Background
Tobacco consumption is the leading cause of death in the world, and frequent inhalation of cigarette smoke toxicants causes both short-term and long-term health effects [
1,
2]. Surgeon General’s Advisory Committee (SGAC) of United States indicates tobacco smoking is a health hazard of sufficient importance, and is associated with the increased risk of health problems [
3]. Generally, tobacco smoking has negative health effect and is the single largest preventable cause of morbidity and mortality all over the world [
4]. World Health Organization (WHO) estimates that the number of people addict to tobacco smoking is over 1 billion, and over 8 million people will die from tobacco related diseases by 2030 if the current trend continues [
5]. In order to curb the elevated prevalence of tobacco smoking, many public health interventions have been attempted in efforts, including health literacy campaigns, targeted smoking bans, advertise restrictions, graphic warning labels and excise taxes, etc. [
6,
7].
As a way of communication with consumers, cigarette package has become more important following restrictions on other types of tobacco advertisement [
8], and is a key component of marketing mix for tobacco industries that aimed at reinforcing brand appeal and discouraging negative cognition which might cause smokers quitting [
9]. Overwhelming studies demonstrate that advertising exposure predicts increased trend of tobacco smoking behavior globally [
10,
11]. A systematic review indicates the causal relationship between advertisement exposure and youth smoking initiation and adult smoking continuation, and tobacco advertisement also contributes to higher rates of smoking initiation and smoking cessation relapse [
10]. The WHO Framework Convention on Tobacco Control (FCTC) recommends the removal of all tobacco industry branding and mandates graphic warning labels on cigarette package, which is crucial for decreasing the high prevalence of tobacco consumption worldwide [
12].
In recent years, tobacco control advocates have sought to place health information on cigarette package [
8]. Based on communication and health behavior theories [
13], message impact framework has been established and applied successfully in cigarette health warning labels (HWLs) research [
14]. The message impact framework assumes that features of HWLs will influence smokers’ behavior by a chain of psychological events which ultimately changes their smoking behaviors [
15]. Graphic warning labels (GWLs), as a kind of HWLs on tobacco product package, communicate health risks associated with tobacco use and serve as a population level smoking cessation measure [
16]. GWLs have been proven to be effective in eliciting negative responses to tobacco smoking, increasing reported intention to quit, and modifying beliefs about tobacco smoking dangers [
17,
18]. A study in Shanghai demonstrated that approximately 80% of smokers would consider smoking less, and 48% of smokers reported the intention to quit smoking due to the assumed GWLs on cigarette package [
19], and another study in California and North Carolina indicated that 40% of current smokers attempted to quit smoking due to pictorial warning labels [
15]. Warning labels with larger graphics in addition to textual messages are associated with a greater impact than smaller text only labels. Observational as well as randomized controlled trails indicate increased tobacco smoking cessation in population where GWLs have been implemented [
16]. The guidelines for placing GWLs on cigarette package were issued in the Article 11 of FCTC by WHO, calls for countries to adopt pictorial labels on cigarette packages, with warnings covering at least 50% in the front and back of the display areas [
1]. Even though GWLs have been adopted in many countries, the implementation of GWLs is still under debate in China [
17].
China is facing a public crisis with an estimated of 320 million people are smokers. The Global Adult Survey (GATS) conducted in 2010 indicate that nearly 1 million smokers die from tobacco related diseases, and about 52% of non-smokers are exposed to secondhand tobacco smoke [
13,
18,
19]. China signed the WHO FCTC in 2003 and implemented the FCTC in 2006, but official assessment report indicates that China has made limited progress toward tobacco control and the current smoking prevalence is still high [
13]. To reduce the health burden of tobacco smoking, smokers in China need to be encouraged to quit smoking [
20]. However, research conducted in 1996, 2002 and 2010 in China suggests that the majority of current smokers have no intention to quit smoking [
20,
21]. So further studies examining intention to quit smoking among smokers and exploring the salient tobacco control policies are crucial to decrease smoking prevalence and reduce diseases burden in China.
In this paper, we conduct a cross-sectional study in rural areas of Shanghai, China. We aim to understand the smoking intensity, smoking duration and smoking cessation intention among current smokers, and to explore how smoking cessation intention will be influenced by the assumed graphic warming labels among smokers in Shanghai, China.
Discussion
In this study, we identified that over 58% of current smokers had smoking cessation intention due to GWLs on cigarette package. Moreover, about 40% of current smokers who had no plan to quit in a year reported smoking cessation intention due to GWLs. The findings were in line with previous studies [
8,
23]. Brewer, et al. [
24] demonstrated that affixing GWLs on cigarette package encouraged about 40% of 2149 current smokers planned to quit, which was consistent with findings in this study. GWLs increased smoking cessation intention by increasing attention to the physical harm warnings, inducing emotional response, eliciting negative reactions, avoidance of warning and considering the warning message. In light of the sufficient evidence of GWLs for tobacco control, the fraction of countries having GWLs increased significantly from 15% in 2007, to 55% in 2014 and to over 61% in 2017 [
13].
