence will lead to perceived susceptibility; magnitude of noxiousness will lead to perceived severity; response efficacy depictions will lead to perceived response efficacy; and 30.

(35) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. self-efficacy depictions will lead to perceived self-efficacy. The initial model contained only first three factors, the fourth was added later (Witte, 1992). Then, cognitive mediation processes will elicit protection motivation, which was defined by Rogers (1975) as “an intervening variable that has the typical characteristics of a motive: it arouses, sustains, and directs activity” (p. 98). According to Rogers (1975), the message will be accepted when all four variables are on the high level. However, further studies have failed to predict the interactions between all four variables (Witte, 1992). Later, Rogers (1983) reformulated and extended his PMT. He added the differentiation between maladaptive response and adaptive response (Figure 3). Here Rogers (1983) states that in threat appraisal if the rewards for performing this behavior will be higher than perceived severity and perceived susceptibility of the danger, then person will continue performing that behavior. Therefore, to decrease the probability of a maladaptive response it is important to increase the perceived threat (severity/susceptibility) (Witte, 1992). Also, in the coping appraisal, by increasing perceived efficacy (response efficacy or self-efficacy), the probability of adaptive behavior will also increase.. Figure 3. Protection Motivation Theory (1983). Source: Witte (1992).. Witte (1992) stated that in both PMT models, “fear is given a backseat role” (p. 335). As 31.

(36) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. it is presented on the Figure 4, fear only affects the message acceptance through severity/susceptibility (Rogers, 1983). Also, Witte (1992) stated two key problems in the PMT model. First, there are some inconsistences between the model predictions and empirical findings (i.e., increasing susceptibility/severity with few rewards should decrease the likelihood of a maladaptive response; even if efficacy is at a low level as long as it is still greater than response costs). Second, there are some flaws in the relations between some of the variables (PMT does not provide the explanation of how threat appraisal and coping appraisal work together to influence behavior). Adding to these two problems, Witte (1992) also stated that both PMT models “fail to explain the specific factors leading to message rejection” (p. 337) During the evolution of fear appeals, starting from the drive models, where fear was given a central role, the role of fear faded by the time PMT and SEU were proposed (Rogers, 1985; Dillard, 1992; Witte, 1992). In his research, Dillard (1992) was talking about fear being excluded from fear appeal studies. It is very important that previous theories make clear explanations about danger control process, of how people try to prevent the threat from happening by changing their attitudes, intentions and behavior. However, previous models did not concentrate on the other possible outcome, on fear control, on why and how people deny or avoid message, leading to message rejection. Extended Parallel Process Model (EPPM) was developed by Kim Witte (1992). She 32.

(37) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. reviewed and extended Leventhal‟s (1970) theory; also she integrated other models (Janis, 1967; Rogers, 1975, 1983) and included danger control and fear control processes. The EPPM is presented on Figure 5. The EPPM addresses both the emotional and cognitive factors that help message processing and relates these processes to a success or failure of fear appeal messages (Witte, 1992, 1994; Gore & Bracken, 2005).. Figure 4. Extended Parallel Process Model (EPPM).. According to EPPM, the main message components are self-efficacy, response efficacy, susceptibility and severity. When a person sees the fear appeal message, two appraisals will be initiated: evaluation of threat and evaluation of the recommended response to the threat. If the perceived threat is low, then person will have no motivation to process the message further. However, if the perceived threat is high, then person is motivated to continue to the second appraisal. If perceived efficacy is high (with high level of perceived threat), “the danger control process will be initiated” (Witte, 1992, p. 338). It means that individual feels scared, however he is able to adopt the recommended response and control the danger (Thesenvitz, 2000). On the other hand, if perceived efficacy is low (with high level of perceived threat), “the fear control process will be initiated” (Witte, 1992, p. 338). It means 33.

(38) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. that individual does not believe that he is able to adopt the recommended response (for example, it is too hard or too expensive). Then individual will focus on the way to control the fear. He may deny the fact that he is at the risk, avoid or ignore the message. Also it can cause the boomerang effect (when individual will do even more of unhealthy behavior) (Thesenvitz, 2000). According to EPPM (Witte, 1992), fear is a very important component that “may contribute to the motivation to process a message if it is cognitively appraised” (p.338). The fear appeal message should first make individual think of previously experienced fear that will make him think about the threat described in the message. Witte (1992) states that personal experience, culture and other characteristics affect the way each person perceives and evaluates the message. Therefore, threat and efficacy appraisal will certainly be influenced by individual differences. In her study, Kim Witte (1992) presents 11 propositions and the key variables of EPPM that help to better understand the way EPPM works. The first proposition states that when perceived threat is low, then there is no further message processing, and at the same time it does not matter if perceived efficacy level is high or low. It is true, because, according to Witte (1992), if the threat is high, then individual perceives more fear and gets more motivated to get involved. However, when the threat is low, individual will have no motivation to process message further, he may believe that the 34.

