Downloaded from http://tobaccocontrol.bmj.com/ on September 2, 2017 - Published by group.bmj.com
TC Online First, published on August 28, 2017 as 10.1136/tobaccocontrol-2017-053679 Brief report
Reclaiming the value of pictorial health warning labels in Jordan Nour A Obeidat,1 Mai Al-Hadid,2 Asma A Hatoqai,1 Rawan A Shihab,1 Feras I Hawari1 ►► Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ tobaccocontrol-2017-053679). 1
Cancer Control Office, King Hussein Cancer Center, Amman, Jordan 2 Independent Researcher, Amman, Jordan Correspondence to Dr Nour A Obeidat, Head of Applied Research, Cancer Control Office, Cancer Control Office, King Hussein Cancer Center,11941, Amman, Jordan; n obeidat@khcc.j o Received 2 February 2017 Revised 3 July 2017 Accepted 5 July 2017
Abstract Background In Jordan, four non-graphic pictorial health warning labels (PHWLs) concerning a limited selection of tobacco-caused harms have been used since 2011; however, research suggests that they may be ineffective. Objectives To explore Jordanian smokers’ reactions to novel PHWLs featuring various health themes and/ or graphic and symbolic imagery and to discuss existing PHWLs in light of the novel PHWLs. Methods We conducted 14 focus groups (FGs) with smokers who assessed 12 novel PHWLs and commented on four existing PHWLs. Data were analysed using an inductive approach. Results Six themes emerged from the FG discussions: understanding the overall meaning of PHWLs, the impact of graphic images, magnitude and controllability of harm, personal or vicarious experiences, the futility of quitting and fatalism. PHWLs depicting graphic respiratory and oral tobacco-caused harms resonated with most smokers. Smokers also sought direct, harm-specific taglines when trying to understand the overall PHWL. Some smokers viewed the PHWLs as exaggerated, and while the majority acknowledged that smoking was harmful, they felt that PHWLs would not accomplish their goal of inducing quitting. Conclusions Our findings support the use of graphic imagery to communicate tobacco-caused harms (particularly respiratory ones) and the use of specific taglines explaining the mechanism of harm depicted.
Sample
The sample (online supplementary 4) comprised daily cigarette smokers stratified by age (younger: 18–24; older: late 30s or older), gender and education (whether participants had a university degree). We planned two FGs per stratum (n=16),4 and undertook one pilot FG.
Measurement framework and tools
We developed a discussion guide based on publicly available guidelines regarding how to pretest and evaluate PHWLs in an FG setting (online supplementary 5).4 5
Data coding and analysis
FGs groups were moderated by an independent consultant, recorded and transcribed. The moderator and a research assistant took notes and the research team undertook statement-by-statement transcribing and double-coding. We used a general inductive approach to identify more general themes.6 7
Results Description of sample
The final sample consisted of 14 FGs (see table 1). We present our results according to six themes.
Understanding the overall PHWL Background
In many Eastern Mediterranean countries, pictorial health warning labels (PHWLs) fail to meet WHO recommendations.1 For example, in Jordan, where 32% of adults are regular smokers (online supplementary 1),2 the four PHWLs in circulation since 2011 cover only 40% of cigarette packs, address limited health harms and are not graphic.3 To provide recommendations for selecting more effective PHWLs, we explored Jordanian smokers’ reactions to a variety of PHWLs.
Methods
We employed a qualitative research design using focus groups (FGs). We received ethical approval from the institutional review board at King Hussein Cancer Center. To cite: Obeidat NA, AlHadid M, Hatoqai AA, et al. Tob Control Published Online First: [please include Day Month Year]. doi:10.1136/ tobaccocontrol-2017-053679
Tested material
In consultation with local tobacco control experts, we narrowed a collection of culturally appropriate PHWLs to 12 for FG testing (online supplementary 2 and supplementary 3).
Participants’ understanding of image and text combinations depended on the health harm depicted, tagline used and abstract imagery employed.
Health harm depicted
Participants recognised and understood conventional smoking harms such as respiratory and oral diseases. However, PHWLs that focused on less well-known health harms such as blindness and vascular damage were confusing. For example, in response to the PHWL ‘Smoking causes blindness’, which featured an image of a cloudy eye, one FG member stated: I don’t know what an eye looks like inside, so [PHWL2] didn’t really influence me because I don’t know how [the eye has] changed.
