Avoidance Of Tobacco Health Warnings? An Eye-Tracking Approach

Aims Among three eye-tracking studies, we examined how cigarette pack features affected visual attention and self-reported avoidance of and reactance to warnings. Design Study 1: smoking status x warning immediacy (short-term versus long-term health consequences) x warning location (top versus bottom of pack). Study 2: smoking status x warning framing (gain-framed versus loss-framed) x warning format (text-only versus pictorial). Study 3: smoking status x warning severity (highly severe versus moderately severe consequences of smoking). Setting University of Bristol, UK, eye-tracking laboratory. Participants Study 1: non-smokers (n = 25), weekly smokers (n = 25) and daily smokers (n = 25). Study 2: non-smokers (n = 37), smokers contemplating quitting (n = 37) and smokers not contemplating quitting (n = 43). Study 3: non-smokers (n = 27), weekly smokers (n = 26) and daily smokers (n = 26). Measurements For all studies: visual attention, measured as the ratio of the number of fixations to the warning versus the branding, self-reported predicted avoidance of and reactance to warnings and for study 3, effect of warning on quitting motivation. Findings Study 1: greater self-reported avoidance [mean difference (MD) = 1.14; 95% confidence interval (CI) = 0.94, 1.35,P < 0.001, eta(2)(p) = 0.64] and visual attention (MD = 0.89, 95% CI = 0.09, 1.68,P = 0.03, eta(2)(p) = 0.06) to long-term warnings, but not for reactance (MD = 0.14, 95% CI = -0.04, 0.32,P = 0.12, eta(2)(p) = 0.03). Increased visual attention to warnings on the upper versus lower half of the pack (MD = 1.8; 95% CI = 0.33, 3.26,P = 0.02, eta(2)(p) = 0.08). Study 2: higher self-reported avoidance of (MD = 0.70; 95% CI = 0.59,0.80,P < 0.001, eta(2)(p) = 0.61) and reactance to (MD = 0.37; 95% CI = 0.27, 0.47,P < 0.001, eta(2)(p) = 0.34) loss-framed warnings but little evidence of a difference for visual attention (MD = 0.52; 95% CI = -0.54, 1.58,P = 0.30, eta(2)(p) = 0.01). Greater visual attention, avoidance and reactance to pictorial versus text-only warnings (allPs < 0.001, eta(2)(p) > 0.25). Study 3: greater self-reported avoidance of (MD = 0.37; 95% CI = 0.25, 0.48,P < 0.001, eta(2)(p) = 0.33) and reactance to (MD = 0.14; 95% CI = 0.05, 0.23,P = 0.003, eta(2)(p) = 0.11) highly severe warnings but findings were inconclusive as to whether there was a difference in visual attention (MD = -0.55; 95% CI = -1.5, 0.41,P = 0.24, eta(2)(p) = 0.02). Conclusions Subjective and objective (eye-tracking) measures of avoidance of health warnings on cigarette packs produce different results, suggesting these measure different constructs.Visual avoidance of warnings indicates low-level disengagement with warnings, while self-reported predicted avoidance reflects higher-level engagement with warnings.