(39) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. message is irrelevant. On the other hand, if perceived threat is high, then perceived efficacy level will determine whether danger control or fear control process will dominate (Witte, 1992; Thesenvitz, 2000). When an individual receives a message with high perceived threat (he believes that he is at risk of a serious danger), he starts evaluating, whether the recommended response is a good one to reduce the threat (perceived response efficacy), and whether he can actually perform this recommended response (perceived self-efficacy). When both, perceived self-efficacy and perceived response efficacy are high, then individual will believe that he can prevent the danger; then he will be motivated to accept the message and to make adaptive changes, such as attitude, intention, or behavior changes (Witte, 1992). Therefore danger control means concentrating on dealing with threat and trying to find the solutions to reduce the threat (Gore & Bracken, 2005). It leads to propositions that when perceived threat and perceived efficacy levels are high, it will lead to message acceptance; and that “cognitions about threat and efficacy cause attitude, intention, or behavior changes” (Rogers, 1983; Witte, 1992, p. 340). Fear control is an emotional process that occurs involuntarily, when individual‟s well-being is threatened and when threat cannot be avoided or reduced (Lazarus, 1991; Witte, 1992). The fear control process can occur when the perceived efficacy of response is low; when individual perceives high threat and he does not believe that recommended response provided in the message can help to reduce the threat, or he is not able to perform the 35.

(40) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. recommended response. This will result in maladaptive outcomes, such as denial of the threat, message rejection, or boomerang effect (Witte, 1992; Gore & Bracken, 2005). Therefore, Witte (1992) proposes that “as perceived threat increases when perceived efficacy is low, people will do the opposite of what is advocated” (p. 341). Next important concept of the EPPM is the critical point. It occurs when individual‟s perceptions of threat start to overweight his perceptions of efficacy of the recommended response (Witte, 1992; Gore & Bracken, 2005). It means that individual starts to believe that he cannot avoid a threat from happening (Witte, 1992, 1994; Witte et al., 2001; Gore & Bracken, 2005). Then fear control process starts to dominate, and except of controlling the danger, individual starts controlling fear (Gore & Bracken, 2005). In her study, Witte (1992) emphasized importance of fear, which is caused by threat appraisal. Then, perceived efficacy determines if fear will be increased (low perceived efficacy) and cause maladaptive responses, or fear will be cognitively assessed and then reduced (high perceived efficacy). In addition, Witte (1992) notes that “Fear does not directly cause adaptive changes, but fear can influence adaptive changes when it is mediated by perceived threat in high perceived efficacy conditions” (p. 344). Fear appeal is considered as one of the most frequently used methods to make people try to help themselves (Williams, 2012). It is widely used in anti-smoking campaigns. Research in Australia in 1997 showed that “fear campaign was the best way to convince adults to quit 36.

(41) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. smoking” (Thesenvitz, 2000, p. 1). It also stated that fear appeal anti-smoking campaign can provide information about how important it is to quit smoking and at the same time it can make individual believe that he can find a way to help himself to quit smoking (Thesenvitz, 2000). Along with the fear appeal theory, there was an extensive research done by David Hammond. For many years he has been analyzing graphic warning labels in different countries. Therefore, current research is going to follow Hammond‟s way to evaluate graphic warning labels on cigarette packs in Russia. As it was proved by previous research (Fong et al., 2009; Gallopel-Morvan, Gabriel, Le Gall-Ely, Rieunier, & Urien, 2011; Hammond, 2011; Mutti et al., 2013), graphic warning labels are a good example of fear appeal strategy in anti-smoking campaigns that is used in many countries. They are easy to understand, they can activate emotional responses, and generate fear, disgust, and anxiety. Warning messages and concrete information on quitting (quitline number), accompanying graphic warnings, can provide additional support, increase self-efficacy level and therefore increase the chance of positive behavior change (Williams, 2012).. 37.

(42) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. Research Question. Research in different countries, such as Canada, USA, Brazil, and Australia, demonstrates that graphic warning labels on cigarette packs are among the most common means of communicating the health risks of smoking with impact on both smokers and non-smokers. Graphic warning labels provide health knowledge and risk perceptions, cause intentions to quit, quit attempts, use of smoking quit lines, and decreasing cigarette consumption (Hammond et al., 2006; Environics Research Group, 2007; Shanahan & Elliott, 2009; Huang et al., 2014). Before the implementation of the graphic warning labels in Russia, research by Wade, Merrill, and Lindsay (2010) showed that Russians support the government, they are willing to see graphic warning labels on cigarette packs in Russia, and that these labels should be as graphic as possible, in order to best deter Russian population from smoking. After the implementation of graphic warning labels on cigarette packs in Russia in June 2013, there was not much research done to analyze the effectiveness of these new warning labels. Therefore, this research seeks to find the impacts that graphic warning labels on cigarette packs in Russia have on college students in Russia. It is important to find out what emotions, behaviors, and feedbacks do college students have on each of 12 existing graphic warning labels on cigarette packs in Russia. Therefore, the research question states:. 38.