Most participants misattributed microvascular harms depicted in one PHWL (PHWL5) to diabetes rather than smoking, or in the case of another PHWL (PHWL10), misunderstood the harm being depicted, with women associating the image of bladder cancer harms with ‘feminine’ gynaecological problems, infertility and ‘uterine cancer’.
Obeidat NA, et al. Tob Control 2017;0:1–3. doi:10.1136/tobaccocontrol-2017-053679
Copyright Article author (or their employer) 2017. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://tobaccocontrol.bmj.com/ on September 2, 2017 - Published by group.bmj.com
Brief report Table 1 Overview of focus groups conducted among Jordanian lay public Stratum
Number of focus groups
Number of participants
Average age
Men, aged late 30s+, with no university degree
2
12
47
Men, aged late 30s+, with university degree
2
12
43
Men, aged 18–24, with no university degree
2
12
18
Men, aged 18–24, with or attaining university degree
2
12
19
Women, aged late 30s+, with no university degree
3*
18
44
Women, aged 18–24, with no university degree
2
12
21
Women, aged 18–24, with or attaining university degree
1
6
20
*Includes pilot focus group.
Tagline used
Images combined with taglines that did not describe the precise condition depicted (blood vessel damage, PHWL5) or provided a general warning (‘Smoking causes a slow and painful death’, PHWL8), elicited confusion. When participants found an image unintuitive, they looked to the tagline for an explanation; however, they found some messages perplexing if they did not describe the image precisely: I think this is cancer in the larynx? Cancer? As in tumor? So the image says smoking causes a painful and slow death…even in the words they aren’t specifying what it is. (PHWL8)
Taglines also took on particular importance in PHWLs displaying harms when participants felt uncertain of the underlying mechanism of the novel harm shown: If they had written something about what the disease is or some sort of information…people may understand…[moderator mentions the written statement on bladder cancer]…I understand… but I need more information about bladder cancer. What is it? (PHWL10)
Abstract imagery
Participants found abstract images ineffective or difficult to link directly to smoking; several participants also misinterpreted the images literally. In response to an image of a skull smoking a cigarette (PHWL12), a participant stated: It doesn’t really have an effect, because the skull is associated with many dangers, not only smoking in particular. That’s why if I see it on a cigarette pack, it wouldn’t draw my attention…we see it a lot… It’s too general.
In response to an image of a prison composed of cigarettes (PHWL13), a participant asked: ‘Does this mean [smoking] leads to other bad things that can get you in trouble, like marijuana?’
Another participant explained to her: If someone’s son is smoking and he can’t find a way to get his cigarettes, he may steal to get them, and where will this lead? Prison.
Graphic PHWLs
Participants found graphic PHWLs more salient, fear-provoking and disgusting than other PHWLs. These reactions were strongest with graphic images featuring known harms of smoking (lung cancer, oral cancers and damage to teeth). One participant explained: 2
I’m sure if this image was put on cigarette packs, one wouldn’t buy the pack…this gives you facts, and they’ve opened up someone’s chest and we can see it’s actually real.
The magnitude and controllability of harm
Most PHWLs presented severe harms that some participants viewed as ‘exaggerated’, regardless of the warning relevance and salience. Responses ranged from genuine bewilderment that such severe harms could possibly exist, to vehement assertion (by a few participants) that the harms were fabricated to vilify tobacco. For example, in response to an image of a diseased foot accompanied by the tagline ‘Smoking damages your blood vessels’ (PHWL5), one participant stated: We know that there are risks for smoking, bigger ones than… foot problems. They’re going overboard with this. They’ve started including things that–for me–have no relation, they’re not logical. Damaging blood vessels, that is a correct statement. But you don’t prove this to me with a picture of toes or a messed up foot. (PHWL5)
Many participants relied on a self-serving optimism to distance themselves from severe harms, regarding these harms as applicable only to much heavier or older smokers, or smokers with comorbidities. Participants also saw ‘aesthetic’ harms (wrinkles and damaged teeth) as either manageable or inevitable: I’m convinced of this [image of broken and missing teeth]…but this is normal. It’s not like cancer. There are dentists…that can fix everything. But cancer is hard to treat. (PHWL4)
Personal or vicarious experiences
Participants with personal or vicarious experiences related to the depicted harm on the PHWL found the PHWL convincing. Conversely, many younger participants felt too young to be concerned with any of the harms on the PHWLs. As one young woman stated: I'm 20 years old. I don’t think about death.