Anh Ngo, et al. [
12] demonstrated that GWLs were associated with a 0.9–3 percentage point decrease in adult smoking prevalence and with a reduction of 230–287 sticks of per capita cigarette consumption. In this study, we noticed that 41.85% of smokers in Shanghai had plan to quit smoking in a year, which was higher than that in ITC China Survey in 2006 (26%), and Shanghai Tobacco Control Survey in 2013 (20%) [
20]. Meanwhile, more current smokers would consider to quit smoking due to GWLs, so we predicted that the prevalence of tobacco smoking would decrease gradually if GWLs was adopted in Shanghai, China. Whereas, we should notice that 47.92% of current smokers in this study had previously tried to quit smoking but all relapsed. The high percentage of smoking cessation intention were not equal to the high percentage of actual cessation behavior in the future, so incorporating tobacco control measures covering the repeated intervention and professional counseling contrapuntally would promote the smoking cessation intention transferring into actual cessation behavior.
Previous studies proved that smokers with heavier nicotine dependence were not fully process graphic health warning labels, and graphic warning labels might not change their demand for cigarette, or strongly influence their motivation to quit [
25,
26]. In this study, we identified that current smokers with lower smoking intensity, longer smoking duration, and lower tobacco burden had higher smoking cessation intention, which was in line with findings of previous studies. Reasons for GWLs induce smokers consider quitting smoking are well explained by the message impact framework [
14,
15], some studies also suggest that GWLs may prompt defensive reactions in smokers that cause warnings to have effects that are opposite of what is intended [
27]. In China, a long smoking duration predicts the elder age and lower monthly income, smokers with longer smoking duration are also prone to have chronic diseases problems, makes them sensitive to tobacco control measures including GWLs on cigarette package. Meanwhile, lower smoking intensity indicates a mild nicotine dependence among smokers, so they are prone to change their smoking habits with the assumed GWLs on cigarette package.
A growing body of researches have demonstrated that women experience significant health disparities related to tobacco smoke [
28,
29]. Women have lower rates of successfully quitting, and experience greater risk of certain health consequences of smoking [
30]. Furthermore, women smokers response more strongly to GWLs on cigarette package, and are more likely to consider smoking cessation due to GWLs [
31,
32]. In this study, we identified that female smokers had over 2.4 folds of smoking cessation intention due to GWLs in comparison with male smokers, which was in line with previous evidences that graphic warning labels were more effective in motivating female smokers to quit [
32]. This might attribute to the fact that women are more sensitive to malignancies and respiratory illnesses depicted on top of the cigarette package, and then induced strong negative emotions [
4,
31,
32]. We recommend that sex differences in smoking cessation intention due to GWLs on cigarette packs should be considered when adopting GWLs into tobacco control measures.
To our knowledge, this study is the first attempt to exclusively estimate how smoking cessation intention would be influenced by the assumed graphic warning labels (GWLs) in Shanghai, China. The findings in this study indicate that smoking cessation intention due to the assumed GWLs on cigarette packs is high among current smokers, so incorporating GWLs into tobacco control measures would discourage tobacco smoking in Shanghai, China. A key strength of this study was that data was collected through face to face interview by an Android pad assisted electronic questionnaires, the automated logical check schedule in data collection process and the whole course audio record ensured a high data quality. In this study, we applied a special multistage sampling methods due to the low prevalence of tobacco smoking among female population in China (about 3%), in which we choose one male smoker and one female smoker from each selected households whenever possible to increase the sample size of female smoker, is another strengthen of this study.
There are some limitations in this study. Firstly, the sample of smokers was judiciously selected based on the geographical representation, but not a random sample of the entire smoking population in Shanghai, and the 1104 smokers in this study was a relatively smaller sample in comparison with the large number of tobacco smokers in Shanghai, which limited the generalization of findings in this study. Secondly, smoking cessation intention due to the assumed GWLs on cigarette package was just the attitude of smokers but not the actual behavior change, which impeded the observation of real effect, so implementing an intervention and follow-up study would be a major step forward to evaluate the actual effect of GWLs as tobacco control measure. Thirdly, we only employed graphic warning labels to explore its association with smoking cessation intention among smokers, however, other factors including physicians’ advice for quit, tobacco retail price increase, tobacco control advertisements as well as tobacco control campaigns such as ‘the Chinese International Quit and Win Competition’ may also affect the smoking cessation intention among current smokers. Fourth, answers were self-reported by participants which might induce recall bias and report bias, and other confounding factors such as experienced tobacco smokers, nicotine dependence and exposure time duration to GWLs could also bias the results. So the incorporation of some improvements should be considered in further studies.
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