(43) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. RQ: How do Russian college students react on graphic warning labels on cigarette packs in Russia? Using fear appeal theory and Witte‟s EPPM, this research is going to evaluate graphic warning labels on cigarette packs in Russia. Each of 12 graphic warning labels is going to be evaluated; emotions, attitudes, behaviors towards existing warning labels are going to be discussed, and advantages and disadvantages of the graphic warnings‟ implementation are going to be pointed out.. 39.

(44) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. Method. As it was mentioned earlier, current research aims to find out how college students in Russia evaluate graphic warning labels on cigarette packs in Russia, to see what emotions and feedbacks do these images on cigarette packs have on young smokers, and to point out advantages and disadvantages of implementation of graphic warning labels in Russia. According to Hammond (2011), conducting a focus group is a good way to discuss experiences, opinions and attitudes. Focus group usually consists of 6-12 people with similar interests or characteristics (Evaluation briefs, 2008). Focus group discussion is conducted in an informal way so that participants feel comfortable to express their thoughts openly and freely. During the focus group session, different views can be explored, important issues and ideas can be discussed, specific questions or concerns can be pointed out. According to Hammond (2011), focus groups provide a great opportunity to collect the feedback on the pictures used on the warning labels and the ways these warning labels can be improved.. Participants. There were 12 Russian students invited to take part in focus group. As the study is not gender-oriented, both male and female participants were chosen to take part in focus group. Also, both, frequent smokers and social smokers were invited. Due to some reasons, only 7 participants showed up to take part in the focus group. This 40.

(45) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. amount of people is still acceptable to hold the event. All of the participants received a small payment for taking part in the focus group. Participants‟ age varied from 16 to 22 years old. There were 5 female and 2 male participants presented. All of them were residents of the Russian Federation. All of them were current students. Also, all of them confirmed that they are either frequent smokers (2 male, 3 female) or social smokers (2 female). More information about participants is presented on the Table 1.. Gender. Age. Occupation. Smoking. Age started smoking. Want to quit. Tried to quit. F1. Female. 22. Student. Sometimes. 20. Yes. No. F2. Female. 20. Student. 13. No. Yes. F3. Female. 18. Student. 16. No. No. F4. Female. 19. Student. 13. Refuse. No. F5. Female. 18. Student. 16. Yes. Yes. M1. Male. 20. Student. 17. No. No. M2. Male. 16. Student. 13. No. Yes. Every day (10-15 cig/day) Sometimes Every day (5 cig/day) Every day (Half pack/day) Every day (Half pack/day) Every day (15 cig - pack/day). Table 1. Focus group participants: general information and smoking behavior. Procedure. Focus group preparation started 3-4 weeks before the date it was conducted. The focus group was held on 28th of August, 2014 from 14.30 to 17.00 in the office borrowed specially for this event. The actual discussion time was 1 hour and 30 minutes. All participants were able to choose any seat around the table. To help moderator on that event, one assistant was 41.

(46) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. invited. There were few papers that participants had to fill in before and during the focus group. First was the agreement to take part in the focus group, where participants were also notified about audio and video recording. There were also two questionnaires that each focus group participant has to fill in. First questionnaire consisted of three parts: general questions, smoking behavior, and individualism – collectivism level. The second questionnaire included evaluation forms for each of 12 pictures presented on cigarette packs in Russia. Each participant had a schedule of the event and syllabus, including approximate discussion questions, on the table. After participants filled in the agreement and first questionnaire, the discussion started. First of all, participants were informed about the goal of the focus group. They were also notified that they are free to ask any questions during the event. There are two approaches to discuss the warning labels described by Hammond (2011): to discuss and compare all labels at the same time, or discuss each label one by one. In this research the second approach has been used: each of the 12 pictures currently used in Russia was discussed individually. This approach can provide more information on each warning label. Right after each picture discussion, participants needed to fill in the evaluation form from the second questionnaire. After all graphic warnings have been discussed, a conclusion has been made by 42.