Most participants related to oral and respiratory harms, largely because these harms are more commonly known and something experienced personally or vicariously: You wake up in the morning, your mouth is dry and it’s an irritating feeling. You want to exercise but you can’t. You run five meters and you pant. You climb ten steps and you're tired…for us, this is what we experience as smokers on a daily basis. So seeing this [image of damaged lungs, PHWL9] expressed a lot.
Women (and older men) with children felt PHWLs concerning smoking harms during pregnancy were relevant. However, older women felt conflicted, because the majority smoked during Obeidat NA, et al. Tob Control 2017;0:1–3. doi:10.1136/tobaccocontrol-2017-053679
Downloaded from http://tobaccocontrol.bmj.com/ on September 2, 2017 - Published by group.bmj.com
Brief report pregnancy, and all stated that they had delivered healthy children.
Futility of smokers quitting
The futility of deterring smokers from smoking using PHWLs was a recurring topic. Many participants reiterated that while they realised smoking was harmful, permanently quitting seemed too difficult. As one participant noted, This [diseased tongue] wouldn’t make me quit. We are already being [negatively] impacted by smoking and yet we don’t stop.
At best, some participants believed that PHWLs would inspire some smokers to lower their cigarette consumption or smoke away from others who could be harmed, or would avoid unpleasant PHWLs by requesting a pack with another PHWL. One participant drew an analogy with speed signs: It’s like a speeding radar and how it protects people for a distance of 200–300 meters, drivers will slow down for 200–300 meters, so does this warning [diseased tongue], it could lead people to reduce the number of cigarettes even if temporarily after seeing the photo.
Fatalism
While most participants generally acknowledged smoking caused diseases such as cancer, heart disease and oral diseases, they saw death itself in God’s hands. One participant explained: ‘A person is going to die anyway, whether or not he smokes; We believe what these [PHWLs] are saying. Smoking destroys everything in the body. But it doesn’t kill you. Death is in the hands of God’.
Current PHWLs
Towards the end of each FG, participants were invited to comment on the current PHWLs. There was consensus that most existing PHWLs were benign and lacked salience due to their non-graphic nature. Participants also commented that current PHWLs typically focused on a health harm that was relevant to select age groups (secondhand smoke and child health), and some saw these messages as suggesting that smokers should avoid smoking near children rather than quit. Only one of the four circulating PHWLs—a shroud lying on a stack of cigarettes— resonated with the majority due to its foreboding nature.
Discussion
Our study exploring how Jordanian smokers interpreted novel PHWLs showed that smokers better understood and responded to PHWLs that depicted respiratory and oral smoking-caused harms and employed graphic imagery and specific taglines to explain the accompanying image. Smokers also tended to view many of the depicted harms as exaggerated, and most felt that the ultimate aim of PHWLs (to inspire smokers to quit) was futile. Some of our findings are consistent with other studies that suggest smokers are likely to be indifferent to non-graphic or drawn images8 and that younger smokers feel removed from longer term severe health harms and respond better to immediate harms.9 Our study has limitations. Participants were not selected randomly to participate; thus, our findings are not generalisable to all Jordanian smokers. We also were unable to recruit certain key groups, including older, educated women smokers and smokers in their mid-20s to mid-30s, who may have been more responsive to images featuring children. However, given Obeidat NA, et al. Tob Control 2017;0:1–3. doi:10.1136/tobaccocontrol-2017-053679
the dearth of research in this area in Jordan, our study offers insight into possible changes to Jordanian PHWLs that should be further explored. Specifically, our findings suggest that existing PHWLs in Jordan lack impact and that new PHWLs that use graphic images of well-known tobacco-caused harms and avoid general, non-specific warnings and abstract imagery are likely to be more effective. In adopting new warnings, policymakers should also consider expanding their size to be consistent with WHO recommendations.
What this paper adds ►► Despite a high smoking rate, Jordan does not follow WHO
recommendations regarding the size and content of pictorial health warning labels (PHWLs) on tobacco products. ►► In our study, Jordanian smokers characterised existing PHWLs as benign. Their responses to alternative PHWLs suggested that new PHWLs should include graphic imagery focused on well-known tobacco-caused harms, such as oral and respiratory damage. Acknowledgements This study was funded by the WHO (Jordan Office). We would like to thank Ms Rania Sabbah for her efforts in facilitating the arrangement of focus groups throughout the project and for moderating focus group discussions. Contributors NAO: contributed to the conception and design of the project; data entry, coding and analysis/interpretation of data; drafting the submission and revising it critically with other coauthors; and approving and generating the final version of the manuscript. She is guarantor. MAH: contributed to data entry, coding and analysis/interpretation of data; drafting the submission and revising it critically; and approving the version to be published. AAH: contributed to design of the project; data acquisition and monitoring of overall data collection and study progress; drafting the submission and revising it critically; and approving the version to be published. RAS: contributed to design of the project; data acquisition and monitoring of overall data collection and study progress; drafting the submission and revising it critically; and approving the version to be published. FIH: contributed to the conception and design of the project; drafting the submission and revising it critically; and approving and generating the final version of the manuscript. Competing interests None declared. Ethics approval IRB at King Hussein Cancer Center. Provenance and peer review Not commissioned; externally peer reviewed. Data sharing statement Data can be requested from the corresponding author. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
References
1 WHO report on the global tobacco epidemic, 2015. http://www.who.int/tobacco/ global_report/2015/r eport/en/. 2 Jaghbir M, Shreif S, Ahram M. Pattern of cigarette and waterpipe smoking in the adult population of Jordan. East Mediterr Health J 2014;20:529–37. 3 Hawari FI, Bader RK, Beano HM, et al. Perceptions of young jordanian adults to proposed anti-tobacco pictorial warning labels. BMC Public Health 2011;11:414. 4 Hammond D, Reid J. Pre-testing and evaluating warning messages for tobacco products. http://www.tobaccolabels.c a/wp/wp-content/uploads/2013/11/Pre-t esting- and-Evaluating-Warning-M essages-for-Tobacco-Products-G uide-Hammond-and-Reid- 2011.pdf. 5 Hammond D. Tobacco labelling & packaging toolkit: a guide to FCTC Article 11. Waterloo, ON: Tobacco Labelling Resource Centre, 2009. http://www.tobaccolabels.ca/ toolkit/. 6 Palinkas LA. Qualitative and mixed methods in mental health services and implementation research. J Clin Child Adolesc Psychol 2014;43:851–61. 53. 7 Thomas DR. A General Inductive Approach for Analyzing Qualitative evaluation data. Am J Eval 2006;27:237–46. 8 Hammond D. Health warning messages on tobacco products: a review. Tob Control 2011;20:327–37. 9 Hoek J, Hoek-Sims A, Gendall P. A qualitative exploration of young adult smokers’ responses to novel tobacco warnings. BMC Public Health 2013;13:609.
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TC Online First, published on August 28, 2017 as 10.1136/tobaccocontrol-2017-053679 Brief report
Reclaiming the value of pictorial health warning labels in Jordan Nour A Obeidat,1 Mai Al-Hadid,2 Asma A Hatoqai,1 Rawan A Shihab,1 Feras I Hawari1 ►► Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ tobaccocontrol-2017-053679). 1
Cancer Control Office, King Hussein Cancer Center, Amman, Jordan 2 Independent Researcher, Amman, Jordan Correspondence to Dr Nour A Obeidat, Head of Applied Research, Cancer Control Office, Cancer Control Office, King Hussein Cancer Center,11941, Amman, Jordan; n obeidat@khcc.j o Received 2 February 2017 Revised 3 July 2017 Accepted 5 July 2017
Abstract Background In Jordan, four non-graphic pictorial health warning labels (PHWLs) concerning a limited selection of tobacco-caused harms have been used since 2011; however, research suggests that they may be ineffective. Objectives To explore Jordanian smokers’ reactions to novel PHWLs featuring various health themes and/ or graphic and symbolic imagery and to discuss existing PHWLs in light of the novel PHWLs. Methods We conducted 14 focus groups (FGs) with smokers who assessed 12 novel PHWLs and commented on four existing PHWLs. Data were analysed using an inductive approach. Results Six themes emerged from the FG discussions: understanding the overall meaning of PHWLs, the impact of graphic images, magnitude and controllability of harm, personal or vicarious experiences, the futility of quitting and fatalism. PHWLs depicting graphic respiratory and oral tobacco-caused harms resonated with most smokers. Smokers also sought direct, harm-specific taglines when trying to understand the overall PHWL. Some smokers viewed the PHWLs as exaggerated, and while the majority acknowledged that smoking was harmful, they felt that PHWLs would not accomplish their goal of inducing quitting. Conclusions Our findings support the use of graphic imagery to communicate tobacco-caused harms (particularly respiratory ones) and the use of specific taglines explaining the mechanism of harm depicted.