(47) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. participants, introducing their point of view on the smoking situation in Russia in total, on the existing graphic warnings in Russia, comparing them with the graphic warnings in other countries, and providing the ways graphic warning labels in Russia can be improved.. Measures. Hammond (2011) stated that the most effective message is not the one that is liked the most, but the one that makes individuals feel uncomfortable, concerned about the problem. Therefore it is very important to evaluate all opinions that participants told during the focus group session. However, focus group initiated many different emotions and ideas. To make information more clear to analyze, it is important to group all the information provided by participants into few general areas. First of all, to prove that all 12 warning labels use fear appeal, level of fear will be measured by evaluating, if participants feel frightened, nervous, uncomfortable, anxious, tense, or nauseated (Witte, 1998). This will help to measure the perceived severity of the warning label. Graphic warning labels will be evaluated according to seven general areas proposed by Hammond (2011) and Hammond, Fong, McDonald, Brown, and Cameron (2004): Attention, Communication, Identification, Effect, Emotional Reactions, Avoidance, and Credibility. These areas can provide general information on how effective the graphic warning labels are. Attention will be measured by evaluating if participants pay attention or notice particular 43.

(48) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. graphic warning labels, if they feel that the warning labels are attractive or eye-catching. Communication will be measured by asking participants if they understand and believe the messages provided on the graphic warning labels. Identification will be measured by asking participants if they believe that the harmful consequences presented on graphic warning labels, such as impotence, amputation, or addiction, can happen to them if they keep smoking. This can help to evaluate the perceived susceptibility of the warning label. Effect of the warning labels will be measured by evaluating if these graphic warning labels make participants think of reducing or quitting smoking, and by evaluating participants‟ knowledge that smoking can lead to these consequences. Avoidance will be measured by evaluating if participants have tried to avoid the warning labels by any means, such as covering pictures, using different cigarette case, or requesting another cigarette pack with different warning label. Emotional Reactions will be measured by evaluating if participants feel fear, disgust, discomfort or any other emotions while looking at the graphic warning labels. Credibility will be measured by evaluating if participants believe that the threats presented on the graphic warning labels can really be harmful for their health, and if the pictures correctly represent those harmful consequences. Using these general areas it will be easier to evaluate the warnings according to the 44.

(49) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. EPPM. If the participants believe that they are at the risk for experiencing the threat (identification), then the perceived susceptibility of the warning label is high. However, if participants do not believe that the risks shown on the warning labels will happen to them, then the perceived susceptibility of the message is low. If the participants feel scared of the consequences (fear, emotional reactions), then the perceived severity is high, however if participants do not experience fear or any other negative emotions, then the perceived severity of the message will be low. The efficacy will be measured by communication, effect, avoidance and credibility of the warning label.. 45.

(50) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. Results. During the focus group all 12 graphic warning labels used in Russia have been discussed by 7 Russian college students. First graphic warning label discussed was the “Amputation”. This warning label caught attention of all the participants. Almost all participants (6 out of 7, both male and female) rated this warning label as scary. The first look at the picture made them feel uncomfortable, disgusting, fastidious, filthy, dirty and having vomiting reflex. One of the participants admitted that the picture is too scary. That makes the level of perceived severity of the message very high. This may also be the reason why all of the participants tried to avoid looking at the picture even during the focus group session. Participants wanted to flip the pack, tear the picture off the pack, or choose the cigarette pack with other picture. It was also mentioned that picture is located on the back side of the cigarette pack; therefore you do not really have to look at it while taking a new cigarette. At the same time all the participants pointed out that picture looks fake: blue background, very intense colors, “looks like bad Photoshop”. This made the warning label appear not realistic, and it was hard for participants to believe that this can happen to them if they keep smoking (“it will not happen to me”, “anything but this”, “this does not reflect smoking”, etc.). This makes the level of perceived susceptibility of the message very low. Therefore participants rated this warning label as not. 46.

(51) EVALUATION OF GRAPHICAL WARNINGS ON CIGARETTE PACKS IN RUSSIA. effective. They insisted that this warning label will not help them to quit smoking. Only one of the participants mentioned that when she saw this graphic warning label for the first time, it made her put the cigarette off. However, then she admitted that she does not believe that these consequences will happen to her, so she doesn‟t feel like quitting. Therefore, according to the EPPM, even the perceived severity of the message was high, the perceived susceptibility was low. As a result, the message was rated as not effective; it did not make participants think about the problem and caused the message avoidance. The next warning label discussed was “Suffering”. Only one focus group participant (female) said that picture caught her attention, while other participants rated this warning label as “not impressive” and “not catching attention”. When participants just saw the picture, it was very difficult for them to understand the meaning and the reason why it was used on the cigarette packs (“why suffer”, “suffer for what”, “what is on the picture”, and “cannot understand what suffering is all about”). They pointed out that it takes time to understand the picture (“need to study picture carefully to understand”); however for the warning label to be effective, it must not only catch attention, but be easy to understand at the same time. Also, all participants agreed that both picture and slogan are not scary. Moreover, they reported that this warning label has a very low level of credibility (“word is too abstract”, “image is not suitable”, “not realistic”). Participants said that the image looks fake (“bad quality”, “bad Photoshop”), therefore it makes them feel indifferent to the picture and to the topic (“does not 47.