Sample
The sample (online supplementary 4) comprised daily cigarette smokers stratified by age (younger: 18–24; older: late 30s or older), gender and education (whether participants had a university degree). We planned two FGs per stratum (n=16),4 and undertook one pilot FG.
Measurement framework and tools
We developed a discussion guide based on publicly available guidelines regarding how to pretest and evaluate PHWLs in an FG setting (online supplementary 5).4 5
Data coding and analysis
FGs groups were moderated by an independent consultant, recorded and transcribed. The moderator and a research assistant took notes and the research team undertook statement-by-statement transcribing and double-coding. We used a general inductive approach to identify more general themes.6 7
Results Description of sample
The final sample consisted of 14 FGs (see table 1). We present our results according to six themes.
Understanding the overall PHWL Background
In many Eastern Mediterranean countries, pictorial health warning labels (PHWLs) fail to meet WHO recommendations.1 For example, in Jordan, where 32% of adults are regular smokers (online supplementary 1),2 the four PHWLs in circulation since 2011 cover only 40% of cigarette packs, address limited health harms and are not graphic.3 To provide recommendations for selecting more effective PHWLs, we explored Jordanian smokers’ reactions to a variety of PHWLs.
Methods
We employed a qualitative research design using focus groups (FGs). We received ethical approval from the institutional review board at King Hussein Cancer Center. To cite: Obeidat NA, AlHadid M, Hatoqai AA, et al. Tob Control Published Online First: [please include Day Month Year]. doi:10.1136/ tobaccocontrol-2017-053679
Tested material
In consultation with local tobacco control experts, we narrowed a collection of culturally appropriate PHWLs to 12 for FG testing (online supplementary 2 and supplementary 3).
Participants’ understanding of image and text combinations depended on the health harm depicted, tagline used and abstract imagery employed.
Health harm depicted
Participants recognised and understood conventional smoking harms such as respiratory and oral diseases. However, PHWLs that focused on less well-known health harms such as blindness and vascular damage were confusing. For example, in response to the PHWL ‘Smoking causes blindness’, which featured an image of a cloudy eye, one FG member stated: I don’t know what an eye looks like inside, so [PHWL2] didn’t really influence me because I don’t know how [the eye has] changed.
Most participants misattributed microvascular harms depicted in one PHWL (PHWL5) to diabetes rather than smoking, or in the case of another PHWL (PHWL10), misunderstood the harm being depicted, with women associating the image of bladder cancer harms with ‘feminine’ gynaecological problems, infertility and ‘uterine cancer’.
Obeidat NA, et al. Tob Control 2017;0:1–3. doi:10.1136/tobaccocontrol-2017-053679
Copyright Article author (or their employer) 2017. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://tobaccocontrol.bmj.com/ on September 2, 2017 - Published by group.bmj.com
Brief report Table 1 Overview of focus groups conducted among Jordanian lay public Stratum
Number of focus groups
Number of participants
Average age
Men, aged late 30s+, with no university degree
2
12
47
Men, aged late 30s+, with university degree
2
12
43
Men, aged 18–24, with no university degree
2
12
18
Men, aged 18–24, with or attaining university degree
2
12
19
Women, aged late 30s+, with no university degree
3*
18
44
Women, aged 18–24, with no university degree
2
12
21
Women, aged 18–24, with or attaining university degree
1
6
20
*Includes pilot focus group.
Tagline used
Images combined with taglines that did not describe the precise condition depicted (blood vessel damage, PHWL5) or provided a general warning (‘Smoking causes a slow and painful death’, PHWL8), elicited confusion. When participants found an image unintuitive, they looked to the tagline for an explanation; however, they found some messages perplexing if they did not describe the image precisely: I think this is cancer in the larynx? Cancer? As in tumor? So the image says smoking causes a painful and slow death…even in the words they aren’t specifying what it is. (PHWL8)
Taglines also took on particular importance in PHWLs displaying harms when participants felt uncertain of the underlying mechanism of the novel harm shown: If they had written something about what the disease is or some sort of information…people may understand…[moderator mentions the written statement on bladder cancer]…I understand… but I need more information about bladder cancer. What is it? (PHWL10)
Abstract imagery
Participants found abstract images ineffective or difficult to link directly to smoking; several participants also misinterpreted the images literally. In response to an image of a skull smoking a cigarette (PHWL12), a participant stated: It doesn’t really have an effect, because the skull is associated with many dangers, not only smoking in particular. That’s why if I see it on a cigarette pack, it wouldn’t draw my attention…we see it a lot… It’s too general.
In response to an image of a prison composed of cigarettes (PHWL13), a participant asked: ‘Does this mean [smoking] leads to other bad things that can get you in trouble, like marijuana?’
Another participant explained to her: If someone’s son is smoking and he can’t find a way to get his cigarettes, he may steal to get them, and where will this lead? Prison.
Graphic PHWLs
Participants found graphic PHWLs more salient, fear-provoking and disgusting than other PHWLs. These reactions were strongest with graphic images featuring known harms of smoking (lung cancer, oral cancers and damage to teeth). One participant explained: 2
I’m sure if this image was put on cigarette packs, one wouldn’t buy the pack…this gives you facts, and they’ve opened up someone’s chest and we can see it’s actually real.
The magnitude and controllability of harm
Most PHWLs presented severe harms that some participants viewed as ‘exaggerated’, regardless of the warning relevance and salience. Responses ranged from genuine bewilderment that such severe harms could possibly exist, to vehement assertion (by a few participants) that the harms were fabricated to vilify tobacco. For example, in response to an image of a diseased foot accompanied by the tagline ‘Smoking damages your blood vessels’ (PHWL5), one participant stated: We know that there are risks for smoking, bigger ones than… foot problems. They’re going overboard with this. They’ve started including things that–for me–have no relation, they’re not logical. Damaging blood vessels, that is a correct statement. But you don’t prove this to me with a picture of toes or a messed up foot. (PHWL5)
Many participants relied on a self-serving optimism to distance themselves from severe harms, regarding these harms as applicable only to much heavier or older smokers, or smokers with comorbidities. Participants also saw ‘aesthetic’ harms (wrinkles and damaged teeth) as either manageable or inevitable: I’m convinced of this [image of broken and missing teeth]…but this is normal. It’s not like cancer. There are dentists…that can fix everything. But cancer is hard to treat. (PHWL4)
Personal or vicarious experiences
Participants with personal or vicarious experiences related to the depicted harm on the PHWL found the PHWL convincing. Conversely, many younger participants felt too young to be concerned with any of the harms on the PHWLs. As one young woman stated: I'm 20 years old. I don’t think about death.
Most participants related to oral and respiratory harms, largely because these harms are more commonly known and something experienced personally or vicariously: You wake up in the morning, your mouth is dry and it’s an irritating feeling. You want to exercise but you can’t. You run five meters and you pant. You climb ten steps and you're tired…for us, this is what we experience as smokers on a daily basis. So seeing this [image of damaged lungs, PHWL9] expressed a lot.
Women (and older men) with children felt PHWLs concerning smoking harms during pregnancy were relevant. However, older women felt conflicted, because the majority smoked during Obeidat NA, et al. Tob Control 2017;0:1–3. doi:10.1136/tobaccocontrol-2017-053679
Downloaded from http://tobaccocontrol.bmj.com/ on September 2, 2017 - Published by group.bmj.com
Brief report pregnancy, and all stated that they had delivered healthy children.
Futility of smokers quitting
The futility of deterring smokers from smoking using PHWLs was a recurring topic. Many participants reiterated that while they realised smoking was harmful, permanently quitting seemed too difficult. As one participant noted, This [diseased tongue] wouldn’t make me quit. We are already being [negatively] impacted by smoking and yet we don’t stop.
At best, some participants believed that PHWLs would inspire some smokers to lower their cigarette consumption or smoke away from others who could be harmed, or would avoid unpleasant PHWLs by requesting a pack with another PHWL. One participant drew an analogy with speed signs: It’s like a speeding radar and how it protects people for a distance of 200–300 meters, drivers will slow down for 200–300 meters, so does this warning [diseased tongue], it could lead people to reduce the number of cigarettes even if temporarily after seeing the photo.
Fatalism
While most participants generally acknowledged smoking caused diseases such as cancer, heart disease and oral diseases, they saw death itself in God’s hands. One participant explained: ‘A person is going to die anyway, whether or not he smokes; We believe what these [PHWLs] are saying. Smoking destroys everything in the body. But it doesn’t kill you. Death is in the hands of God’.
Current PHWLs
Towards the end of each FG, participants were invited to comment on the current PHWLs. There was consensus that most existing PHWLs were benign and lacked salience due to their non-graphic nature. Participants also commented that current PHWLs typically focused on a health harm that was relevant to select age groups (secondhand smoke and child health), and some saw these messages as suggesting that smokers should avoid smoking near children rather than quit. Only one of the four circulating PHWLs—a shroud lying on a stack of cigarettes— resonated with the majority due to its foreboding nature.
Discussion
Our study exploring how Jordanian smokers interpreted novel PHWLs showed that smokers better understood and responded to PHWLs that depicted respiratory and oral smoking-caused harms and employed graphic imagery and specific taglines to explain the accompanying image. Smokers also tended to view many of the depicted harms as exaggerated, and most felt that the ultimate aim of PHWLs (to inspire smokers to quit) was futile. Some of our findings are consistent with other studies that suggest smokers are likely to be indifferent to non-graphic or drawn images8 and that younger smokers feel removed from longer term severe health harms and respond better to immediate harms.9 Our study has limitations. Participants were not selected randomly to participate; thus, our findings are not generalisable to all Jordanian smokers. We also were unable to recruit certain key groups, including older, educated women smokers and smokers in their mid-20s to mid-30s, who may have been more responsive to images featuring children. However, given Obeidat NA, et al. Tob Control 2017;0:1–3. doi:10.1136/tobaccocontrol-2017-053679
the dearth of research in this area in Jordan, our study offers insight into possible changes to Jordanian PHWLs that should be further explored. Specifically, our findings suggest that existing PHWLs in Jordan lack impact and that new PHWLs that use graphic images of well-known tobacco-caused harms and avoid general, non-specific warnings and abstract imagery are likely to be more effective. In adopting new warnings, policymakers should also consider expanding their size to be consistent with WHO recommendations.
What this paper adds ►► Despite a high smoking rate, Jordan does not follow WHO
recommendations regarding the size and content of pictorial health warning labels (PHWLs) on tobacco products. ►► In our study, Jordanian smokers characterised existing PHWLs as benign. Their responses to alternative PHWLs suggested that new PHWLs should include graphic imagery focused on well-known tobacco-caused harms, such as oral and respiratory damage. Acknowledgements This study was funded by the WHO (Jordan Office). We would like to thank Ms Rania Sabbah for her efforts in facilitating the arrangement of focus groups throughout the project and for moderating focus group discussions. Contributors NAO: contributed to the conception and design of the project; data entry, coding and analysis/interpretation of data; drafting the submission and revising it critically with other coauthors; and approving and generating the final version of the manuscript. She is guarantor. MAH: contributed to data entry, coding and analysis/interpretation of data; drafting the submission and revising it critically; and approving the version to be published. AAH: contributed to design of the project; data acquisition and monitoring of overall data collection and study progress; drafting the submission and revising it critically; and approving the version to be published. RAS: contributed to design of the project; data acquisition and monitoring of overall data collection and study progress; drafting the submission and revising it critically; and approving the version to be published. FIH: contributed to the conception and design of the project; drafting the submission and revising it critically; and approving and generating the final version of the manuscript. Competing interests None declared. Ethics approval IRB at King Hussein Cancer Center. Provenance and peer review Not commissioned; externally peer reviewed. Data sharing statement Data can be requested from the corresponding author. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
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Reclaiming the value of pictorial health warning labels in Jordan Nour A Obeidat, Mai Al-Hadid, Asma A Hatoqai, Rawan A Shihab and Feras I Hawari Tob Control published online August 28, 2017
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